Delivery Of Nutrition Services Research Articles

Assessment of Effect of COVID 19 Pandemic on the Utilization of Maternal Newborn Child Health and Nutrition Services in Somali Region of Ethiopia

Background: Somali Region of Ethiopia recorded the first confirmed case of SARS-CoV-2 (COVID 19) pandemic on 26th April 2020. The study aimed to assess the effect of the pandemic on the utilization of maternal new-born and child health services. Subjects and Method: This was a retrospective chart review of monthly DHIS database of health facilities in Farfan zone of Somali Region and test of association using t test was used to compare the mean reduction in utilization of maternal and child health services three months before (January – March 2020) and three months during the pandemic (April 2020 to June 2020) at p value set at significant level of 5%. The outcome measure was the utilization of maternal and child health services. Results: The mean reductions in OPD per capita for children under five, children who received first dose of pentavalent vaccines and pregnant women who received first ANC before and during the pandemic was 14.26%, t=1.07; 95% CI= 283.17 to 725.17; p= 0.325); 12.51%, t=0.74; 95% CI= 1439.33 to 2697.31; p= 0.489) and 14.43%, t=0.49; 95% CI= 2363.33 to 3543.41; p= 0.642) respectively, while the mean reduction in skilled birth deliveries conducted at the health facilities was 21.4%, t= 0.97; 95% CI= 319.26 to 736.16 ; p= 0.371). Conclusion: The study provided early effects of COVID 19 on health and health services and the need for policy development on health system strengthening and resilience to withstand future outbreaks. This study indicated that indirect health service effects are substantial and highlights the importance of maintaining routine essential health and nutrition service delivery and the need to explore innovative ways of delivering both preventive and curative essential service. Keywords: COVID 19, pandemic, maternal newborn and child health, utilization, essential services Correspondence: Olusola Oladeji. UNICEF Somali Field Office, Ethiopia. Email: ooladeji@unicef.org. Journal of Epidemiology and Public Health (2020), 05(04): 458-469 https://doi.org/10.26911/jepublichealth.2020.05.04.08

Assessing the nutritional needs of men with prostate cancer

BackgroundNutrition is important for prostate cancer (PC) survivorship care to help achieve a healthy weight, reduce treatment side effects and reduce the risk of developing other chronic diseases. We aimed to advance the understanding of the nutritional needs of men with PC and services that could be potentially implemented to address them.MethodsWe conducted a needs assessment of nutrition services for men with PC drawing on four perspectives; 1) patient evaluation of a nutrition education session in British Columbia (BC), 2) survey of BC health professionals, 3) an environmental scan of existing nutrition services across Canada and 4) a scoping literature review.ResultsPatients expressed a need for more nutrition information and a desire for additional nutrition services. More than 60% of health professionals believed there is a need for more nutrition services for men with PC, and reported the focus should be on weight management or management of PC progression. The environmental scan revealed few existing services for men with PC across Canada, most were inclusive of multiple cancers and not tailored for men with PC. Eighteen completed studies were identified in the scoping literature review. The majority provided combined diet and exercise programs with various formats of delivery such as individual, group and home-based. Overall, 78% of studies reported improvements in one or more of the following measures: dietary intake/ diet quality, body composition, self-efficacy, quality of life, fatigue, practicing health behavior goals and physical function/ exercise. Four studies assessed feasibility, adherence or satisfaction with all reporting positive findings.ConclusionDespite the high prevalence of PC in Canada, and the perceived need for more support by patients and health professionals, there are limited nutrition services for men with PC. Evidence from the literature suggests nutrition services are effective and well-accepted by men with PC. Our findings define a need for standardized nutrition services for men with PC that assess and meet long term nutritional needs. Our findings also provide insight into the type and delivery of nutrition services that may help close the gap in care for men with PC.

Supportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda

IntroductionSuboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision...

Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation

IntroductionMillions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme...

Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis

BackgroundArua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting.MethodsSix facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers.ResultsAll facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality.ConclusionThis study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.

How can mobile phones be used to improve nutrition service delivery in rural Bangladesh?

BackgroundNutrition has been integrated within the health services in Bangladesh as it is an important issue for health and development. High penetration of mobile phones in the community and favourable policy and political commitment of the Government of Bangladesh has created possibilities of using Information Communication Technology such as mobile phones for nutrition programs. In this paper the implementation of nutrition services with a specific focus on infant and young child feeding was explored and the potential for using mobile phones to improve the quality and coverage of nutrition services was assessed.MethodsA qualitative study was conducted in Mirzapur and Chakaria sub-districts, Bangladesh from February–April 2014. We conducted 24 in-depth interviews (mothers of young children), 8 focus group discussions (fathers and grandmothers); and 13 key informant interviews (community health workers or CHWs). We also observed 4 facilities and followed 2 CHWs during their work day. The data was analyzed manually using pre-existing themes.ResultsIn this community, mothers demonstrated gaps in knowledge about IYCF. They depended on their social network and media for IYCF information. Although CHWs were trusted in the community, mothers and their family members did not consider them a good source of nutrition information as they did not talk about nutrition. In terms of ICTs, mobile phones were the most available and used by both CHWs and mothers. CHWs showed willingness to incorporate nutrition counselling through mobile phone as this can enhance their productivity, reduce travel time and improve service quality. Mothers were willing to receive voice calls from CHWs as long as the decision makers in the households were informed.ConclusionsOur study indicated that there are gaps in IYCF related service delivery and there is a potential for using mobile phones to both strengthen the quality of service delivery as well as reaching out to the mothers in the community. It is important however, to consider the community readiness to accept the technology during the design and delivery of the intervention.

Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered

The Academy of Nutrition and Dietetics (Academy) is the world’s largest organization of food and nutrition professionals and the association that represents credentialed nutrition and dietetics practitioners—nutrition and dietetics technicians, registered (NDTRs) and registered dietitian nutritionists (RDNs). An NDTR’s scope of practice in nutrition and dietetics has flexible boundaries to capture the depth and breadth of the individual's practice. The NDTR’s practice expands with advances in many areas, including nutrition, food production, food safety, food systems management, health care, public health, community health, and information and communication technology. The Revised 2017 Scope of Practice for the NDTR reflects the position of the Academy on the essential role of the NDTR in the management and delivery of food and nutrition services. The scope of practice for the NDTR is composed of education and credentialing, practice resources, Academy Standards of Practice and Standards of Professional Performance, codes of ethics, accreditation standards, state and federal regulations, national guidelines, and organizational policy and procedures. The Revised 2017 Scope of Practice for the NDTR is used in conjunction with the Revised 2017 Standards of Practice in Nutrition Care and the Standards of Professional Performance for NDTRs. The Standards of Practice address activities related to direct patient and client care. The Standards of Professional Performance address behaviors related to the technical role of NDTRs. These standards reflect the minimum competent level of nutrition and dietetics practice and professional performance for NDTRs. A companion document addresses the scope of practice for the RDN.

Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist

The Academy of Nutrition and Dietetics (Academy) is the world’s largest organization of food and nutrition professionals and the association that represents credentialed nutrition and dietetics practitioners—registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered (NDTRs). RDNs integrate research, professional development, and practice to stimulate innovation and discovery; collaborate to solve the greatest food and nutrition challenges now and in the future; focus on systemswide impact across the food, wellness, and health sectors; have a global impact in eliminating all forms of malnutrition; and amplify the contribution of nutrition and dietetics practitioners and expand workforce capacity and capability. The Revised 2017 Scope of Practice for the RDN reflects the position of the Academy on the essential role of the RDN in the direction and delivery of food and nutrition services. The scope of practice for the RDN is composed of education and credentialing, practice resources, Academy Standards of Practice and Professional Performance, codes of ethics, accreditation standards, state and federal regulations, national guidelines, and organizational policy and procedures. The Revised 2017 Scope of Practice for the RDN is used in conjunction with the Revised 2017 Standards of Practice (SOP) in Nutrition Care and the Standards of Professional Performance (SOPP) for RDNs. The SOP address activities related to direct patient and client care. The SOPP address behaviors related to the professional role of RDNs. These standards reflect the minimum competent level of nutrition and dietetics practice and professional performance for RDNs. A companion document addresses the scope of practice for the NDTR.

Partnering with women collectives for delivering essential women\u2019s nutrition interventions in tribal areas of eastern India: a scoping study

BackgroundWe examined the feasibility of engaging women collectives in delivering a package of women’s nutrition messages/services as a funded stakeholder in three tribal-dominated districts of Odisha, Jharkhand and Chhattisgarh States, in eastern India. These districts have high prevalence of child stunting and poor government service outreach.MethodsConducted between July 2014 and March 2015, an exploratory mix-methods design was adopted (review of coverage data and government reports, field interviews and focus group discussion with multiple stakeholders and intended communities) to assess coverage of women’s nutrition services. A capacity assessment tool was developed to map all types of community collectives and assess their awareness, institutional and programme capacity as a funded stakeholder for delivering women’s nutrition services/behaviour promotion.ResultsLimited targeting of pre-pregnancy period, delays in first trimester registration of pregnant women, and low micronutrient supplementation supply and awareness issues emerged as key bottlenecks in improving women’s nutrition in these districts. Amongst the 18 different types of community collectives mapped, Self Help Groups (SHGs) and their federations (tier 2 and tier 3), with total membership of over 650,000, emerged as the most promising community collective due to their vast network, governance structure, bank linkage, and regular interface. Nearly 400,000 (or 20% of women) in these districts can be reached through the mapped 31,919 SHGs. SHGs with organisational readiness for receiving and managing grants for income generation and community development activities varied from 41 to 94% across study districts. Stakeholders perceived that SHGs federations managing grants from government and be engaged for nutrition promotion and service delivery and SHG weekly meetings can serve as community interface for discussing/resolving local issues impeding access to services.ConclusionsWomen SHGs (with tier 2 and tier 3) can become direct grantees for strengthening coverage of women’s nutrition interventions in these tribal districts/pockets, provided they are capacitated, supervised and given safe guards against exploitation and violence.

Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh.

BackgroundIn 2011, the Bangladesh Government introduced the National Nutrition Services (NNS) by leveraging the existing health infrastructure to deliver nutrition services to pregnant woman and children. This study examined the quality of nutrition services provided during antenatal care (ANC) and management of sick children younger than five years.MethodsService delivery quality was assessed across three dimensions; structural readiness, process and outcome. Structural readiness was assessed by observing the presence of equipment, guidelines and register/reporting forms in ANC rooms and consulting areas for sick children at 37 primary healthcare facilities in 12 sub-districts. In addition, the training and knowledge relevant to nutrition service delivery of 95 healthcare providers was determined. The process of nutrition service delivery was assessed by observing 381 ANC visits and 826 sick children consultations. Satisfaction with the service was the outcome and was determined by interviewing 541 mothers/caregivers of sick children.ResultsStructural readiness to provide nutrition services was higher for ANC compared to management of sick children; 73% of ANC rooms had >5 of the 13 essential items while only 13% of the designated areas for management of sick children had >5 of the 13 essential items. One in five (19%) healthcare providers had received nutrition training through the NNS. Delivery of the nutrition services was poor: <30% of women received all four key antenatal nutrition services, 25% of sick children had their weight checked against a growth-chart and <1% had their height measured. Nevertheless, most mothers/caregivers rated their satisfaction of the service above average.ConclusionsStrengthening the provision of equipment and increasing the coverage of training are imperative to improve nutrition services. Inherent barriers to implementing nutrition services in primary health care, especially high caseloads during the management of sick under-five children, should be considered to identify alternative and appropriate service delivery platforms before nationwide scale up.

Outcomes and Cost-Effectiveness of Integrating HIV and Nutrition Service Delivery: Pilots in Malawi and Mozambique.

This paper provides the first estimates of impact and cost-effectiveness for integrated HIV and nutrition service delivery in sub-Saharan Africa. HIV and undernutrition are synergistic co-epidemics impacting millions of children throughout the region. To alleviate this co-epidemic, UNICEF supported small-scale pilot programs in Malawi and Mozambique that integrated HIV and nutrition service delivery. We use trends from integration sites and comparison sites to estimate the number of lives saved, infections averted and/or undernutrition cases cured due to programmatic activities, and to estimate cost-effectiveness. Results suggest that Malawi's program had a cost-effectiveness of $11-29/DALY, while Mozambique's was $16-59/DALY. Some components were more effective than others ($1-4/DALY for Malawi's Male motivators vs. $179/DALY for Mozambique's One stop shops). These results suggest that integrating HIV and nutrition programming leads to a positive impact on health outcomes and should motivate additional work to evaluate impact and determine cost-effectiveness using an appropriate research design.

Potentials, Experiences and Outcomes of a Comprehensive Community Based Programme to Address Malnutrition in Tribal India

This paper demonstrates the effect of an innovative community-based management programme on acute malnutrition among children under three years of age, through an observational longitudinal cohort study in tribal blocks in central-eastern India. The key components of the programme include child care through crèches, community mobilisation and systems strengthening to ensure better child feeding and caring practices and delivery of public health and nutrition services. For a cohort of 587 children, the increase in children in the non-wasting category is from 72% to 80% (p&lt;0.001) and the reduction in Severe Acute Malnutrition (SAM) from 8% to 4% (p&lt;0.005), a reduction of 46.6%. Normalcy is fairly well maintained at 89%. Among the severely wasted, 16% show no improvement, 49% moved into a moderate wasting category and 36% to normalcy over 4-6 months. Among the moderately wasted, 26% showed no improvement and 7% declined to a severely wasted category, and 67% moved to normalcy. The average Weight for Height Z-score (WHZ) for the cohort improved from -1.41 in the initial period to -1.13 in November (p&lt;0.0001). This study suggests that this medium term strategy using a rights-based participatory approach for community based management of malnutrition may be comparatively effective by current WHO guidelines and other known community based interventions in terms of mortality, cost, degree and pace of improvements.

Predictors of Essential Health and Nutrition Service Delivery in Bihar, India: Results From Household and Frontline Worker Surveys.

In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs--the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)--through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Little is known, however, about factors that predict effective service delivery by these frontline workers (FLWs) or receipt of services by households. This study examined the predictors of use of 4 services: (1) immunization information and services, (2) food supplements, (3) pregnancy care information, and (4) general nutrition information. Data are from a 2012 cross-sectional survey of 6,002 households in 400 randomly selected villages in 1 district of Bihar state, as well as an integrated survey of 377 AWWs and 382 ASHAs from the same villages. For each of the 4 service delivery outcomes, logistic regression models were specified using a combination of variables hypothesized to be supply- and demand-side drivers of service utilization. About 35% of households reported receiving any of the 4 services. Monetary immunization incentives for AWWs (OR = 1.55, CI = 1.02-2.36) and above-median household head education (OR = 1.39, CI = 1.05-1.82) were statistically significant predictors of household receipt of immunization services. Higher household socioeconomic status was associated with significantly lower odds of receiving food supplements (OR = 0.87, CI = 0.79-0.96). ASHAs receiving incentives for institutional delivery (OR = 1.52, CI = 0.99-2.33) was marginally associated with higher odds of receiving pregnancy care information, and ASHAs who maintained records of pregnant women was significantly associated with households receiving such information (OR = 2.25, CI = 1.07-4.74). AWWs receiving immunization incentives was associated with significantly higher odds of households receiving general nutrition information (OR = 1.92, CI = 1.08-3.41), suggesting a large spillover effect of incentives from product- to information-oriented services. Product-oriented incentives affect delivery of both product- and information-oriented services, although household factors are also important. In India, existing government programs can mitigate supply- and demand-side constraints to receiving essential interventions by optimizing existing incentives for FLWs in national programs, helping FLWs better organize their work, and raising awareness among groups who are less likely to access services.

Evaluative Ethnography is useful for Understanding the Impact Pathways of Performance‐Based Incentives on Health Worker Motivation

Performance‐based incentives (PBIs) have shown potential to improve the delivery of health and nutrition services to vulnerable populations. Strikingly, assessments of PBIs rarely incorporate qualitative approaches, making it difficult for policymakers to fully evaluate their utility. We employed evaluative ethnography to assess the impact of a longitudinal‐control PBI intervention to improve prevention of vertical transmission of HIV service delivery in rural Mozambique.Evaluative ethnography is a structured and theory‐grounded approach to qualitative research. The motivation, opportunity, and ability framework and focused ethnographic methods characterized our evaluative ethnographic approach.image Table 1. Utilization of focused ethnography and quantitative methods to assess impact of the performance‐based incentive intervention on delivery of prevention of vertical transmission of HIV (PVT) services Method Participants Intervention Phase n Evaluative Ethnography Methodology Semi‐structured interviews Women accessing PVT services, their family members, community leaders, facility‐ and community‐based health workers Formative 67 Group discussions Facility‐ and community‐based health workers, district leaders Formative, on‐going implementation 100 Participant observation Facility‐ and community‐based health workers On‐going implementation 140 Semi‐structured interviews Facility‐ and community‐based health workers, district leaders Final evaluation 15 Quantitative Assessment Methodology Surveys of health worker motivation Facility‐ and community‐based health workers Formative, on going implementation, final evaluation 147 Participant observation and exit interviews revealed the major barriers to the intervention (e.g. obstructionist officials, resource constraints). This was critical to understanding the quantitative finding that the PBIs did not significantly affect health worker motivation or delivery of services within the 12‐month implementation period.Although PBIs did not impact service delivery, evaluative ethnography allowed us to identify the principal problem areas. Considering the challenging nature of nutrition and health interventions in low‐resource health systems, we demonstrate that evaluative ethnography can augment conventional quantitative assessments.

The perceived impact of the National Health Service on personalised nutrition service delivery among the UK public.

Personalised nutrition (PN) has the potential to reduce disease risk and optimise health and performance. Although previous research has shown good acceptance of the concept of PN in the UK, preferences regarding the delivery of a PN service (e.g. online v. face-to-face) are not fully understood. It is anticipated that the presence of a free at point of delivery healthcare system, the National Health Service (NHS), in the UK may have an impact on end-user preferences for deliverances. To determine this, supplementary analysis of qualitative data obtained from focus group discussions on PN service delivery, collected as part of the Food4Me project in the UK and Ireland, was undertaken. Irish data provided comparative analysis of a healthcare system that is not provided free of charge at the point of delivery to the entire population. Analyses were conducted using the 'framework approach' described by Rabiee (Focus-group interview and data analysis. Proc Nutr Soc 63, 655-660). There was a preference for services to be led by the government and delivered face-to-face, which was perceived to increase trust and transparency, and add value. Both countries associated paying for nutritional advice with increased commitment and motivation to follow guidelines. Contrary to Ireland, however, and despite the perceived benefit of paying, UK discussants still expected PN services to be delivered free of charge by the NHS. Consideration of this unique challenge of free healthcare that is embedded in the NHS culture will be crucial when introducing PN to the UK.

Current Coding Practices and Patterns of Code Use of Registered Dietitian Nutritionists: The Academy of Nutrition and Dietetics 2013 Coding Survey

Coding, coverage, and reimbursement for nutrition services are vital to the dietetics profession, particularly to registered dietitian nutritionists (RDNs) who provide clinical care. The objective of this study was to assess RDN understanding and use of the medical nutrition therapy (MNT) procedure codes in the delivery of nutrition services. Its design was an Internet survey of all RDNs listed in the Academy of Nutrition and Dietetics (Academy)/Commission on Dietetics Registration database as of September 2013 who resided in the United States and were not retired. Prior coding and coverage surveys provided a basis for survey development. Parameters assessed included knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use, payer reimbursement patterns, complexity of the patient population served, time spent in the delivery of initial and subsequent care, and practice demographics and management. Results show that a majority of respondents were employed by another and provided outpatient MNT services on a part-time basis. MNT codes were used for the provision of individual services, with minimal use of the MNT codes for group services and subsequent care. The typical patient carries two or more diagnoses. The majority of RDNs uses internal billing departments and support staff in their practices. The payer mix is predominantly Medicare and private/commercial insurance. Managers and manager/providers were more likely than providers to carry malpractice insurance. Results point to the need for further education regarding the full spectrum of Current Procedural Terminology codes available for RDN use and the business side of ambulatory MNT practice, including the need to carry malpractice insurance. This survey is part of continuing Academy efforts to understand the complex web of relationships among clinical practice, coverage, MNT code use, and reimbursement so as to further support nutrition services codes revision and/or expansion.

Implementing nutrition interventions in Ghana at district level: Gaps and opportunities

Malnutrition among women and children is an underlying cause of high morbidity and mortality in the developing world. Ghana is one of 36 countries with a high prevalence (&gt; 20%) of chronic stunting in childhood. Although proven and inexpensive technologies and interventions exist to address maternal and child malnutrition, their implementation remains at a low scale in many developing countries, including Ghana. In Ghana, barriers to scaling up nutrition actions have been identified at the national level, yet little is known about the situation at the district and sub-district levels where nutrition interventions are directly delivered. The current study assessed district-level capacity and commitment for accelerating implementation of effective nutrition interventions to address the high burden of maternal and child malnutrition. In June 2010, key informant interviews involving technical officers, clinicians, nurses, and administrative staff, and a desk review of program and administrative reports were conducted in the Omanye District (pseudonym). Using the framework from the WHO landscape analysis of readiness to scale up nutrition actions, interviews explored questions of commitment (financial, planning, collaborations) and capacity (human resources, job aids, skills) to implement nutrition actions in the district. Most key nutrition interventions were being implemented in the Omanye District including growth promotion, micronutrient supplementation, behavior change communication on infant and young child feeding, and a pilot project for community management of severe acute malnutrition. Interventions are challenged, however, by barriers including inadequate financial commitment, low prioritization of nutrition, inadequate personnel, and insufficient job aids. Because nutrition was relatively underfunded in the district, nutrition technical officers had been shifted to perform other or additional tasks. Insufficient investment and inadequate capacity prevents delivery of quality nutrition services in the Omanye District. Interventions that prioritize and improve investment in nutrition actions are needed to optimize nutrition services at the district level in Ghana.

Evolution of the Child Health Day Strategy for the Integrated Delivery of Child Health and Nutrition Services

In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-to-reach and older children who are often missed by routine, fixed-site health services. To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010from global monitoring databases for vitamin A and immunization. Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more_services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.

Policies and Program Implementation Experience to Improve Maternal Nutrition in Ethiopia

Maternal undernutrition persists as a serious problem in Ethiopia. Although there are maternal nutrition interventions that are efficacious and effective in improving maternal, neonatal, and child health (MNCH) outcomes, implementation has been limited. This study explored needs, perceptions, priorities,facilitatingfactors and barriers to implementation of relevant policies and programs to find opportunities to improve maternal nutrition in Ethiopia Background information was compiled and synthesized for a situation analysis. This informed focus group discussions and in-depth interviews with mothers, community leaders, health workers, and district health officials in four woredas (districts) in Tigray and Southern Nations, Nationalities and Peoples Region. Findings focused on three priority issues: maternal anemia, intrauterine growth retardation (IUGR), and maternal thinness and stunting. Community-level investigations found that women's low status, food insecurity and poverty, and workload were key factors perceived to contribute to women's undernutrition. Awareness of and demand for services to improve women's nutrition were low, except for high demand for supplementary food. On the supply side, barriers included low prioritization of maternal nutrition in health and nutrition service delivery and weak technical capacity to deliver context-sensitive maternal nutrition interventions at all levels. Community-based health and nutrition services were promising platforms for expanding access to interventions such as micronutrient supplements and social and behavior change communication. Investments are needed to support these community-based programs, including training, supplies, supervision and monitoring. To address IUGR at scale, increased access to cash or food transfers could be explored.

Economic analysis model for inpatient parenteral nutrition: A pilot study

AbstractAim: Parenteral nutrition is a high‐cost but essential support service in contemporary health care, yet no model exists to determine the total cost. This study aimed to create a cost analysis model identifying both direct and indirect costs of parenteral nutrition inpatient care.Methods: A health economics analysis model was constructed and used to create an audit tool for measuring parenteral nutrition costs in seven predefined categories. This tool was piloted on a cohort of 21 consecutive patients commencing parenteral nutrition at a large city hospital between March and April 2008. These patients were prospectively audited for a maximum 12 days or until parenteral nutrition cessation (192 patient days). Costs and adherence to evidence‐based guidelines were compared across the seven categories and between patient subgroups determined by ward locality upon commencement.Results: The mean total cost for all parenteral nutrition patients was $1579(NZD)/day, of which non‐parenteral hospital costs comprised 85%. For patients treated solely outside the intensive care unit, cost was $1045 per day, of which 24% was directly attributed to provision of parenteral nutrition. Formula accounted for nearly two‐thirds (63%) of parenteral nutrition direct costs and 8.5% of that prescribed was wasted. Return to oral or enteral nutrition was achieved in 57% patients within 12 days of commencing parenteral nutrition.Conclusions: Direct costs involved in providing parenteral nutrition appear to be less than previously reported, and represent a relatively small proportion of the total cost of care. This cost category analysis may have application in measuring and comparing parenteral nutrition service delivery in other institutions.