Despite governmental efforts to close the gender gap and global calls including Sustainable Devel... more Despite governmental efforts to close the gender gap and global calls including Sustainable Development Goal 5 to promote gender equality, the sobering reality is that gender inequities continue to persist in Canadian global health institutions. Moreover, from health to the economy, security to social protection, COVID-19 has exposed and heightened pre-existing inequities, with women, especially marginalized women, being disproportionately impacted. Women, particularly women who face bias along multiple identity dimensions, continue to be at risk of being excluded or delegitimized as participants in the global health workforce and continue to face barriers in career advancement to leadership, management and governance positions in Canada. These inequities have downstream effects on the policies and programmes, including global health efforts intended to support equitable partnerships with colleagues in low- and middle- income countries. We review current institutional gender inequit...
This End-line review report highlights progress attained, lessons and challenges experienced duri... more This End-line review report highlights progress attained, lessons and challenges experienced during the implementation of the Investment Case (IC) for the Sharpened Plan and makes recommendations for the development of the next Sharpened Plan and Investment Case (IC). The focus of the report is on the progress in the implementation of the five strategic shifts and resource commitments, assessing performance against targets for the implementation period 2015/16-2019/20. The review was undertaken by the Maternal Newborn and
Background: The complementary feeding (CF) period accompanies a critical window of vulnerability.... more Background: The complementary feeding (CF) period accompanies a critical window of vulnerability. During this time, failure to consume adequate energy, protein, vitamins and minerals is a significant concern and can lead to poor growth outcomes, increased susceptibility to infections, allergies, and diseases, and lower developmental potential. It is therefore of utmost importance to determine the most optimal time to start CF. The objective of this review is to assess the impact of early and late of introduction of CF on infant health, nutrition and developmental outcomes.Methods: We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We will search MEDLINE, Embase, CINAHL, CENTRAL, Web of Science, and other databases and key organizational websites using terms related to complementary feeding and infants. We will also search clinicaltrials.gov for ongoing trials. We will include experimental (randomized trials (individually or clu...
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustain... more As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
Background: Uganda has achieved a considerable reduction in childhood stunting over the past 2 de... more Background: Uganda has achieved a considerable reduction in childhood stunting over the past 2 decades, although accelerated action will be needed to achieve 2030 targets. Objectives: This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda. Methods: This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-indifference multivariable hierarchical modeling; 3) national-and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives. Results: Stunting prevalence declined by 14% points from 2000 to 2016, although geographical, wealth, urban/rural, and educationbased inequalities persist. Child growth curves demonstrated substantial improvements in child height-forage z-scores (HAZs) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women's empowerment, cultural norms, water and sanitation, dietary intake/diversity, and reduced childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multisectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors. Conclusions: Uganda's success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated, and rural populations along with high-burden districts.
ABSTRACTBackgroundChild stunting and linear growth faltering have declined over the past few deca... more ABSTRACTBackgroundChild stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress.ObjectivesTo synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting.MethodsWe did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition.ResultsSeveral countries have dramatically reduced child stunting prevalence, with or without ...
ABSTRACTBackgroundChronic undernutrition in children continues to be a global public health conce... more ABSTRACTBackgroundChronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y.ObjectivesThe aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level.MethodsThis study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000–2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken.ResultsNational stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child heigh...
ABSTRACTCoronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globa... more ABSTRACTCoronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globally, including progress in maternal and child nutrition. Although there has been focus on rising rates of childhood wasting in the short term, maternal and child undernutrition rates are also likely to increase as a consequence of COVID-19 and its impacts on poverty, coverage of essential interventions, and access to appropriate nutritious foods. Key sectors at particular risk of collapse or reduced efficiency in the wake of COVID-19 include food systems, incomes, and social protection, health care services for women and children, and services and access to clean water and sanitation. This review highlights key areas of concern for maternal and child nutrition during and in the aftermath of COVID-19 while providing strategic guidance for countries in their efforts to reduce maternal and child undernutrition. Rooted in learnings from the exemplars in Global…
ABSTRACTFood environments may promote access to unhealthy foods, contributing to noncommunicable ... more ABSTRACTFood environments may promote access to unhealthy foods, contributing to noncommunicable diseases in low- and middle- income countries (LMICs). This review assessed published evidence on the effects of food environment interventions on anthropometric (BMI and weight status) outcomes in school-aged children (5–9 y) and adolescents (10–19 y) (SACA) in LMICs. We summarized randomized controlled trials (RCTs) and quasi-experimental studies (QES) published since 2000 to August 2019 in the peer-reviewed and gray literature that assessed the effects of food-related behavioral and environmental interventions on diet-related health outcomes in SACA in LMICs. Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched using appropriate keywords, Medical Subject Headings, and free text terms. Eleven RCTs and 6 QES met the inclusion criteria, testing multicomponent behavioral and environmental interventions in schools. Analysis of 6 RCTs (n = 17,054) suggested an o...
In many low- and middle-income countries (LMICs) the double burden of malnutrition is high among ... more In many low- and middle-income countries (LMICs) the double burden of malnutrition is high among adolescent girls, leading to poor health outcomes for the adolescent herself and sustained intergenerational effects. This underpins the importance of adequate dietary intake during this period of rapid biological development. The aim of this systematic review was to summarize the current dietary intake and practices among adolescent girls (10–19 years) in LMICs. We searched relevant databases and grey literature using MeSH terms and keywords. After applying specified inclusion and exclusion criteria, 227 articles were selected for data extraction, synthesis, and quality assessment. Of the included studies, 59% were conducted in urban populations, 78% in school settings, and dietary measures and indicators were inconsistent. Mean energy intake was lower in rural settings (1621 ± 312 kcal/day) compared to urban settings (1906 ± 507 kcal/day). Self-reported daily consumption of nutritious ...
The Campbell Collaboration | www.campbellcollaboration.org Background The problem, condition or i... more The Campbell Collaboration | www.campbellcollaboration.org Background The problem, condition or issue Current estimates indicate that some form of malnutrition (undernutrition, overweight or obesity, and poor dietary habits) affects one in three people worldwide (International Food Policy Research Institute, 2016), and the 2016 Global Burden of Disease study has placed poor dietary habits as one of the leading risk factors for mortality globally (Collaborators GBDRF, 2017). Over the past decade, there has been great momentum around addressing malnutrition in all its forms and commitment to actions that can accelerate progress to reduce its associated burden of morbidity and mortality. In 2012, the World Health Assembly (WHA) adopted the 2025 Global Targets for Maternal, Infant and Young Child Nutrition and in 2013, WHA adopted targets for non-communicable diseases (NCDs), including several nutrition-relevant targets (International Food Policy Research Institute, 2016). More recently, the United Nations elevated its efforts through a global declaration of 17 Sustainable Development Goals (SDGs), where at least 12 of the 17 goals feature indicators relevant to nutrition. In line with these targets, the decade of 2016-2025 has been declared the Decade of Action on Nutrition (International Food Policy Research Institute, 2016). To this end, prioritizing critical actions to address school-age children and adolescent nutrition, is necessary to achieve these milestones. At the forefront of malnutrition and poor dietary intake is the food system. The food system According to the Food and Agriculture Organization (FAO) High Level Panel of Global Food and Nutrition Security, the food system is defined as 'a system that embraces all the elements (environment, people, inputs, processes, infrastructure, institutions, markets and trade) and activities that relate to the production, processing, distribution and marketing, preparation and consumption of food and the outputs of these activities, including socioeconomic and environmental outcomes' (High Level Panel of Experts, 2017). Importantly, this group identified three food system typologies (i.e. traditional, mixed and modern), based on distinct inputs (natural resources, human capital, physical capital, agriculture and food technology), outputs (food purchasing patterns, diet, health and environmental sustainability) and processes (food production, supply chains and the food environment) Table 1. The transition from traditional to industrial food systems has been linked to urbanization, policy liberalization, agricultural productivity and income growth. In addition, the Global Nutrition Report, (International Food Policy Research Institute, 2015) defined two additional food system typologies (emerging and transitioning food systems), which are variations of the mixed food system, often observed in low-and middle-income countries (LMICs). Importantly, multiple types of food systems, and their associated food supply chains and food environments can co-exist within a single country simultaneously. Within traditional (or rural) food systems, there is a greater proportion of informal food markets (i.e. wet markets, mobile street vendors), compared to formal food outlets, as food is Almiron
Lead review author: The lead author is the person who develops and coordinates the review team, d... more Lead review author: The lead author is the person who develops and coordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the ongoing updates of the review.
Background: Micronutrient malnutrition is highly prevalent in low-and middle-income countries (LM... more Background: Micronutrient malnutrition is highly prevalent in low-and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of largescale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts. Objectives: The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs. Methods: All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs. Results: LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential. Conclusions: Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.
IMPORTANCE Previous work has underscored subnational inequalities that could impede additional he... more IMPORTANCE Previous work has underscored subnational inequalities that could impede additional health gains in Kenya. OBJECTIVE To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018. EXPOSURES Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered. MAIN OUTCOMES AND MEASURES Absolute and relative measures of inequality in coverage of RMNCAH interventions. RESULTS For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of −7.9% (95% CI, −11.1% to −4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations. CONCLUSIONS AND RELEVANCE Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which (continued) Key Points Question How equitable was coverage of essential reproductive, maternal, newborn, child, and adolescent health interventions in Kenya throughout the Millennium Development Goal period? Findings In this population-based, cross-sectional study of 31 380 women of reproductive age and 29 743 children, regional and socioeconomic inequalities in coverage of several key interventions persisted throughout the study period (2003-2014), placing both the rural and urban poor as well as populations in the northern and eastern regions of Kenya at a significant disadvantage. Meaning For Kenya to improve health equity and achieve its 2030 goals, a targeted approach will be needed to reach populations that are currently lagging behind.
Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for redu... more Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989-2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya's political changes in 2003, ...
Background Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has bee... more Background Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. Although several cross-sectional assessments have been done, a systematic analysis of RMNCH in Kenya was needed to better understand the push and pull factors that govern intervention coverage and influence mortality trends. As such, we aimed to determine coverage and impact of key RMNCH interventions between 1990 and 2015. Methods We did a comprehensive, systematic assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys done between 1989 and 2014. For comparison, we used modelled mortality estimates from the UN Inter-Agency Groups for Child and Maternal Mortality Estimation. We estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the subnational level, and used linear regression methods to understand the determinants of change in intervention coverage during the past decade. Finally, we used the Lives Saved Tool (LiST) to model the effect of intervention scaleup by 2030. Findings After an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several healthsystems-based interventions, such as skilled birth assistance. Multivariable analyses of predictors of change in family planning, skilled birth assistance, and full vaccination suggested that maternal literacy and family size are important drivers of positive change in key interventions across the continuum of care. LiST analyses clearly showed the importance of quality of care around birth for maternal and newborn survival. Interpretation Intensified and focused efforts are needed for Kenya to achieve the RMNCH targets for 2030. Kenya must build on its previous progress to further reduce mortality through the widespread implementation of key preventive and curative interventions, especially those pertaining to labour, delivery, and the first day of life. Deliberate targeting of the poor, least educated, and rural women, through the scale-up of community-level interventions, is needed to improve equity and accelerate progress. Funding US Fund for UNICEF, Bill & Melinda Gates Foundation.
Despite governmental efforts to close the gender gap and global calls including Sustainable Devel... more Despite governmental efforts to close the gender gap and global calls including Sustainable Development Goal 5 to promote gender equality, the sobering reality is that gender inequities continue to persist in Canadian global health institutions. Moreover, from health to the economy, security to social protection, COVID-19 has exposed and heightened pre-existing inequities, with women, especially marginalized women, being disproportionately impacted. Women, particularly women who face bias along multiple identity dimensions, continue to be at risk of being excluded or delegitimized as participants in the global health workforce and continue to face barriers in career advancement to leadership, management and governance positions in Canada. These inequities have downstream effects on the policies and programmes, including global health efforts intended to support equitable partnerships with colleagues in low- and middle- income countries. We review current institutional gender inequit...
This End-line review report highlights progress attained, lessons and challenges experienced duri... more This End-line review report highlights progress attained, lessons and challenges experienced during the implementation of the Investment Case (IC) for the Sharpened Plan and makes recommendations for the development of the next Sharpened Plan and Investment Case (IC). The focus of the report is on the progress in the implementation of the five strategic shifts and resource commitments, assessing performance against targets for the implementation period 2015/16-2019/20. The review was undertaken by the Maternal Newborn and
Background: The complementary feeding (CF) period accompanies a critical window of vulnerability.... more Background: The complementary feeding (CF) period accompanies a critical window of vulnerability. During this time, failure to consume adequate energy, protein, vitamins and minerals is a significant concern and can lead to poor growth outcomes, increased susceptibility to infections, allergies, and diseases, and lower developmental potential. It is therefore of utmost importance to determine the most optimal time to start CF. The objective of this review is to assess the impact of early and late of introduction of CF on infant health, nutrition and developmental outcomes.Methods: We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We will search MEDLINE, Embase, CINAHL, CENTRAL, Web of Science, and other databases and key organizational websites using terms related to complementary feeding and infants. We will also search clinicaltrials.gov for ongoing trials. We will include experimental (randomized trials (individually or clu...
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustain... more As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
Background: Uganda has achieved a considerable reduction in childhood stunting over the past 2 de... more Background: Uganda has achieved a considerable reduction in childhood stunting over the past 2 decades, although accelerated action will be needed to achieve 2030 targets. Objectives: This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda. Methods: This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-indifference multivariable hierarchical modeling; 3) national-and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives. Results: Stunting prevalence declined by 14% points from 2000 to 2016, although geographical, wealth, urban/rural, and educationbased inequalities persist. Child growth curves demonstrated substantial improvements in child height-forage z-scores (HAZs) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women's empowerment, cultural norms, water and sanitation, dietary intake/diversity, and reduced childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multisectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors. Conclusions: Uganda's success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated, and rural populations along with high-burden districts.
ABSTRACTBackgroundChild stunting and linear growth faltering have declined over the past few deca... more ABSTRACTBackgroundChild stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress.ObjectivesTo synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting.MethodsWe did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition.ResultsSeveral countries have dramatically reduced child stunting prevalence, with or without ...
ABSTRACTBackgroundChronic undernutrition in children continues to be a global public health conce... more ABSTRACTBackgroundChronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y.ObjectivesThe aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level.MethodsThis study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000–2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken.ResultsNational stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child heigh...
ABSTRACTCoronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globa... more ABSTRACTCoronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globally, including progress in maternal and child nutrition. Although there has been focus on rising rates of childhood wasting in the short term, maternal and child undernutrition rates are also likely to increase as a consequence of COVID-19 and its impacts on poverty, coverage of essential interventions, and access to appropriate nutritious foods. Key sectors at particular risk of collapse or reduced efficiency in the wake of COVID-19 include food systems, incomes, and social protection, health care services for women and children, and services and access to clean water and sanitation. This review highlights key areas of concern for maternal and child nutrition during and in the aftermath of COVID-19 while providing strategic guidance for countries in their efforts to reduce maternal and child undernutrition. Rooted in learnings from the exemplars in Global…
ABSTRACTFood environments may promote access to unhealthy foods, contributing to noncommunicable ... more ABSTRACTFood environments may promote access to unhealthy foods, contributing to noncommunicable diseases in low- and middle- income countries (LMICs). This review assessed published evidence on the effects of food environment interventions on anthropometric (BMI and weight status) outcomes in school-aged children (5–9 y) and adolescents (10–19 y) (SACA) in LMICs. We summarized randomized controlled trials (RCTs) and quasi-experimental studies (QES) published since 2000 to August 2019 in the peer-reviewed and gray literature that assessed the effects of food-related behavioral and environmental interventions on diet-related health outcomes in SACA in LMICs. Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched using appropriate keywords, Medical Subject Headings, and free text terms. Eleven RCTs and 6 QES met the inclusion criteria, testing multicomponent behavioral and environmental interventions in schools. Analysis of 6 RCTs (n = 17,054) suggested an o...
In many low- and middle-income countries (LMICs) the double burden of malnutrition is high among ... more In many low- and middle-income countries (LMICs) the double burden of malnutrition is high among adolescent girls, leading to poor health outcomes for the adolescent herself and sustained intergenerational effects. This underpins the importance of adequate dietary intake during this period of rapid biological development. The aim of this systematic review was to summarize the current dietary intake and practices among adolescent girls (10–19 years) in LMICs. We searched relevant databases and grey literature using MeSH terms and keywords. After applying specified inclusion and exclusion criteria, 227 articles were selected for data extraction, synthesis, and quality assessment. Of the included studies, 59% were conducted in urban populations, 78% in school settings, and dietary measures and indicators were inconsistent. Mean energy intake was lower in rural settings (1621 ± 312 kcal/day) compared to urban settings (1906 ± 507 kcal/day). Self-reported daily consumption of nutritious ...
The Campbell Collaboration | www.campbellcollaboration.org Background The problem, condition or i... more The Campbell Collaboration | www.campbellcollaboration.org Background The problem, condition or issue Current estimates indicate that some form of malnutrition (undernutrition, overweight or obesity, and poor dietary habits) affects one in three people worldwide (International Food Policy Research Institute, 2016), and the 2016 Global Burden of Disease study has placed poor dietary habits as one of the leading risk factors for mortality globally (Collaborators GBDRF, 2017). Over the past decade, there has been great momentum around addressing malnutrition in all its forms and commitment to actions that can accelerate progress to reduce its associated burden of morbidity and mortality. In 2012, the World Health Assembly (WHA) adopted the 2025 Global Targets for Maternal, Infant and Young Child Nutrition and in 2013, WHA adopted targets for non-communicable diseases (NCDs), including several nutrition-relevant targets (International Food Policy Research Institute, 2016). More recently, the United Nations elevated its efforts through a global declaration of 17 Sustainable Development Goals (SDGs), where at least 12 of the 17 goals feature indicators relevant to nutrition. In line with these targets, the decade of 2016-2025 has been declared the Decade of Action on Nutrition (International Food Policy Research Institute, 2016). To this end, prioritizing critical actions to address school-age children and adolescent nutrition, is necessary to achieve these milestones. At the forefront of malnutrition and poor dietary intake is the food system. The food system According to the Food and Agriculture Organization (FAO) High Level Panel of Global Food and Nutrition Security, the food system is defined as 'a system that embraces all the elements (environment, people, inputs, processes, infrastructure, institutions, markets and trade) and activities that relate to the production, processing, distribution and marketing, preparation and consumption of food and the outputs of these activities, including socioeconomic and environmental outcomes' (High Level Panel of Experts, 2017). Importantly, this group identified three food system typologies (i.e. traditional, mixed and modern), based on distinct inputs (natural resources, human capital, physical capital, agriculture and food technology), outputs (food purchasing patterns, diet, health and environmental sustainability) and processes (food production, supply chains and the food environment) Table 1. The transition from traditional to industrial food systems has been linked to urbanization, policy liberalization, agricultural productivity and income growth. In addition, the Global Nutrition Report, (International Food Policy Research Institute, 2015) defined two additional food system typologies (emerging and transitioning food systems), which are variations of the mixed food system, often observed in low-and middle-income countries (LMICs). Importantly, multiple types of food systems, and their associated food supply chains and food environments can co-exist within a single country simultaneously. Within traditional (or rural) food systems, there is a greater proportion of informal food markets (i.e. wet markets, mobile street vendors), compared to formal food outlets, as food is Almiron
Lead review author: The lead author is the person who develops and coordinates the review team, d... more Lead review author: The lead author is the person who develops and coordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the ongoing updates of the review.
Background: Micronutrient malnutrition is highly prevalent in low-and middle-income countries (LM... more Background: Micronutrient malnutrition is highly prevalent in low-and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of largescale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts. Objectives: The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs. Methods: All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs. Results: LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential. Conclusions: Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.
IMPORTANCE Previous work has underscored subnational inequalities that could impede additional he... more IMPORTANCE Previous work has underscored subnational inequalities that could impede additional health gains in Kenya. OBJECTIVE To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018. EXPOSURES Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered. MAIN OUTCOMES AND MEASURES Absolute and relative measures of inequality in coverage of RMNCAH interventions. RESULTS For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of −7.9% (95% CI, −11.1% to −4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations. CONCLUSIONS AND RELEVANCE Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which (continued) Key Points Question How equitable was coverage of essential reproductive, maternal, newborn, child, and adolescent health interventions in Kenya throughout the Millennium Development Goal period? Findings In this population-based, cross-sectional study of 31 380 women of reproductive age and 29 743 children, regional and socioeconomic inequalities in coverage of several key interventions persisted throughout the study period (2003-2014), placing both the rural and urban poor as well as populations in the northern and eastern regions of Kenya at a significant disadvantage. Meaning For Kenya to improve health equity and achieve its 2030 goals, a targeted approach will be needed to reach populations that are currently lagging behind.
Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for redu... more Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989-2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya's political changes in 2003, ...
Background Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has bee... more Background Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. Although several cross-sectional assessments have been done, a systematic analysis of RMNCH in Kenya was needed to better understand the push and pull factors that govern intervention coverage and influence mortality trends. As such, we aimed to determine coverage and impact of key RMNCH interventions between 1990 and 2015. Methods We did a comprehensive, systematic assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys done between 1989 and 2014. For comparison, we used modelled mortality estimates from the UN Inter-Agency Groups for Child and Maternal Mortality Estimation. We estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the subnational level, and used linear regression methods to understand the determinants of change in intervention coverage during the past decade. Finally, we used the Lives Saved Tool (LiST) to model the effect of intervention scaleup by 2030. Findings After an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several healthsystems-based interventions, such as skilled birth assistance. Multivariable analyses of predictors of change in family planning, skilled birth assistance, and full vaccination suggested that maternal literacy and family size are important drivers of positive change in key interventions across the continuum of care. LiST analyses clearly showed the importance of quality of care around birth for maternal and newborn survival. Interpretation Intensified and focused efforts are needed for Kenya to achieve the RMNCH targets for 2030. Kenya must build on its previous progress to further reduce mortality through the widespread implementation of key preventive and curative interventions, especially those pertaining to labour, delivery, and the first day of life. Deliberate targeting of the poor, least educated, and rural women, through the scale-up of community-level interventions, is needed to improve equity and accelerate progress. Funding US Fund for UNICEF, Bill & Melinda Gates Foundation.
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