Developing a community facilitator‐led participatory learning and action women's group intervention to improve infant feeding, care and dental hygiene practices in South Asian infants: NEON programme

Abstract Introduction The Nurture Early for Optimal Nutrition (NEON) study is a multiphase project that aims to optimize feeding, care and dental hygiene practices in South Asian children <2 years in East London, United Kingdom. The multiphase project uses a participatory learning and action (PLA) approach facilitated by a multilingual community facilitator. In this paper, we elaborate on the process and results of the Intervention Development Phase in the context of the wider NEON programme. Methods Qualitative community‐based participatory intervention codevelopment and adaptation. Setting Community centres in East London and online (Zoom) meetings and workshops. Participants In total, 32 participants registered to participate in the Intervention Development Phase. Four Intervention Development workshops were held, attended by 25, 17, 20 and 20 participants, respectively. Results Collaboratively, a culturally sensitive NEON intervention package was developed consisting of (1) PLA group facilitator manual, (2) picture cards detailing recommended and nonrecommended feeding, care and dental hygiene practices with facilitators/barriers to uptake as well as solutions to address these, (3) healthy infant cultural recipes, (4) participatory Community Asset Maps and (5) list of resources and services supporting infant feeding, care and dental hygiene practices. Conclusion The Intervention Development Phase of the NEON programme demonstrates the value of a collaborative approach between researchers, community facilitators and the target population when developing public health interventions. We recommend that interventions to promote infant feeding, care and dental hygiene practices should be codeveloped with communities. Recognizing and taking into account both social and cultural norms may be of particular value for infants from ethnically diverse communities to develop interventions that are both effective in and accepted by these communities. Patient and Public Involvement and Engagement Considerable efforts were placed on Patient/Participant and Public Involvement and Engagement. Five community facilitators were identified, each of which represented one ethnic/language group: (i) Bangladeshi/Bengali and Sylheti, (ii) Pakistani/Urdu, (iii) Indian/Gujrati, (iv) Indian/Punjabi and (v) Sri Lankan/Tamil. The community facilitators were engaged in every step of the study, from the initial drafting of the protocol and study design to the Intervention Development and refinement of the NEON toolkit, as well as the publication and dissemination of the study findings. More specifically, their role in the Intervention Development Phase of the NEON programme was to: 1. Support the development of the study protocol, information sheets and ethics application.2. Ensure any documents intended for community members are clear, appropriate and sensitively worded.3. Develop strategies to troubleshoot any logistical challenges of project delivery, for example, recruitment shortfalls.4. Contribute to the writing of academic papers, in particular reviewing and revising drafts.5. Develop plain language summaries and assist in dissemination activities, for example, updates on relevant websites.6. Contribute to the development of the NEON intervention toolkit and recruitment of the community members.7. Attend and contribute to Intervention Development workshops, ensuring the participant's voices were the focus of the discussion and workshop outcomes.

1. Support the development of the study protocol, information sheets and ethics application.
2. Ensure any documents intended for community members are clear, appropriate and sensitively worded. 3. Develop strategies to troubleshoot any logistical challenges of project delivery, for example, recruitment shortfalls. 4. Contribute to the writing of academic papers, in particular reviewing and revising drafts. 5. Develop plain language summaries and assist in dissemination activities, for example, updates on relevant websites. 6. Contribute to the development of the NEON intervention toolkit and recruitment of the community members. 7. Attend and contribute to Intervention Development workshops, ensuring the participant's voices were the focus of the discussion and workshop outcomes. growth and brain development. There is mounting evidence to show that influences during pregnancy (such as high maternal prepregnancy body mass index, excess gestational weight gain, gestational diabetes, tobacco exposure) and infancy (e.g., high infant birth weight or accelerated infant weight gain) may alter lifetime risk of nutrition and dental-related diseases. 1 Feeding practices developed during this critical period can therefore impact a child's nutrition, growth, dental health and cognitive development. Healthy, age-appropriate feeding practices are known to be associated with decreased risk of heart disease, obesity and diabetes in the long term, with suboptimal practices having the opposite effect. 2 Studies in the past have shown that Britain's minority ethnic population is most disadvantaged across a range of social and economic outcomes. These social and economic inequalities underpinned by ethnicity are fundamental causes of many health inequalities amongst different ethnic groups in the United Kingdom.
Some of the widest disparities have been observed to be in the South Asian population, with the Pakistani and, to an even greater extent, the Bangladeshi communities, standing out as the most disadvantaged compared to other ethnicities. 3 The World Health Organization (WHO) Infant and Young Children Feeding Guidelines have been adopted by many countries. Despite this uptake, a systematic review of studies assessing feeding practices, and the sociocultural beliefs that underpin them, in children <2 years old within South Asian families living in the United Kingdom, India, Pakistan and Bangladesh show that nonrecommended complementary feeding practices continue to be followed. [4][5][6][7] Further, adult migrants from low-and middle-income countries (LMICs) moving to high-income countries (HICs) have been shown to be at increased risk of developing metabolic disorders, such as obesity and type II diabetes compared to the host population. 8 Factors that affect these feeding practices persisting following migration included bicultural issues or low acculturation levels and conflicting information provided by health professionals and the information shared by extended family, and religious and community leaders in which the latter have an influencing role in affecting feeding practices within the South Asian Community. [4][5][6] In contrast, barriers to engagement with WHO-recommended complementary feeding practices in South Asian countries included conflicts about the best use of mothers' time, short birth intervals and poverty. [4][5][6] Based on the findings that highlight the need for targeted early-life interventions, and its potential to prevent the development of short-and long-term outcomes and reduce lifetime health inequalities. Further, evidence about the drivers of non-recommended feeding practices among recently migrated South Asian communities in HICs suggests that tailored, culturally sensitive interventions have the potential to change behaviours, thereby reducing children's increased risk of developing metabolic disorders later in life. 7 At present, however, the number of such tailored and culturally sensitive interventions is limited, most are developed for the majority population. 9 Health services in the United Kingdom continue to provide mostly unidirectional information based on guidelines and NHS recommendations to parents/carers on the optimal nutrition, care and dental hygiene practices for their children. Specific ethnic groups may be thus marginalized by this universal approach as most of the advice is not tailored to their cultural practices. This inevitably results in an inability to appropriately support families in skills development, which is key to providing optimal infant feeding, care and dental hygiene support.
Respecting the seven theoretical domains framework of intervention acceptability (i.e., affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs and self-efficacy) would further support the design of a tailored approach that optimizes intervention acceptability and hence, uptake. 10 Considering the limited NHS resources and the NHS 10-year Forward Plan, which aims to shift the emphasis to the community, there is a clear need for low-cost culturally sensitive interventions that utilize a strengths-based approach.
Community-based participatory research may be one effective way to design and implement culturally targeted interventions successfully. 11 The Participatory Learning and Action (PLA) group approach, one form of participatory research, is a low-cost, community-based, intervention mostly employed in LMICs. [12][13][14][15] It involves an iterative process whereby multilingual facilitators guide participants through a four-stage cycle of identifying and prioritizing contextual issues, designing strategies to address these issues, implementing these strategies and a postimplementation evaluation. 16 It views research as a collective enterprise between researchers and the researched, taking place in familiar community settings. 11 By empowering the target population and making use of local community assets where possible, the PLA approach has the potential to be applied and adapted to different population groups and topic areas. Evidence from a number of studies has shown positive effects of using a PLA approach. In a meta-analysis of seven cluster randomized controlled trials (RCTs) in LMICs, PLA was shown to be effective, reducing maternal and neonatal mortality by 37% and 23%, respectively. 12 A RCT has also demonstrated PLA groups to reduce maternal depression, increase exclusive breastfeeding rates, and decrease under five morbidity. 14 Additionally, in a Mumbai-based RCT, PLA groups achieved improvements in maternal practices and care-seeking behaviour. 15 This strategy's success in an LMIC setting led to its official endorsement by WHO as a cost-effective strategy to improve maternal and infant survival in rural low-resource settings. 17 Considerable evidence has since been published on the feasibility of adapting reverse innovations for implementation in other resource-constrained settings; 18,19 however, the applicability and feasibility of this approach in an HIC context, such as that of the United Kingdom, remains relatively unexplored.
The Nurture Early for Optimal Nutrition (NEON) programme was created with the aim to improve infant feeding, care and dental hygiene practices in South Asian minority groups using a communitybased, participatory approach.
The NEON programme consists of two stages. The first stage entailed a formative and feasibility study, which focused on the

| Community facilitators
Community facilitators are female local facilitators with experience in running community groups who are leaders in their community.
When trying to identify suitable community facilitator candidates, the following inclusion criteria were considered:

South Asian residents across Tower Hamlets, Newham and Waltham
Forest were recruited to take part in several Intervention Development workshops, detailed in Table 1 below.
Inclusion criteria for community members were: 1. Mothers/carers (any age) of an infant aged <24 months, 2. resident in Tower Hamlets, Newham or Waltham Forest and 3. from the South Asian background (Indian, Pakistani or Sri Lankan in Newham and Bangladeshi in Tower Hamlets).
The community members were recruited through the community facilitators' informal networks and word-of-mouth, and through the online campaigns on social media platforms (e.g., Facebook, Instagram).  This is outlined in Figure 3 below.

| NEON formative and feasibility study findings
In the NEON formative and feasibility study, the pilot 'Participatory Learning' group intervention tested three PLA group meetings. The intervention was developed through a series of workshops with

T A B L E 1 Intervention Development meetings-participants and objectives
Intervention Development meeting number Objectives

Meeting 1
• Induction and overview of the NEON study.
• To review the Community Asset Map adding local assets recommended by community members to providing services and support to aid infant feeding, care and dental hygiene.

Meeting 4
• Providing cultural infant recipes.

Meeting 5
• To review the picture cards providing information on recommended and nonrecommended feeding, care and dental hygiene practices and barriers and solutions for infants <2 years old.

Meeting 6
• To review the picture cards providing information on recommended and nonrecommended feeding, care and dental hygiene practices and barriers and solutions for infants <2 years old.

Meeting 7
• To review the list of resources and services supporting infant feeding, care and dental hygiene practices. • Consensus on all tools.

Meeting 8
• Meeting with the public health infant nutritionist to further review the recipes book.   Table 2 below.

| Intervention Development workshops
The recruitment of participants was achieved through snowballing using the community facilitators network as well as online advertising campaigns using social media platforms (e.g., Facebook, Instagram). These advertisement posters were codeveloped in English and translated to the local languages of our South Asian target population (Gujarati, Punjabi, Urdu, Bengali and Tamil).

| Conceptual framework
A NEON conceptual map was first codeveloped based on the findings from the previous stage of the NEON programme (the NEON formative study) 16  Based on the Dahlgren-Whitehead socioecological model, this map highlights the individual, sociocultural and environmental factors that were found to influence infant feeding, care and dental hygiene practices in our target population (e.g., South Asian origin infants aged <2 years in East London).    Table 3 shows the characteristics of the study participants.

| Data analysis
In a collaborative approach, the NEON core team, community facilitators and participants of our target population developed and revised a culturally sensitive NEON intervention toolkit consisting of:

Workshop 1 (n = 25)
• To review the community assets map adding local assets recommended by community members to provide services and support to aid infant feeding, care and dental hygiene.

Workshop 2 (n = 17)
• To review the healthy baby recipes book that provides culturally sensitive South Asian recipes and general recommendations for infants <2 years old.

Workshop 3 (n = 20)
• To review the picture cards providing information on recommended and nonrecommended feeding, care and dental hygiene practices and barriers and solutions for infants <2 years old.
Workshop 4 (n = 20) • To review a list of resources and services supporting infant feeding, care and dental hygiene practices.
• Consensus on all tools.

Healthy Baby Recipes book.
3. Community Asset Map.

List of local resources and services supporting infant feeding, care
and dental hygiene practices.
Quality is assured by experts (e.g., dentists, health visitors, dieticians and medical practitioners). It is envisaged that (2) and (3) will become trusted community resources. 28

| Picture cards
The picture cards represent one of the key educational resources for PLA group facilitators. Aimed as tools to stimulate discussion and problem-solving during group exercises with participants, they were initially designed as visual and thematic prompts displaying information related to feeding, care and dental hygiene practices.
Their initial design was based on findings from the NEON formative study and was codeveloped and used during the first stage of the NEON programme during the NEON feasibility study.
A further refinement of the picture cards was done based on the NEON feasibility study findings and as part of the Intervention Development meetings and workshops in the NEON Intervention Development Phase. The content was further revised, in an iterative codevelopment process involving the community facilitators whose input aided in the simplification of all 45 cards and the removal of five cards that provided repetitive information.
In a third and final step, the revised picture cards were reviewed by a PLA expert who suggested merging and condensing them into four subcategories, outlined below: 1. Recommended feeding, care and dental hygiene practices.
3. Barriers to feeding, care and dental hygiene practices.
4. Solutions to feeding, care and dental hygiene practices.
During the third workshop with the wider South Asian community members, the picture cards were shared with the community to gain their perspective and improvement suggestions asking them to allow further refinement of both the content of the cards and the pictures associated with each card.
In a final step, the picture cards were subject to review by the NEON Core Team and experts in the field (dentists, nutritionists and health visitors).
The picture cards are subsequently to be utilized in the next NEON Pilot feasibility RCT phase.

| Healthy Baby Recipes
The Healthy Baby Recipes are designed as a resource providing advice on and ideas for age-appropriate, culturally sensitive meals for South Asian infants.

As all of the components of the NEON toolkit, the Healthy Baby
Recipes were created and refined in a participatory approach between community facilitators, community members, as well as the infant public health nutritionist (H. C.), the NEON Core Team and experts in the field of Infant nutrition.
As part of the Intervention Development meetings, the selected NEON community facilitators were initially asked to provide cultural recipes for infants aged <2 years commonly used in their community.
To ensure alignment with food requirements and international WHO recommendations for each infant age group (e.g., 6-9 months, 9-18 months, etc.), an infant public health nutritionist (H. C.) was consulted to review the suggested recipes and provide further suggestions.
Together with an infant public health nutritionist at First Steps Nutrition, the NEON team revised the recipe contents and pictures. Furthermore, community facilitators were made aware of, and explained the rationale behind, the changes made so as to ensure this information is also passed on to the target population.
In the eighth Intervention Development meeting, both recommended and nonrecommended practices were discussed in detail, highlighting the key questions that the community has about optimal nutrition for the infant. Thereafter, the community members in the second workshop reviewed the recipe book and suggested final amendments in terms of layout and presentation, as well as the title of some recipes so as to assure that they are both visually pleasing and culturally appropriate. A final revision and review of the recipe book were undertaken by the NEON core team and the steering team. Figure 4 illustrates the NEON tool for Health Baby Recipes.

| Community Asset Map
The Community Asset Map is a tool that lists and visually displays key locations related to infant feeding, care and dental hygiene practices in East London. Local assets were suggested by community facilitators, community members and experts during one of the Intervention Development meetings. Collaboratively, places and locations thought to shape infant feeding, care and dental hygiene practices were identified. The list of providers was later subcategorized based on the type and colour coordinated as follows: GPs and healthcare centres (red), children/community centres (green), community and worship places (purple), parks (yellow) and others (brown).
The first draft of NEON's Community Asset Map tool was then refined by community members during the first Intervention Development workshop. Participants were asked to review the places on the map for each category and their suggestions for any other places that they considered to be influential in feeding, care and dental hygiene practices. | 2425 local food banks in the community (black). Figure 5 represents the final version of the NEON assets map.

| List of local resources and services
The shop. Figure 6 shows the list of local resources and services

| Digital platform (Eredbook)
Based on the findings from the NEON feasibility study suggesting the use of a digital platform to provide access to the NEON toolkit, it was decided to make all resources available in a virtual format for the pilot feasibility RCT participants. This was achieved by collaborating with an online health and education platform, Eredbook-an NHS  and dental hygiene practices should be codeveloped with communities. Recognizing and taking into account both social and cultural norms may be of particular value for infants from ethnically diverse communities to develop interventions that are both effective in and accepted by these communities. Furthermore, as the communities are considered the codevelopers, these products will become the community's trusted resources, which will also lead to community ownership and ensure sustainability.