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Integrating nutrition into health systems: What the evidence advocates.

ABSTRACT: There is considerable evidence of positive health and nutrition outcomes resulting from integrating nutrition-specific interventions into health systems; however, current knowledge on establishing and sustaining effective integration of nutrition into health systems is limited. The objective of this review is to map the existing types of integration platforms and review the evidence on integrated health and nutrition programmes' impacts on specific nutrition outcomes. A literature search was conducted, and integrated nutrition programmes were examined through the lens of the six World Health Organization (WHO) building blocks, including the demand side. Forty-five studies were included in this review, outlining the integration of nutrition-specific interventions with various programmes, including integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non-nutrition outcomes with no adverse effects on primary programme delivery. Through the lens of the six WHO building blocks, service delivery and health workforce were found to be well-integrated, but governance, information systems, finance and supplies and technology were less well-integrated. Integrating nutrition-specific interventions into health systems may ensure efficient service delivery while having an impact on nutrition outcomes. There is no single successful model of integration; it varies according to the context and demands of the particular setting in which integration occurs. There is a need for more well-planned programmes considering all the health systems building blocks to ensure compliance and sustainability.

SUBMITTER: Salam RA

PROVIDER: S-EPMC6594109 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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Integrating nutrition into health systems: What the evidence advocates.

Salam Rehana A RA Das Jai K JK Bhutta Zulfiqar A ZA

Maternal & child nutrition 20190101

There is considerable evidence of positive health and nutrition outcomes resulting from integrating nutrition-specific interventions into health systems; however, current knowledge on establishing and sustaining effective integration of nutrition into health systems is limited. The objective of this review is to map the existing types of integration platforms and review the evidence on integrated health and nutrition programmes' impacts on specific nutrition outcomes. A literature search was con ...[more]

PMID: 30748112

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Project description:BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Project description:BACKGROUND:In 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. METHODS:Service 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. RESULTS:Structural 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. CONCLUSIONS:Strengthening 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.

Project description:BackgroundObjective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes.MethodsSystematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria.ResultsOf 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models.ConclusionsTargeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.

Project description:In 2018, the Government of Madhya Pradesh initiated the feasibility testing of integrating an algorithmic approach (assess, give, counsel, treat) to strengthen antenatal nutrition services in routine government-funded programmes coupled with a health system thinking approach to strengthen the health service delivery platform. Implementation phases included (1) an evidence review and stakeholder consultations (April 2018) and (2) a health systems strengthening preparedness phase (May-December 2018), including pilot testing in Vidisha district (January-December 2019) covering ∼54 100 pregnant women with 237 antenatal contact points through 241 government auxiliary nurse midwives/staff nurses. During 2020-21, feasibility testing was expanded to an additional 7 districts. We used programme registers of the Auxiliary Nurse Midwives Registers (2019-21) and National Family Health Survey data for 2016 and 2021 to show changes in the Vidisha district and 7 expansion districts. We compare the performance of Vidisha district with Ashok Nagar district, where no such intervention occurred. Comparing 2016 and 2021 data, the Vidisha district showed improvements in receipt of antenatal care in the first trimester (29 to 85%) and in four antenatal visits (17 to 54%). Using the difference-in-difference approach, a 42% net increase in first-trimester antenatal check-ups in Vidisha as compared to Ashok Nagar is observed. There was also an improvement in the maternal nutrition budget of the state from USD 8.5 million to USD 17.8 million during this period. The Vidisha initiative offers several lessons in time-effective workflow to deliver all constituents of nutrition services at various antenatal contact points through and via routine government health systems. Continued execution of the algorithm for screening, with longitudinal data on the management of all nutrition risks, will be critical to show its long-term impact on maternal morbidities and birth outcomes.

Project description:BackgroundUnhealthy dietary patterns have in recent decades contributed to an endemic-level burden from non-communicable disease (NCDs) in high-income countries. In low- and middle-income countries rapid changes in diets are also increasingly linked to malnutrition in all its forms as persistent undernutrition and micronutrient deficiencies continue to coexist with a rising prevalence of obesity and associated NCDs. Economic globalization and trade liberalization have been identified as potentially important factors driving these trends, but the mechanisms, pathways and actual impact are subject to continued debate.MethodsWe use a 'rigorous review' to synthesize evidence from empirical quantitative studies analysing the links between economic globalization processes and nutritional outcomes, with a focus on impact as well as improving the understanding of the main underlying mechanisms and their interactions.FindingsWhile the literature remains mixed regarding the impacts of overall globalization, trade liberalization or economic globalization on nutritional outcomes, it is possible to identify different patterns of association and impact across specific sub-components of globalization processes. Although results depend on the context and methods of analysis, foreign direct investment (FDI) appears to be more clearly associated with increases in overnutrition and NCD prevalence than to changes in undernutrition. Existing evidence does not clearly show associations between trade liberalization and NCD prevalence, but there is some evidence of a broad association with improved dietary quality and reductions in undernutrition. Socio-cultural aspects of globalization appear to play an important yet under-studied role, with potential associations with increased prevalence of overweight and obesity. The limited evidence available also suggests that the association between trade liberalization or globalization and nutritional outcomes might differ substantially across population sub-groups. Overall, our findings suggest that policymakers do not necessarily face a trade-off when considering the implications of trade or economic liberalization for malnutrition in all its forms. On the contrary, a combination of nutrition-sensitive trade policy and adequate regulation of FDI could help reduce all forms of malnutrition. In the context of trade negotiations and agreements it is fundamental, therefore, to protect the policy space for governments to adopt nutrition-sensitive interventions.

Project description:BackgroundSophisticated recommendation systems are used more and more in the health sector to assist consumers in healthy decision making. In this study we investigate consumers' evaluation of hypothetical health recommendation systems that provide personalized nutrition advice. We examine consumers' intention to use such a health recommendation system as a function of options related to the underlying system (e.g. the type of company that generates the advice) as well as intermediaries (e.g. general practitioner) that might assist in using the system. We further explore if the effect of both the system and intermediaries on intention to use a health recommendation system are mediated by consumers' perceived effort, privacy risk, usefulness and enjoyment.Methods204 respondents from a consumer panel in the Netherlands participated. The data were collected by means of a questionnaire. Each respondent evaluated three hypothetical health recommendation systems on validated multi-scale measures of effort, privacy risk, usefulness, enjoyment and intention to use the system. To test the hypothesized relationships we used regression analyses.ResultsWe find evidence that the options related to the underlying system as well as the intermediaries involved influence consumers' intention to use such a health recommendation system and that these effects are mediated by perceptions of effort, privacy risk, usefulness and enjoyment. Also, we find that consumers value usefulness of a system more and enjoyment less when a general practitioner advices them to use a health recommendation system than if they use it out of their own curiosity.ConclusionsWe developed and tested a model of consumers' intention to use a health recommendation system. We found that intermediaries play an important role in how consumers evaluate such a system over and above options of the underlying system that is used to generate the recommendation. Also, health-related information services seem to rely on endorsement by the medical sector. This has considerable implications for the distribution as well as the communication channels of health recommendation systems which may be quite difficult to put into practice outside traditional health service channels.

Project description:BackgroundThe effects of food insecurity linked to climate change will be exacerbated in subsistence communities that are dependent upon food systems for their livelihoods and sustenance. Place-and community-based forms of surveillance are important for growing an equitable evidence base that integrates climate, food, and health information as well as informs our understanding of how climate change impacts health through local and Indigenous subsistence food systems.MethodsWe present a case-study from southwestern Uganda with Batwa and Bakiga subsistence communities in Kanungu District. We conducted 22 key informant interviews to map what forms of monitoring and knowledge exist about health and subsistence food systems as they relate to seasonal variability. A participatory mapping exercise accompanied key informant interviews to identify who holds knowledge about health and subsistence food systems. Social network theory and analysis methods were used to explore how information flows between knowledge holders as well as the power and agency that is involved in knowledge production and exchange processes.ResultsThis research maps existing networks of trusted relationships that are already used for integrating diverse knowledges, information, and administrative action. Narratives reveal inventories of ongoing and repeated cycles of observations, interpretations, evaluations, and adjustments that make up existing health and subsistence food monitoring and response. These networks of local health and subsistence food systems were not supported by distinct systems of climate and meteorological information. Our findings demonstrate how integrating surveillance systems is not just about what types of information we monitor, but also who and how knowledges are connected through existing networks of monitoring and response.ConclusionApplying conventional approaches to surveillance, without deliberate consideration of the broader contextual and relational processes, can lead to the re-marginalization of peoples and the reproduction of inequalities in power between groups of people. We anticipate that our findings can be used to inform the initiation of a place-based integrated climate-food-health surveillance system in Kanungu District as well as other contexts with a rich diversity of knowledges and existing forms of monitoring and response.

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Integrating nutrition into health systems: What the evidence advocates.

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Integrating nutrition into health systems: What the evidence advocates.

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