Building a Stronger System for Tracking Nutrition-Sensitive Spending: A Methodology and Estimate of Global Spending for Nutrition-Sensitive Foreign Aid

Background: There is growing awareness that the necessary solutions for improving nutrition outcomes are multisectorial. As such, investments are increasingly directed toward nutrition-sensitive approaches that not only address an underlying or basic determinant of nutrition but also seek to achieve an explicit nutrition goal or outcome. Understanding how and where official development assistance (ODA) for nutrition is invested remains an important but complex challenge, as development projects components vary in their application to nutrition outcomes. Currently, no systematic method exists for tracking nutrition-sensitive ODA. Objective: To develop a methodology for classifying and tracking nutrition-sensitive ODA and to produce estimates of the amount of nutrition-sensitive aid received by countries with a high burden of undernutrition. Methods: We analyzed all financial flows reported to the Organization for Economic Co-Operation and Development\u27s Development Assistance Committee Creditor Reporting Service in 2010 to estimate these investments. We assessed the relationships between national stunting prevalence, stunting burden, under-5 mortality, and the amount of nutrition-specific and nutrition-sensitive ODA. Results: We estimate that, in 2010, a total of $379.4 million (M) US dollars (USD) was committed to nutrition-specific projects and programs of which 25 designated beneficiaries (countries and regions) accounted for nearly 85$320 M). A total of $1.79 billion (B) was committed to nutrition-sensitive spending, of which the top 25 countries/regions accounted for$1.4 B (82%). Nine categories of development activities accounted for 75% of nutrition-sensitive spending, led by Reproductive Health Care (30.4%), Food Aid/Food Security Programs (14.1%), Emergency Food Aid (13.2%), and Basic Health Care (5.0%). Multivariate linear regression models indicate that the amount of nutrition-sensitive (P = .001) and total nutrition ODA was significantly predicted by stunting prevalence (P = .001). The size of the total population of stunted children significantly predicted the amount of nutrition-specific ODA (P \u3c .001). Conclusion: The recipient profile of nutrition-specific and nutrition-sensitive ODA is related but distinct. Nutrition indicators are associated with the level of nutrition-related ODA commitments to recipient countries. A reliable estimate of nutrition spending is critical for effective planning by both donors and recipients and key for success, as the global development community recommits to a new round of goals to address the interrelated causes of undernutrition in low-income countries

Assessment of Supplemental Feeding with a Locally-Produced Ready-to-Use-Food: The Byokulia Bisemeye mu Bantu Program in Bundibugyo, Uganda

Background. Low quality complementary foods and caregiver feeding practices contribute to child growth faltering throughout the developing world. Ready-to-use foods (RUF) are energy dense products that do not require cooking and have been effectively used to treat malnutrition. However, studies report low consumption of distributed rations by targeted children. The factors that affect RUF consumption rates and the impact of RUF supplementation on caregiver feeding practices and children's dietary adequacy are not well understood. Methods. This study was conducted among participants in the Byokulia Bisemeye mu Bantu (BBB) supplemental feeding program in Bundibugyo, Uganda. First, to identify the key factors that affect home-based RUF consumption we interviewed caregivers (n=30), RUF producers (n=8) and program staff (n=10) involved in the BBB program. Secondly, to examine RUF consumption patterns and the demographic predictors of RUF consumption, we conducted 24-hour dietary recalls from 135 children during supplementation. Thirdly, we assessed the program impact on caregiver feeding practices and children's diet adequacy by conducting dietary recalls and a feeding practice survey among 61 Post-Program and 61 Comparison caregiver-child dyads. Results. RUF was offered to targeted children by 86% of caregivers, and was included in 46% of targeted children's meals. Program children were offered 35% of the 128 g/day RUF supplement. Qualitative findings indicate that intrahousehold RUF sharing may compromise the nutrient delivery to targeted children. Logistic regression analysis indicates that caregivers with more birth children were less likely to offer RUF to targeted children, and that more frequent program attendance was associated with a greater likelihood of feeding RUF. Post Program children were more likely to meet their dietary requirements, were fed more frequently, and had greater dietary diversity than Comparisons. The diet adequacy of Program children's diet adequacy did not change significantly after RUF rations were discontinued. Conclusions. RUF is well received by caregivers of underweight children; however, a large proportion of distributed RUF may fail to reach targeted children. Caregivers are challenged to feed RUF to targeted children, especially in larger households. Programs that offer complementary feeding education with RUF may promote lasting benefits to child feeding practices and dietary adequacy

Associations between social support, psychological well-being, decision making, empowerment, infant and young child feeding, and nutritional status in Ugandan children ages 0 to 24months

Maternal capabilitiesqualities of mothers that enable them to leverage skills and resources into child healthhold potential influence over mother\u27s adoption of child caring practices, including infant and young child feeding. We developed a survey (n=195) that assessed the associations of 4 dimensions of maternal capabilities (social support, psychological health, decision making, and empowerment) with mothers\u27 infant and young child feeding practices and children\u27s nutritional status in Uganda. Maternal responses were converted to categorical subscales and an overall index. Scale reliability coefficients were moderate to strong ( range=0.49 to 0.80). Mothers with higher social support scores were more likely to feed children according to the minimum meal frequency (odds ratio [OR] [95% confidence interval (CI)]=1.38 [1.10, 1.73]), dietary diversity (OR [95% CI]=1.56 [1.15, 2.11]), iron rich foods, (OR [95% CI]=1.47 [1.14, 1.89]), and minimally acceptable diet (OR [95% CI]=1.55 [1.10, 2.21]) indicators. Empowerment was associated with a greater likelihood of feeding a minimally diverse and acceptable diet. The maternal capabilities index was significantly associated with feeding the minimum number of times per day (OR [95% CI]=1.29 [1.03, 1.63]), dietary diversity (OR [95% CI]=1.44 [1.06, 1.94]), and minimally acceptable diet (OR [95% CI]=1.43 [1.01, 2.01]). Mothers with higher psychological satisfaction were more likely to have a stunted child (OR [95% CI]=1.31 [1.06, 1.63]). No other associations between the capabilities scales and child growth were significant. Strengthening social support for mothers and expanding overall maternal capabilities hold potential for addressing important underlying determinants of child feeding in the Ugandan context

World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings

As the World Health Organization (WHO) infant and young child feeding (IYCF) indicators are increasingly adopted, a comparison of country-specific analyses of the indicators\u27 associations with child growth is needed to examine the consistency of these relationships across contexts and to assess the strengths and potential limitations of the indicators. This study aims to determine cross-country patterns of associations of each of these indicators with child stunting, wasting, height-for-age z-score (HAZ) and weight-for-height z-score (WHZ). Eight studies using recent Demographic and Health Surveys data from a total of nine countries in sub-Saharan Africa (nine), Asia (three) and the Caribbean (one) were identified. The WHO indicators showed mixed associations with child anthropometric indicators across countries. Breastfeeding indicators demonstrated negative associations with HAZ, while indicators of diet diversity and overall diet quality were positively associated with HAZ in Bangladesh, Ethiopia, India and Zambia (P \u3c 0.05). These same complementary feeding indicators did not show consistent relationships with child stunting. Exclusive breastfeeding under 6 months of age was associated with greater WHZ in Bangladesh and Zambia (P \u3c 0.05), although CF indicators did not show strong associations with WHZ or wasting. The lack of sensitivity and specificity of many of the IYCF indicators may contribute to the inconsistent associations observed. The WHO indicators are clearly valuable tools for broadly assessing the quality of child diets and for monitoring population trends in IYCF practices over time. However, additional measures of dietary quality and quantity may be necessary to understand how specific IYCF behaviours relate to child growth faltering

Impact of lipid-based nutrient supplementation (LNS) on children\u27s diet adequacy in Western Uganda

Lipid-based nutrient supplements (LNS) can help treat undernutrition; however, the dietary adequacy of children supplemented with LNS, and household utilisation patterns are not well understood. We assessed diet adequacy and the quality of complementary foods by conducting a diet assessment of 128 Ugandan children, ages 6-59 months, who participated in a 10-week programme for children with moderate acute malnutrition (MAM, defined as weight-for-age z-score \u3c -2). Caregivers were given a weekly ration of 650 kcal day (-1) (126 g day(-1)) of a peanut/ soy LNS. Two 24-h dietary recalls were administered per child. LNS was offered to 86% of targeted children at least once. Among non-breastfed children, over 90% met their estimated average requirement (EAR) cut-points for all examined nutrients. Over 90% of breastfed children met EAR cut-points for nutrient density for most nutrients, except for zinc where 11.7% met cut-points. A lower proportion of both breastfed and non-breastfed children met adjusted EARs for the specific nutritional needs of MAM. Fewer than 20% of breastfed children met EAR nutrient-density guidelines for MAM for zinc, vitamin C, vitamin A and folate. Underweight status, the presence of a father in the child\u27s home, and higher programme attendance were all associated with greater odds of feeding LNS to targeted children. Children in this community-based supplemental feeding programme who received a locally produced LNS exhibited substantial micronutrient deficiencies given the special dietary needs of this population. These results can help inform programme strategies to improve LNS targeting, and highlight potential nutrient inadequacies for consumers of LNS in community-based settings

Under­lying Determinants of and Solutions for Malnutrition in Low-­and Middle-­Income Countries

The text provides a much-needed resource for established researchers and practitioners of public health nutrition. Each chapter is authored by preeminent experts in the field, and the book includes aids for classroom learning, including case studies, learning objectives, and review questions. A rigorous introduction to foundational knowledge, Public Health Nutrition concludes with a discussion of current and future solutions for pressing health issues

Reply to Correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102165/1/mcn12107.pd

Health Economics in Public Health

BACKGROUND: Economic analysis is an important tool in deciding how to allocate scarce public health resources; however, there is currently a dearth of such analysis by public health researchers. METHODS: Public health researchers and practitioners were surveyed to determine their current use of health economics and to identify barriers to use as well as potential strategies to decrease those barriers in order to allow them to more effectively incorporate economic analyses into their work. Data collected from five focus groups informed survey development. The survey included a demographic section and 14 multi-part questions. Participants were recruited in 2006 from three national public health organizations through e-mail; 294 academicians, practitioners, and community representatives answered the survey. RESULTS: Survey data were analyzed in 2007. Despite an expressed belief in the importance of health economics, more than half of the respondents reported very little or no current use of health economics in their work. Of those using health economics, cost-benefit and cost-effectiveness analysis and determination of public health costs were cited as the measures used most frequently. The most important barriers were lack of expertise, funding, time, tools, and data, as well as discomfort with economic theory. The resource deemed most important to using health economics was collaboration with economists or those with economic training. Respondents indicated a desire to learn more about health economics and tools for performing economic analysis. CONCLUSIONS: Given the importance of incorporating economic analysis into public health interventions, and the desire of survey respondents for more collaboration with health economists, opportunities for such collaborations should be increased

Maternal participation in a nutrition education program in Uganda is associated with improved infant and young child feeding practices and feeding knowledge: a post-program comparison study

Abstract Background Cost-effective approaches to improve feeding practices and to reduce undernutrition are needed in low-income countries. Strategies such as nutritional counseling, food supplements, and cash transfers can substantially reduce undernutrition among food-insecure populations. Lipid-based nutrient supplements (LNS) are an increasingly popular strategy for treating and preventing undernutrition and are often delivered with nutrition education. The post-program effects of participation in a LNS-supported supplemental feeding program on Infant and Young Child Feeding (IYCF) practices and caregiver child feeding knowledge are not well understood. The objective of this study was to understand whether children’s diet quality and caregiver nutrition knowledge was improved after participation in such a program. Methods We conducted a post-program comparison group study to compare feeding practices and caregiver nutrition knowledge among mother-child dyads who completed a nutrition education program and a community comparison group in western Uganda. We administered a feeding practices survey and two 24-h dietary recalls to 61 Post-Program (PP) caregivers and children ages 6 to 59 months (mean age = 25.1 months) who participated in a supplemental feeding program (which included growth monitoring, caregiver nutrition education, and LNS) and a Comparison Group (CG) of 61 children and caregivers. PP caregivers were recruited 4 to 8 weeks after program participation ended. We hypothesized that PP caregivers would report better IYCF practices and greater knowledge of key nutrition education messages related to IYCF. Results PP children had higher dietary diversity scores (3.0 vs 2.1, p =0.001) than CG children, and were more fed more frequently (3.0 vs 2.1 times per day, p = 0.001). IYCF indicators were higher in the PP group for minimum meal frequency (44.8% vs. 37.9%), minimum dietary diversity (10.3 vs. 3.4%), iron-rich complementary foods (17.2 vs. 20.7%), and minimally acceptable diet (10.3% vs 3.6%), but differences were non-significant. Caregivers in the PP group demonstrated greater knowledge of healthful IYCF practices. Conclusions Nutrition education can be effective to improve caregiver feeding practices and children’s dietary diversity and the frequency by which they are fed. A 10-week nutrition education and supplemental feeding program appears to provide some benefit to children in terms of dietary diversity and frequency of meals, and caregiver knowledge of feeding 1 to 2 months after program completion. However, children in this rural Ugandan region have diets that are still largely inadequate, highlighting the need for enhanced interventions and policies to promote diverse and appropriate diets for young children in this region. Future follow-up work in LNS-supported programs is recommended to understand how other similar approaches influence children's diet quality after program completion in other contexts