1
|
Cormick G, Moraa H, Zahroh RI, Allotey J, Rocha T, Peña-Rosas JP, Qureshi ZP, Hofmeyr GJ, Mistry H, Smits L, Vogel JP, Palacios A, Gwako GN, Abalos E, Larbi KK, Carroli G, Riley R, Snell KI, Thorson A, Young T, Betran AP, Thangaratinam S, Bohren MA. Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review. BMJ Open 2023; 13:e070677. [PMID: 38135336 DOI: 10.1136/bmjopen-2022-070677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia. DESIGN Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach. DATA SOURCES MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022. ELIGIBILITY CRITERIA We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators. RESULTS Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium. CONCLUSION Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions. PROSPERO REGISTRATION NUMBER CRD42021239143.
Collapse
Affiliation(s)
- Gabriela Cormick
- Centro de Investigaciones en Epidemiología y Salud Pública (Consejo Nacional de Investigaciones Científicas y Técnicas- CONICET), Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
- Universidad Nacional de La Matanza, San Justo, Provincia de Buenos Aires, Argentina
| | | | - Rana Islamiah Zahroh
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
| | - Thaís Rocha
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand Faculty of Health Sciences, East London, Eastern Cape, South Africa
- University of Botswana, Gaborone, Botswana
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Luc Smits
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Joshua Peter Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Alfredo Palacios
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Centre for Health Economics, University of York, York, UK
| | | | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Santa Fe, Argentina
| | - Richard Riley
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Anna Thorson
- Human Reproduction Program/World Health Organization (Geneva), Geneva, Switzerland
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Dept. of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Ana Pilar Betran
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37466272 PMCID: PMC10355136 DOI: 10.1002/14651858.cd013603.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
Collapse
Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
3
|
Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37434293 PMCID: PMC10335778 DOI: 10.1002/14651858.cd013603.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
Collapse
Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
4
|
Jhaveri NR, Poveda NE, Kachwaha S, Comeau DL, Nguyen PH, Young MF. Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India. Front Nutr 2023; 10:1185696. [PMID: 37469540 PMCID: PMC10352842 DOI: 10.3389/fnut.2023.1185696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023] Open
Abstract
Background Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India. Objective This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption. Methods We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework. Results For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages. Conclusion Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.
Collapse
Affiliation(s)
- Neha R. Jhaveri
- Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Natalia E. Poveda
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Hubert Department of Global Health, Emory University, Atlanta, GA, United States
| | - Shivani Kachwaha
- Program in Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Dawn L. Comeau
- Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Phuong H. Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, United States
| | - Melissa F. Young
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Hubert Department of Global Health, Emory University, Atlanta, GA, United States
| |
Collapse
|
5
|
Pokhrel KN, Thapa S, Garner P, Caws M, Dhital R, Gurung SC, Fox T, Shrestha S. Should all pregnant women take calcium supplements in Nepal? GRADE evidence to policy assessment. Glob Health Action 2022; 15:2128283. [PMID: 36239949 PMCID: PMC9578478 DOI: 10.1080/16549716.2022.2128283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The WHO recommends oral calcium supplementation (1.5–2.0 g) in pregnant women to reduce the risk of pre-eclampsia living in areas with low dietary calcium intake. Although maternal mortality is high in Nepal and eclampsia causes at least 20% of maternal deaths, implementing WHO recommendations would be a major undertaking. Objective This review aimed to assess whether the current evidence supports the blanket supplementation of calcium to prevent pre-eclampsia among pregnant women in Nepal. Methods We used a structured approach to appraise the evidence for calcium supplementation in Nepal. We identified what may influence the impact of calcium supplementation in Nepal and conducted a situation analysis in the country covering maternal mortality, pre-eclampsia occurrence, and existing government policy provisions for supplementation. We also consulted with experts and government officials to explore their perspectives and experience on supplementation. We then used AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) to appraise the Cochrane Systematic Review of calcium supplementation. Finally, we used these data in a GRADE (Grading of Recommendations Assessment, Development and Evaluation)–Evidence to Decision framework to reach a policy recommendation. Results Our assessment of the Cochrane Review showed that the recommendation made by the WHO is based on weak evidence and trial findings that are not consistent between studies. The Cochrane Review found low certainty of the evidence for benefit (reduction in pre-eclampsia and maternal mortality). Conversely, there is a high certainty of the evidence of undesirable effects (HELLP [haemolysis, elevated liver enzymes and low platelets] syndrome) although this is uncommon. The likely absolute reduction in maternal deaths projected to Nepal was estimated to be low, while the implementation costs were high. Stakeholders also raised several concerns regarding feasibility, acceptability, appropriate dosing, and risk communication. Conclusions This review concludes that the blanket supplementation of calcium cannot be recommended in Nepal. A better approach may be to identify high-risk pregnant women and manage their antenatal visits and delivery to prevent mortality from pre-eclampsia.
Collapse
Affiliation(s)
- Khem Narayan Pokhrel
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal.,Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Saki Thapa
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maxine Caws
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal.,Department of Clinical Sciences, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine Liverpool
| | - Raghu Dhital
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Suman Chandra Gurung
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal.,Department of Clinical Sciences, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine Liverpool
| | - Tilly Fox
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Samjhana Shrestha
- READ-It Project, Birat Nepal Medical Trust, Kathmandu, Nepal.,Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
6
|
Differential Effects of Three Nutritional Supplements on the Nutrient Intake of Pregnant Women Enrolled in a Conditional Cash Transfer Program in Mexico: A Cluster Randomized Trial. Nutrients 2022; 14:nu14153003. [PMID: 35893857 PMCID: PMC9332738 DOI: 10.3390/nu14153003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Supplementation in malnourished pregnant women should not displace natural healthy foods. Objective: To estimate the differential effects of three nutritional supplements on macro- and micronutrient intake of pregnant women beneficiaries of the conditional cash transfer program Prospera (CCT-POP). Methods: Prospective cluster randomized trial. Communities were randomly assigned to receive a fortified beverage (Beverage), micronutrient tablets (Tablets), or micronutrient powder (MNP). Pregnant women (at <25 weeks) were recruited. The food frequency questionnaire was applied at 25 and 37 weeks of pregnancy and at one and three months postpartum (mpp). Differential effects of the three supplements on the median change in nutrient intake from baseline to each follow-up stage were estimated. Results: Median change in protein intake from dietary and supplement sources were significantly lower for MNP and Tablets than for Beverages (baseline to 37 w: −7.80 ± 2.90 and −11.54 ± 3.00, respectively; baseline to 1 mpp: −7.34 ± 2.90 for MNP, p < 0.001). Compared to Beverages, median increases were higher for the MNP for vitamins C (31.2 ± 11.7, p < 0.01), E (1.67 ± 0.81, p < 0.05), and B12 (0.83 ± 0.27, p < 0.01) from baseline to 37 wk; from baseline to 1 mpp, there was a higher median increase in B12 (0.55 ± 0.25, p < 0.05) and folate (63.4 ± 24.3, p < 0.01); and from baseline to 3 mpp, a higher median increase in iron (2.38 ± 1.06, p < 0.05) and folate (94.4 ± 38.1, p < 0.05). Conclusions: Intake of micronutrients was higher for MNP and Tablets, likely due to food displacement among Beverage consumers. Although iron bioavailability and absorption inhibitors were not considered for the present analyses, the distribution of Tablets or MNP had several advantages in this context where micronutrient deficiency remains high among pregnant women, but macronutrient intake is generally adequate or even high.
Collapse
|
7
|
Gomes F, Ashorn P, Askari S, Belizan JM, Boy E, Cormick G, Dickin KL, Driller‐Colangelo AR, Fawzi W, Hofmeyr GJ, Humphrey J, Khadilkar A, Mandlik R, Neufeld LM, Palacios C, Roth DE, Shlisky J, Sudfeld CR, Weaver C, Bourassa MW. Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations. Ann N Y Acad Sci 2022; 1510:52-67. [PMID: 35000200 PMCID: PMC9306576 DOI: 10.1111/nyas.14733] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/27/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
Most low‐ and middle‐income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500‐mg doses/day). WHO recommends 1.5–2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low‐dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost‐effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron‐containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food‐based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.
Collapse
Affiliation(s)
- Filomena Gomes
- Nutrition Science Program New York Academy of Sciences New York City New York
- NOVA Medical School Universidade NOVA de Lisboa Lisboa Portugal
| | - Per Ashorn
- Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
| | | | - Jose M. Belizan
- Institute for Clinical Effectiveness and Health Policy/CONICET Buenos Aires Argentina
| | - Erick Boy
- International Food Policy Research Institute Washington District of Columbia
| | - Gabriela Cormick
- Institute for Clinical Effectiveness and Health Policy/CONICET Buenos Aires Argentina
| | | | | | - Wafaie Fawzi
- Harvard T.H. Chan School of Public Health Boston Massachusetts
| | - G. Justus Hofmeyr
- University of Botswana Gaborone Botswana
- University of the Witwatersrand and Walter Sisulu University Mthatha South Africa
| | - Jean Humphrey
- Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | | | - Rubina Mandlik
- Hirabai Cowasji Jehangir Medical Research Institute Pune India
| | | | | | - Daniel E. Roth
- The Hospital for Sick Children and University of Toronto Toronto Ontario Canada
| | - Julie Shlisky
- Nutrition Science Program New York Academy of Sciences New York City New York
| | | | | | - Megan W. Bourassa
- Nutrition Science Program New York Academy of Sciences New York City New York
| |
Collapse
|
8
|
Martin SL, McCann JK, Gascoigne E, Allotey D, Fundira D, Dickin KL. Engaging family members in maternal, infant and young child nutrition activities in low- and middle-income countries: A systematic scoping review. MATERNAL & CHILD NUTRITION 2021; 17 Suppl 1:e13158. [PMID: 34241961 PMCID: PMC8269148 DOI: 10.1111/mcn.13158] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 12/20/2022]
Abstract
The influence of fathers, grandmothers and other family members on maternal, infant and young child nutrition practices has been well documented for decades, yet many social and behavioural interventions continue to reach only mothers. While recent guidelines recommend involving fathers, grandmothers and other family members in maternal and child nutrition, we lack a comprehensive review of interventions that have engaged them. This scoping review aimed to address this gap by describing social and behavioural interventions to engage family members in maternal and child nutrition in low- and middle-income countries. We systematically searched PubMed, Scopus, Web of Science, Global Health and CINAHL for peer-reviewed studies meeting inclusion criteria. We screened 6,570 abstracts, evaluated 179 full-text articles, and included 87 articles from 63 studies. Studies reported a broad range of approaches to engage fathers, grandmothers and other family members to support maternal nutrition (n = 6); breastfeeding (n = 32); complementary feeding (n = 6) and multiple maternal and child nutrition practices (n = 19). Interventions were facility and community based; included individual and group-based interpersonal communication, community mobilization, mass media and mHealth; and reached mothers and family members together or separately. Most interventions were located within the health sector; rare exceptions included nutrition-sensitive agriculture, social protection, early child development and community development interventions. Few interventions addressed gender norms, decision-making, and family dynamics or described formative research or theories informing intervention design. These diverse studies can shed light on innovative programme approaches to increase family support for maternal and child nutrition.
Collapse
Affiliation(s)
- Stephanie L. Martin
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Juliet K. McCann
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Emily Gascoigne
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Diana Allotey
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Dadirai Fundira
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Katherine L. Dickin
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| |
Collapse
|
9
|
Cormick G, Betran AP, Romero IB, Cormick MS, Belizán JM, Bardach A, Ciapponi A. Effect of Calcium Fortified Foods on Health Outcomes: A Systematic Review and Meta-Analysis. Nutrients 2021; 13:316. [PMID: 33499250 PMCID: PMC7911363 DOI: 10.3390/nu13020316] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/02/2021] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
Calcium supplementation and fortification are strategies widely used to prevent adverse outcome in population with low-calcium intake which is highly frequent in low-income settings. We aimed to determine the effectiveness and cost-effectiveness of calcium fortified foods on calcium intake and related health, or economic outcomes. We performed a systematic review and meta-analysis involving participants of any age or gender, drawn from the general population. We searched PubMed, Agricola, EMBASE, CINAHL, Global Health, EconLit, the FAO website and Google until June 2019, without language restrictions. Pair of reviewers independently selected, extracted data and assessed the risk of bias of included studies using Covidence software. Disagreements were resolved by consensus. We performed meta-analyses using RevMan 5.4 and subgroup analyses by study design, age group, and fortification levels. We included 20 studies of which 15 were randomized controlled trials (RCTs), three were non-randomised studies and two were economic evaluations. Most RCTs had high risk of bias on randomization or blinding. Most represented groups were women and children from 1 to 72 months, most common intervention vehicles were milk and bakery products with a fortification levels between 96 and 1200 mg per 100 g of food. Calcium intake increased in the intervention groups between 460 mg (children) and 1200 mg (postmenopausal women). Most marked effects were seen in children. Compared to controls, height increased 0.83 cm (95% CI 0.00; 1.65), plasma parathyroid hormone decreased -1.51 pmol/L, (-2.37; -0.65), urine:calcium creatinine ratio decreased -0.05, (-0.07; -0.03), femoral neck and hip bone mineral density increased 0.02 g/cm2 (0.01; 0.04) and 0.03 g/cm2 (0.00; 0.06), respectively. The largest cost savings (43%) reported from calcium fortification programs came from prevented hip fractures in older women from Germany. Our study highlights that calcium fortification leads to a higher calcium intake, small benefits in children's height and bone health and also important evidence gaps for other outcomes and populations that could be solved with high quality experimental or quasi-experimental studies in relevant groups, especially as some evidence of calcium supplementation show controversial results on the bone health benefit on older adults.
Collapse
Affiliation(s)
- Gabriela Cormick
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina;
- Centro de Investigaciones Epidemiolóicas y Salud Púlica (CIESP-IECS), CONICET, Ciudad de Buenos Aires 1414, Argentina; (A.B.); (A.C.)
- Departament de Salud, Universidad Nacional de La Matanza (UNLAM), San Justo 1903, Argentina;
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 1211 Geneva, Switzerland;
| | - Iris Beatriz Romero
- Departament de Salud, Universidad Nacional de La Matanza (UNLAM), San Justo 1903, Argentina;
| | - Maria Sol Cormick
- Departament de Diagnóstico por Imágenes, Fleni, Montañeses 2325, Ciudad de Buenos Aires C1428, Argentina;
| | - José M. Belizán
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina;
- Centro de Investigaciones Epidemiolóicas y Salud Púlica (CIESP-IECS), CONICET, Ciudad de Buenos Aires 1414, Argentina; (A.B.); (A.C.)
| | - Ariel Bardach
- Centro de Investigaciones Epidemiolóicas y Salud Púlica (CIESP-IECS), CONICET, Ciudad de Buenos Aires 1414, Argentina; (A.B.); (A.C.)
- Centro Cochrane Argentino-Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina
| | - Agustín Ciapponi
- Centro de Investigaciones Epidemiolóicas y Salud Púlica (CIESP-IECS), CONICET, Ciudad de Buenos Aires 1414, Argentina; (A.B.); (A.C.)
- Centro Cochrane Argentino-Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina
| |
Collapse
|
10
|
Okwaraji YB, Hill Z, Defar A, Berhanu D, Wolassa D, Persson LÅ, Gonfa G, Schellenberg JA. Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5803. [PMID: 32796574 PMCID: PMC7459764 DOI: 10.3390/ijerph17165803] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 01/10/2023]
Abstract
An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.
Collapse
Affiliation(s)
- Yemisrach B. Okwaraji
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Zelee Hill
- Institute for Global Health, University College London, London WC1E 6BT, UK;
| | - Atkure Defar
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar 41822, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Desta Wolassa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Geremew Gonfa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Joanna A. Schellenberg
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
| |
Collapse
|
11
|
Martin SL, McCann JK, Gascoigne E, Allotey D, Fundira D, Dickin KL. Mixed-Methods Systematic Review of Behavioral Interventions in Low- and Middle-Income Countries to Increase Family Support for Maternal, Infant, and Young Child Nutrition during the First 1000 Days. Curr Dev Nutr 2020; 4:nzaa085. [PMID: 32607463 PMCID: PMC7311193 DOI: 10.1093/cdn/nzaa085] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Fathers, grandmothers, and other family members' influence on maternal, infant, and young child nutrition (MIYCN) is widely recognized, yet synthesis of the effectiveness of engaging them to improve nutrition practices during the first 1000 d is lacking. We examined the impact of behavioral interventions to engage family members in MIYCN in low- and middle-income countries through a mixed-methods systematic review. We screened 5733 abstracts and included 35 peer-reviewed articles on 25 studies (16 with quantitative and 13 with qualitative data). Most quantitative studies focused on early breastfeeding, primarily engaging fathers or, less often, grandmothers. Most found positive impacts on exclusive breastfeeding rates and family members' knowledge and support. The few quantitative studies on complementary feeding, maternal nutrition, and multiple outcomes also suggested benefits. Qualitative themes included improved nutrition behaviors, enhanced relationships, and challenges due to social norms. Interventions engaging family members can increase awareness and build support for MIYCN, but more rigorous study designs are needed. This systematic review is registered at PROSPERO as CRD42018090273, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90273.
Collapse
Affiliation(s)
- Stephanie L Martin
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Juliet K McCann
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Emily Gascoigne
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diana Allotey
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dadirai Fundira
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| |
Collapse
|