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

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

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

Examination of facilitators and barriers to home-based supplemental feeding with ready-to-use food for underweight children in western Uganda: Factors affecting home-based supplemental feeding with RUF

Poor complementary feeding practices and low quality complementary foods are significant causes of growth faltering and child mortality throughout the developing world. Ready-to-use foods (RUF) are energy dense, lipid-based products that do not require cooking or refrigeration, that have been used to prevent and treat malnutrition among vulnerable children. The effectiveness of these products in improving child nutritional status depends on household use by caregivers. To identify the key facilitators and barriers that influence appropriate in-home RUF consumption by supplemental feeding program beneficiaries, we conducted individual interviews among caregivers (n=80), RUF producers (n=8) and program staff (n=10) involved in the Byokulia Bisemeye mu Bantu (BBB) supplemental feeding program in Bundibugyo, Uganda. By documenting caregiver perceptions and feeding practices related to RUF, we developed a conceptual framework of factors that affect appropriate feeding with RUF. Findings suggest that locally produced RUF is well received by caregivers and children, and is perceived by caregivers and the community to be a healthy supplemental food for malnourished children. However, child feeding practices, including sharing of RUF within households, compromise the nutrient delivery to the intended child. Interventions and educational messages informed by this study can help to improve RUF delivery to targeted beneficiaries

Maternal Literacy, Facility Birth, and Education Are Positively Associated with Better Infant and Young Child Feeding Practices and Nutritional Status among Ugandan Children

Background: Understanding maternal factors that influence child feeding is necessary to inform intervention planning in settings in which mothers experience substantial social vulnerabilities. Objective: The purpose of this study was to assess maternal sociodemographic factors that may constrain women\u27s caring capabilities and subsequent child nutrition in Uganda. Methods: We analyzed data from the 2006 and 2011 Uganda Demographic and Health Surveys to model the associations between maternal sociodemographic factors, child feeding practices, and anthropometry with multivariate logistic regression models. Results: The proportion of children fed according to recommended guidelines declined in Uganda from 2006 to 2011. Mothers who lacked literacy skills were less likely to achieve recommended complementary feeding indicators; however, literacy was not associated with breastfeeding practices. Mothers in the upper 60% wealth percentile were more likely to meet minimum meal frequency, diversity, and adequacy indicators. Mothers who gave birth at health facilities (2006 OR: 0.49; 95% CI: 0.26, 0.91; P \u3c 0.05) and who were in the upper 60% wealth percentile (2011 OR: 0.43; 95% CI: 0.21, 0.69) were less likely to exCIusively breastfeed until 6 mo. There were no significant associations between age at first pregnancy, maternal education, and infant and young child feeding practices. Women with a formal education had children with lower stunting and underweight probabilities in both time periods (OR range: 0.43-0.74). Women who delivered in childbirth facilities were less likely to have a child with low weight-for-age, length-for-age, or weight-for-length z scores (OR range: 0.59-0.82). Marital status, the age at first child birth, not accepting domestic violence, freedom to travel away from home, and involvement in household and reproductive decisions were not associated with child anthropometry in either time period. Conclusions: Mothers with low literacy skills, who deliver their children at home, and who lack formal education are particularly at risk of poor child feeding and represent a group that may benefit from enhanced interventions that address their particular vulnerabilities. Factors that contribute to improved maternal feeding capabilities but may impair breastfeeding practices need to be better understood