Community-based Nutrition Programs Research Articles

Assessment of a Community-Based Nutrition Program for Women and Children in Nepal Using Demographic and Health Survey.

Undernutrition is a particularly acute problem in middle- and low-income countries. The "Suaahara" program is a 5-year community-focused program in Nepal, aimed at improving the health and nutrition of pregnant and lactating women and their children under the age of 2 years. This research contributes to evidence on the impact of the "Suaahara" program in 41 treated districts compared to 34 control districts. Using the difference-in-differences method, we found that the weight-for-height z-score and body mass index z-score of children under the age of 2 in the treated districts significantly increased by 0.223 standard deviations (SDs) and 0.236 SDs, respectively, compared with the control districts 5 years before and after the program. The number of antenatal care visits (at least four visits) and safe deliveries significantly increased for pregnant women by 10.4% and 9.1%, respectively, in the treated districts compared with the control districts. The prevalence of fever in children under 2 years of age was significantly reduced by 6.2% in the treated districts. The results show the significance of a policy evaluation with transparent indicators on public health, which is necessary for policymakers so that they can propose evidence-based policy.

Designing a Community-Based Health Promotion Program for Older Adults Based on Perceived Usefulness, Service Experience, Perceived Value, and Behavioral Intention

ABSTRACT Improving nutritional intake contributes to maintaining the health and quality of life of the older population and reducing individual and societal healthcare costs. We collaborated with two community service hubs and a public health center in Taipei’s Daan District to develop a personalized community-based health and nutrition program using service design. The design was validated through a model encompassing perceived usefulness, service experience, perceived value, and behavioral intention, analyzed using PLS-SEM modeling on 76 individuals. The results showed bidirectional influences among these factors. This study provides practical recommendations for formulating public health policies and health promotion programs for older adults.

Supporting Mealtime Participation Among People Living With Dementia at Home: Challenges and Strategies for Caregivers.

Approximately 60% of people living with dementia at home are unable to routinely participate in mealtime activities (e.g., eating, safe food preparation), warranting assistance to ensure people with dementia meet their health and nutritional needs. The purpose of this study was to characterize these barriers to mealtime participation and identify potential caregiver-led strategies to enhance mealtime activities. We used a qualitative descriptive approach and obtained semistructured interview data from (a) allied health professionals and (b) community-based nutrition program providers who frequently serve people with dementia. Interview data were examined by means of directed content analysis and framework methodology until data saturation was reached. Codes from our analysis were categorized according to constructs drawn from the Socio-Ecological Model for Developing and Implementing Comprehensive Dementia Care. Data were obtained from 20 participants who attributed common mealtime participation barriers to: impairments in functional status, cognitive status deficits, a lack of caregiver knowledge and skills, and unsafe living conditions. Caregiver-led strategies to overcome these barriers included: reducing auditory and visual distractions, providing written cues to perform mealtime activities, eliminating clutter and fall risk hazards, and leveraging community-based nutrition program providers (e.g., home-delivered meal providers). People with dementia face several eating and mealtime participation obstacles. Caregiver-led strategies implemented by family, friends, or community-based nutrition program providers may enhance mealtime activities at home. Findings point to opportunities to develop decision-making tools and resources for caregivers to optimize the health and nutrition of people with dementia.

Harnessing education and lifestyle change to support transitional health for returning citizens: a feasibility study protocol

BackgroundExercise and healthy eating are known to reduce chronic disease risk; however, formerly incarcerated individuals (i.e., returning citizens) face significant social barriers when attempting to engage with existing community-based physical activity and nutrition programs. Given the high disease burden and unique educational needs of returning citizens, this proposed work fills an important gap in the support services currently offered to this population.MethodsThis article describes a process for evaluating the feasibility and acceptability of a physical activity and nutrition intervention tailored to the needs of returning citizens via a partnership between an academic research organization and a community-based reentry program for returning citizens. Staff from the community-based reentry program will train four returning citizens as group fitness instructors and work with a nutritionist to design a 16-week nutrition education curriculum. Reentry program staff will enroll up to 15 formerly incarcerated adults (aged 18 +) in the exercise and nutrition program. Participants will take part in weekly nutrition classes led by the nutritionist and weekly group exercise classes led by a peer instructor. Research staff will evaluate program success in four domains: reach, preliminary effectiveness, implementation, and maintenance.ResultsThis feasibility study will allow us to design and test a program that can eventually be evaluated in a large, randomized trial. It also addresses the multitude of social determinants that impact the health of returning citizens and builds a framework for program sustainability. Individuals recruited as fitness trainers will acquire skills and certifications that may be used to sustain physical fitness activities within the reentry program.ConclusionsThis feasibility study will test our ability to address social determinants that impact the health of returning citizens through a peer-led physical activity and nutrition programming. In the long term, study results may inform development and implementation of reentry programming and policy on a wider scale.

Fathers’ involvement in complementary feeding of children in Damot Woyde District, South Ethiopia: a community-based cross-sectional study

BackgroundIn infant and young child feeding practice parents are the primary agents for childcare activities, such as feeding. Mothers’ role in infant and young child feeding practice has been the focus of previous research. The involvement of fathers in child-feeding practice has rarely been studied. Thus, this study aimed to assess fathers’ involvement in the complementary feeding of children and identify factors associated with it in Southern Ethiopia.MethodsA community-based cross-sectional study was conducted which included a survey, in-depth interviews, and focus group discussions (FGDs). The survey was conducted with 593 fathers who have at least one child of age 6-23 months. Four FGDs were conducted with fathers, and 21 in-depth interviews were conducted with fathers, mothers, and community health workers. The survey data were entered into Epi data software version 1.4.4.0 and statistical analysis was performed using SPSS software version 20. Bivariate and multivariate logistic regression analyses were performed and statistical significance was considered at p < 0.05. All interviews and FGDs were transcribed, coded, categorized, and analyzed using open code software version 4.0.2.ResultsOf the total sample of 593, 50.9% of the fathers in the study were involved in their children’s complementary feeding practices. Fathers with better household income (AOR = 1.56; 95% CI: 1.09, 2.22) and good perception of child complementary feeding practice (AOR = 1.79; 95% CI: 1.28, 2.52) were more likely to be involved in their children’s complementary feeding practice. The majority of the fathers had better knowledge about the recommended complementary feeding practices.ConclusionsIncome-generating activities and behavioral change communication for fathers should be encouraged to improve their involvement in child feeding. Community-based nutrition programs should also give due attention to increasing the involvement of fathers.

Undernutrition and its associated factors among children aged 6 to 59 months in Menz Gera Midir district, Northeast Ethiopia: A community-based cross-sectional study.

Undernutrition can lead to impaired physical growth, restricted intellectual skills, low school performance, reduced working capacity, and rooted disability in adult life. Thus, this study was designed to assess the prevalence and associated factors of undernutrition among children aged 6 to 59 months. A community-based cross-sectional study was conducted among 432 children aged 6 to 59 months in the Menz Gera Midir District. A multi-stage sampling technique was applied to recruit the study participants. Socio-demographic and socio-economic variables were collected by using structured questionnaires. Anthropometric measurements of the children were measured according to the World Health Organization's recommendation. A data collection sheet was used to collect information on the types of foods and number of meals consumed by the child. A bivariable and multivariable logistic regression was performed to identify factors associated with undernutrition. In this study, about 11.3% (95% CI: 8.3-14.3%), 50.2% (95% CI: 45.5-55.0%), and 28% (95% CI: 23.8-32.3%) were wasted, stunted, and underweight, respectively. Children aged 12-23 months (AOR: 1.97; 95% CI: 1.01-3.87), 36-47 months (AOR: 2.05; 95% CI: 1.00-4.19), and being anemic (AOR: 2.92; 95% CI: 1.73-4.92) were found to be an independent predictor of stunting. Moreover, being anemic was found to be significantly associated with wasting (AOR: 6.84; 95% CI: 3.16-14.82). According to the findings of this study, undernutrition was a serious public health issue among 6-59 month old children in the Menz Gera Midir District. Children's age and anemia status were significantly associated with stunting and wasting. Therefore, community-based nutrition programs are vital to reduce childhood undernutrition.

Cross-Sectional Analysis of Oral Healthcare vs. General Healthcare Utilization in Five Low- and Middle-Income Countries.

Oral health is integral to overall health and is often neglected, especially in low- and middle-income countries (LMICs). Oral disease, including untreated dental caries, affects nearly 3.5 billion people globally, contributing to poor health and quality of life. To examine the relationship between the utilization of general healthcare and oral healthcare, we conducted an exploratory cross-sectional study of first-visit interview data collected from a convenience sample of 3,422 low-income mothers and 4,324 children aged 6 months through 6 years participating in a community-based oral health and nutrition program in five LMICs (Ecuador, El Salvador, India, Nepal, and Vietnam) from 2006–2015. We used descriptive and exploratory association analysis to identify patterns of oral healthcare utilization for mothers and children compared to medical care utilization, specifically maternal prenatal care and child immunizations. Overall, 89.6% of the mothers had received prenatal care for at least one child, but only 76.4% had ever received dental care and 50% were currently suffering from oral health symptoms, primarily oral pain. Mothers who received prenatal care were significantly more likely to have accessed dental care compared to those who had not received prenatal care (OR = 2.62, 95% CI: 2.06, 3.32). Overall, 95.4% of the children had current immunizations, but only 30.1% had ever received dental care, and 32.4% were currently suffering from oral pain. Children whose immunizations were up-to-date were more likely to have received dental care, with a significant association in Ecuador (OR = 3.29, 95% CI: 2.06, 5.30). Compared to utilization of general healthcare, oral healthcare was under-utilized by mothers and children in our sample from five LMICs. Integration of prevention- and treatment-oriented oral healthcare into primary medical care services, particularly prenatal care and child immunizations, could help increase access to oral healthcare and improve women's and children's oral health.

Impact of Care Group Participation on Nutrition Knowledge, Behaviour and Practices

Background: Malnutrition is one of the most serious problems affecting the world and it remains a dominant issue in the health of the world’s poorest nations. Community based approaches, such as the Care Group Model, are now recognized as one of the most important avenues for improving nutrition and reducing child mortality. Aims: This study investigated the nutrition impact of nutrition behaviour change communication activities using the Care Group Model approach. Methods: A mixed methods approach using quantitative and qualitative data collection techniques was used. We employed the linear probability model to estimate the determinants of participation in care groups, and we used propensity score matching to determine the impact of the care group approach. The primary target of the care groups were women of child-bearing age and primary caregivers of children under the age of five years. Results: The study offers three major findings: (i) age, family composition and livelihood source of the household are related to household participation in Care Groups, (ii) participation in Care Groups positively impacts household nutrition knowledge and practicing of positive nutrition behaviours, and (iii) household participation in Care Groups positively impacts dietary diversity. Conclusions: The study revealed a positive impact of CGM approach on nutrition behaviour, knowledge and practices. We recommend the integration of the care group approach into all community-based nutrition programme. Key-words: Nutrition behaviour, Care group model, Women, Children, Dietary diversity.

Comparison of Conditional and Marginal Models in Assessing a Child Nutrition Intervention in Armenia.

Child malnutrition is a major issue in conflict zones. Evidence-based interventions and their thorough evaluation could help to eliminate malnutrition. We aimed to assess the causal effect of a community-based multidisciplinary nutrition program for children in a chronic conflict zone near the northeastern border of Armenia on two main outcomes: stunting and anemia. We further compared the interpretations and public health relevance of the obtained effect estimates. In 2016, the study measured hemoglobin and anthropometric measures and collected data from the children's caregivers. We used propensity score matching analyses, inverse probability weighting, and overlap weighting methods to examine the average treatment effects among treated population (ATT), and among population with overlapping weights(ATO). The ATT for stunting among children who participated in the intervention program estimated by propensity score matching analyses (PSM-ATT) was (1.95; 95%CI 1.15-3.28). Nevertheless, children who took part in the program had alower risk of anemia (0.28; 95%CI 0.19-0.42). The ATT, estimated by inverse probability weighting (IPTW-ATT), was slightly lower for stunting (1.82; 95%CI 1.16-2.86) while similar for anemia (0.33; 95%CI 0.23-0.46) compared to PSM-ATT. Compared to the IPTW-ATT and PSM-ATT the ATO was lower for stunting (1.75; 95%CI 1.14-2.68) and similar for anemia (0.31; 95%CI 0.22-0.43). Marginal models could be used in similar quasi-experimental settings to identify the causal effect of interventions in specific populations of interest. Nonetheless, these methods do not eliminate threats to internal validity. Thorough study design and accurate data collection are necessary to improve the efficiency of marginal models.

Implementation of a community-based nutrition program in the community feeding center: a case study from Bantul

Background: Malnutrition among children becomes one of public issues in the population. Community-based nutrition programs provide opportunities to improve current child nutrition and in later life. Objective: To explore the implementation of a community-based nutrition program in Sedayu Subdistrict, Bantul District. Methods: A qualitative study with a single study case was conducted between March and May 2017 in the community feeding center in Argorejo Village, Sedayu Subdistrict, Bantul District. Data were collected from a focus group discussion among mothers of children under-fives, in-depth interviews to community health workers and a nutritionist, and observation during the program activities. Analysis was done by developing coding and themes on the implementation of the program. Results: Several activities were identified in the community-based nutrition program such as anthropometric measurement, nutrition counselling and education, providing healthy snacks during the program, and weekly food supplementation distribution to targeted children. Facilitators of this program included active participation from community health workers, acceptance and supports from the community, and self-subsistent food supplementation. Meanwhile, the barriers of this program were budget allocation, limited numbers and time of health workers, and lacked tools and facilities. Conclusions: Community-based nutrition program in the community feeding center is community-driven program which is from and to the community. The sustainability of this program needs a strong commitment from the government, multisectoral stakeholders, and the community.

Advancing racial justice in patient care encounters—yes, we can!

Advancing racial justice in patient care encounters—yes, we can!

Perceived Impact of COVID-19 on the Dietary Behaviors and Food Security of People in Rural Bangladesh

ObjectivesThis study aims to examine how poor women perceived the impact of COVID-19 in their lives regarding daily routines, food acquisition and consumption, hygiene practices and access to health services in rural Bangladesh.MethodsQuestions about the perceived impact of COVID-19 were included as part of an evaluation survey of a community-based nutrition program, and assessed cross-sectionally in November-December 2020 among a total of 2960 poor or ultra-poor women.Results84–87% of respondents perceived COVID-19 has affected their daily routine in the activities related to diet, work/school, income, social activities and to lesser extent, 78.8% in entertainment activities and 67.9% in health activity. For the current food acquisition and consumption compared to pre-COVID-19 situation, 77.3% reportedless grocery shopping, 74.2% decreased activities of eating with someone else, 39.6% reduced consumption of fresh foods, and 23.4% decreased consumption of stable foods. Also, 92.3% of respondents experienced restriction to market access for food acquisition. In light of this, 74.4% of respondents found food assistance to be helpful coping with a negative impact of COVID-19, the highest among other assistances (below 10%). Only 25.7% of respondents reported wearing facial masks whenever out and 67.9% did not perceive any change of their health and hygiene practices after COVID-19. 58.7% of respondents responded that public health messages were helpful to cope with the current pandemic.ConclusionsWhile COVID-19 has hit every area of routine and lives, food-related activities and assistance were perceived to be affected the hardest compared to other daily activities in rural Bangladesh. People fear about infections through gathering, not wearing masks, and going out, however, disease prevention practices does not follow as much as they fear. This study suggest that the food security intervention deserves urgent attention as well as educational information dissemination on the prevention and protection measures of COVID-19.Funding SourcesWorld Vision Bangladesh, World Vision Korea, KOICA

A Qualitative Evaluation of A Community-Based Nutrition and Health Promotion Program

ABSTRACT Community-based nutrition and health promotion programs play an important role in improving neighborhood health. This article presents findings from an exploratory qualitative evaluation of Eat Healthy, Live Life, a community-based nutrition and health promotion program in East Harlem, a low-income neighborhood of color in New York City. Focus group findings showed that participants adopted new healthy behavior changes and Health Bucks coupons helped increased affordability of fresh produce. This program may be an effective model for impacting health behavior through promotion of good nutrition, physical activity, and utilization of farmers’ markets in low-income neighborhoods of color.

Salinity and Water-Related Disease Risk in Coastal Bangladesh.

An increase in surface and ground-water salinity due to climate change is reported to have become a great threat to the health of coastal inhabitants in Bangladesh. However, little is known about how much such salinity affects the risk of water-related diseases and how such risk can be mitigated in the field. This research examines the association between water-related diseases and coastal salinity along with sociodemographic and anthropometric factors. We conduct questionnaire surveys with 527 households: 273 subjects from the non-salinity and 254 subjects from the salinity rural coastal areas of Bangladesh. The logistic regression analysis demonstrates that the probability of suffering from water-borne, water-washed and water-related diseases are 8%, 14% and 11% higher in the salinity areas than in the non-salinity areas, respectively. However, it is also identified that people who consume rainwater as a drinking source even in the salinity areas have less chances and people who belong to "underweight body mass index" have more chances of being affected by water-related diseases. Overall, the results suggest that the long-term reservation of rainwater and addressing community-based food security & nutrition programs shall be effective countermeasures to reduce the risk of health problems in the coastal population and to sustain their lives even under the threat of land salinity.

Experience of speech pathology and nutritional monitoring of oral feeding in older people from a community-based approach

ABSTRACT Purpose: to describe the changes in the body composition and swallowing of an older-people group from a community-based speech therapy and nutrition program. Methods: a pre-experimental study of a single group was carried out, with prospective timing and pre-post evaluation for three months. The Body Mass Index (BMI), percentage of body fat (%BF), percentage of muscle mass (%MM), percentage of visceral fat (%VF), swallowing performance, and Swallowing Quality of Life (Swall-QoL) were evaluated. The Spearman correlation coefficient and the Mann-Whitney U test were used, significance level p&lt;0.05. Results: 13 older people participated in the study. The average age of the group was 73.8 years (SD= 4.6). The BMI (pre=28.17; post=28.38), %BF (pre=38.5; post=38.7), %MM (pre=24.8; post=24.9) and %VF (pre=14.3; post=14.8) did not present significant differences (p&gt;0.05). The scores obtained in the deglutition test was pre=19.15 and post=18.9. An association between BMI and VF (Rho=0.74; p=0.02) was detected. Conclusion: the program represented a community-based instance of health promotion focus on oral feeding of older people.

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from −1.77 to −1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

Low Economic Class Might Predispose Children under Five Years of Age to Stunting in Ethiopia: Updates of Systematic Review and Meta-Analysis.

Background Malnutrition is major public health problem worldwide, particularly in developing countries including Ethiopia. In 2016, out of 667 million children under five years of age, 159 million were stunted worldwide. The prevalence of stunting has been decreasing greatly from 58% in 2000 to 44% in 2011 and 38% in 2016 in Ethiopia. However, the prevalence of stunting is still high and considered as public health problem for the country. The aim of this systematic review and meta-analysis is to assess the prevalence of stunting and its associations with wealth index among children under five years of age in Ethiopia. Methodology. The databases searched were MEDLINE, Scopus, HINARI, and grey literature studies. The studies' qualities were assessed by two reviewers independently, and any controversy was handled by other reviewers using the Joanna Briggs Institute (JBI) critical appraisal checklist. The JBI checklist was used in assessing the risk of bias and method of measurement for both outcome and independent variables. Especially, the study design, study participants, definition of stunting, statistical methods used to identify the associations, results/data presentations, and odds ratios (ORs) with confidence intervals (CIs) were assessed. In the statistical analysis, the funnel plot, Egger's test, and Begg's test were used to assess publication bias. The I2 statistic, forest plot, and Cochran's Q-test were used to deal with heterogeneity. Results In this review, 35 studies were included to assess the pooled prevalence of stunting. Similarly, 16 studies were used to assess the estimated effect sizes of wealth index on stunting. In this meta-analysis, the pooled prevalence of stunting was 41.5% among children under five years of age, despite its considerable heterogeneity (I2 = 97.6%, p < 0.001, Q = 1461.93). However, no publication bias was detected (Egger's test p=0.26 and Begg's test p=0.87). Children from households with a medium or low/poor wealth index had higher odds of stunting (AOR: 1.33, 95% CI 1.07, 1.65 or AOR: 1.92, 95% CI 1.46, 2.54, respectively) compared to children from households with a high/rich wealth index. Both of the estimated effect sizes of low and medium wealth indexes had substantial heterogeneity (I2 = 63.8%, p < 0.001, Q = 44.21 and I2 = 78.3%, p < 0.001, Q = 73.73) respectively). In estimating the effect, there was no publication bias (small-studies effect) (Egger and Begg's test, p > 0.05). Conclusions The pooled prevalence of stunting was great. In the subgroup analysis, the Amhara region had the highest prevalence of stunting, followed by the Oromia and Tigray regions, respectively. Low economic status was associated with stunting in Ethiopia. This relationship was found to be statistically more accurate in Oromia and Amhara regions. The government should emphasize community-based nutrition programs by scaling up more in these regions, just like the Seqota Declaration.

Reinforcing Roles of Lady Health Workers in Sedayu Community Feeding Center: Six-Steps Program Planning and Evaluation

Child malnutrition remains a challenge in Indonesia public health nutrition field. The assistance of lady health workers child feeding centers becomes important to guard nutritional issues among children in the community. To reinforce roles of lady health workers in the community feeding center, we recruited lady health workers in two community feeding centers of Argodadi and Argorejo villages, Sedayu Subdistrict, Bantul District, in a capacity-building intervention. We were expecting that lady health workers with adequate knowledge and skills can contribute more effectively in the community-based nutrition program including nutritional status assessment and monitoring, nutrition counselling and promotion, general food supplementation, and referral system.

Food agency in low-income households: A qualitative study of the structural and individual factors impacting participants in a community-based nutrition program

Food agency in low-income households: A qualitative study of the structural and individual factors impacting participants in a community-based nutrition program

Utilization of an Economic Development Program in the Context of a Community-Based Nutrition Program in Rural Bangladesh - A Qualitative Study

Abstract Objectives To promote appropriate complementary feeding and improve child nutrition, an economic development (ED) program with income-generating asset transfer was added to the context of a Positive Deviant (PD)/Hearth program that took a behavior change communication approach in rural Bangladesh. Our study examined main elements influencing the program uptake and utilization in four thematic areas: motivation, facilitator, barrier, and performance, comparing the participants who received either PD program only or both PD/ED programs. Methods In-depth interviews (IDI) and focus group discussions (FGD) were conducted for four groups selected by purposive sampling: PD participants (n = 8 for FGD; n = 11 for IDI), husbands of PD participants (n = 9; n = 9), PD/ED participants (n = 8; n = 9), and husbands of PD/ED participants (n = 8; n = 9), in which none of the interviewees were in family relations. All interviews were audio-recorded, transcribed verbatim in Bangla, and re-translated into English. The data was analyzed using a Grounded Theory based approach. Results Both PD and PD/ED groups said child's health benefit being a main motivation of program participation. The PD/ED group was also motivated by the expectation for the financial benefit from the ED program. The main facilitators to continue the program lessons were physical and/or emotional support from her family in both groups, while the PD/ED group also said the assets from the ED program helped feeding their child nutritional foods. The main barriers perceived in the PD group were housework duty, while the PD/ED group mentioned environmental challenges (i.e., flooding) threatening their asset management. Key performance of both groups was an improvement in caregivers’ health knowledge and child nutrition. In the PD/ED group, the distinctive performance was the utilization of assets to practice PD recommendations and the self-esteem of the participants and their family members. Conclusions This study found discrepancies between PD and PD/ED groups in the facilitators, barriers, and performance for program participation and maintenance of the recommended practices. Reviewing these factors will help to understand the paths of program impact. Funding Sources World Vision Bangladesh, World Vision Korea &amp; Korea International Cooperation Agency.