Strengthening nutrition services within integrated community case management (iCCM) of childhood illnesses in the Democratic Republic of Congo: Evidence to guide implementation

Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

BACKGROUND

Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.

METHODS

A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.

RESULTS

The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11-0.52), secondary AOR = 0.16, 95% CI:0.07-0.39), and college and above AOR = 0.08, 95% CI:0.07-0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14-4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99-7.35), and waiting time (AOR = 2.80, 95% CI:1.16-6.79) were factors associated with the acceptability of the program by caregivers.

CONCLUSION AND RECOMMENDATION

The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW's to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Application of the integrated gateway model on child nutrition behaviors in Niger: An exploratory analysis

OBJECTIVE

To identify potential gateway factors and behaviors that are associated with infant and young child feeding (IYCF) practices in the Maradi and Zinder regions of Niger through application of the Integrated Gateway Model.

METHODS

We analyzed data from 2,727 married women of reproductive age including details on child feeding practices for their 2,551 children between the ages of 0 to 23 months. We assessed the association of three gateway behaviors (i.e., any antenatal care, facility delivery, and communication on nutrition practices) and gateway factors (i.e., behavioral determinants, exposure to information, decision-making agency, and woman's group participation) on four IYCF practices (i.e., early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency, and minimum dietary diversity) while controlling for age, parity, educational attainment, and household wealth.

RESULTS

We found antenatal care was associated with exclusive breastfeeding of children 0-5 months [adjusted odds ratio (aOR): 1.17 (95% confidence interval (CI): 1.03-1.33)], and minimum meal frequency of children 6-23 months [aOR: 1.10 (95% CI: 1.03-1.17)], and facility delivery was associated with early initiation of breastfeeding among children 0-5 months [aOR: 2.08 (95% CI: 1.39-3.12)]. We found negative associations with exclusive breastfeeding and communication on nutrition practices with husbands, family/friends, and health workers. Exposure to nutrition messages through radio, women's groups participation, and with health workers was positively associated with minimum dietary diversity. Self-efficacy was positively associated with both early initiation of breastfeeding, exclusive breastfeeding among children 0-5 months and minimum dietary diversity among children 6-23 months. Women's agency was positively associated with early initiation of breastfeeding.

CONCLUSION

The association of antenatal care and facility delivery with child nutrition outcomes suggest intervening before a woman becomes pregnant or early in her pregnancy could improve nutrition outcomes. Programs strengthening the continuum of care should identify gateway behaviors to maximize adoption of priority health behaviors.

Trends in socioeconomic inequalities in malnutrition among children under 5 in the Democratic Republic of the Congo from 2001 to 2018

OBJECTIVE

Malnutrition in the Democratic Republic of the Congo (DRC) has declined over the past 2 decades. However, malnutrition inequality persists. Evaluating trends of socioeconomic disparities in malnutrition among children under 5 y of age in the DRC can help target meaningful interventions.

METHOD

Data from the Multiple Indicator Cluster Survey (2001, 2010, 2018) assessed the prevalence of underweight, stunting, and wasting among children under 5. The Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) measured socioeconomic inequalities. We evaluated trends in the entire national sample and stratified subsamples based on place of residence and wealth index quintiles. The final sample included 42 976 children.

RESULTS

The national prevalence of underweight and wasting decreased from 31% to 26% and 13% to 6% in rural and urban areas. However, trends in stunting prevalence varied between the two areas. Nutritional disparity widened between low- and high-income families (stunting RIIs: 0.61 in 2001, 0.37 in 2018; stunting SIIs: -0.20 in 2001, -0.40 in 2018; underweight RIIs: 0.53 in 2001, 0.35 in 2018; underweight SIIs: -0.21 in 2001, -0.28 in 2018). Urban areas experienced greater inequality than rural areas (stunting in urban RIIs: 0.41 in 2001, 0.33 in 2010, 0.25 in 2018).

CONCLUSION

Despite progress in reducing malnutrition, persistent socioeconomic disparities, particularly in urban areas, remain a serious public health concern in the DRC. Addressing the root causes of malnutrition and ensuring socioeconomically equitable access to nutrition is critical to promote the full potential of children.

Relatively speaking? Partners' and family members' views and experiences of supporting breastfeeding: a systematic review of qualitative evidence

This review aimed to synthesize qualitative evidence of views and experiences of partners and other family members who provided breastfeeding support for a relative. The Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal and Infant Care, and Web of Science were searched. Partners and other family members (e.g. grandmothers, siblings) of women in any countries were included. Included papers were critically appraised. The JBI meta-aggregative approach was used to analyze data and form synthesized findings. Seventy-six papers from 74 studies were included. Five synthesized findings were: (i) spectrum of family members' breastfeeding knowledge, experiences and roles; (ii) the complexity of infant feeding decision making; (iii) the controversy of breastfeeding in front of others; (iv) impact of breastfeeding on family; and (v) it takes more than just family members: support for family members. Partners' and family members' views and experiences of breastfeeding support reflected multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors of the support they provided (or not). Healthcare professionals should engage them in breastfeeding discussions with the woman, and offer tailored and practical guidance relevant to help them to appropriately support the woman. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Exploring the Influence of Social Norms on Complementary Feeding: A Scoping Review of Observational, Intervention, and Effectiveness Studies

The influence of social norms on child feeding is recognized, but guidance is lacking on how to address norms and related perceptions that hinder or support positive nutrition practices. We reviewed recent peer-reviewed and grey literature to summarize social norms relevant to complementary feeding (CF), intervention approaches that address norms, and their impacts on social norms and CF outcomes. Many reports described various norms, customs, and perceptions related to appropriate foods for young children, parenting practices, gender, and family roles, but rarely explored how they motivated behavior. Community engagement and media interventions addressed norms through facilitated discussions, challenging negative norms, portraying positive norms, engaging emotions, and correcting misperceptions. Evaluations of norms-focused interventions reported improved CF practices, but few assessed impacts on social norms. Although multiple contextual factors influence CF practices, evidence suggests the feasibility and effectiveness of addressing social norms as one component of programs to improve CF practices.

Utilization of traditional medicine in primary health care in low- and middle-income countries: a systematic review

This paper reports the findings from the first systematic review of the utilization of traditional medicine (TM) in primary health care (PHC) in low- and middle-income countries (LMICs). PHC is an important component of health care and essential for achieving universal health coverage (UHC). For countries where there is a gap in PHC, TM plays a vital role. It is widely used and has the potential to increase the coverage of PHC and UHC. Hence in situations where TM is recognized in a considerable magnitude, there are scarce evidence and minimal regulation on it and TM practitioners (TMPs). This study aims to identify the current situation in the utilization of TM in PHC or UHC in LMICs. A systematic review and thematic synthesis of qualitative and quantitative studies have been conducted. A total of 56 articles met the criteria and were included in the review. In all, 14 analytic themes have been developed including the current use of TM in PHC, higher accessibility of TM, medical pluralism, national health system, national health policy and national health insurance to include TM, including TMPs in the referral system, utilizing TMPs as community health workers, the needs of scientific research on TM and the need for training both TMPs and conventional medical staffs for better collaboration. The study concluded that it is necessary to further focus on TM in the macro level on strengthening the referral system by including TM to establish a comprehensive service delivery network under UHC and in the micro level to focus on training the TMPs and conventional medicine health workers on both areas to attain more in-depth understanding of each other, which can lead to better collaboration and quality patient care.

Strengthening counseling on barriers to exclusive breastfeeding through use of job aids in Nampula, Mozambique

Introduction

While the Government of Mozambique has galvanized action around exclusive breastfeeding (EBF) as a national priority, only 43% of Mozambican children under six months of age are exclusively breastfed. In the absence of skilled lactation support, challenges mothers experience with breastfeeding may inhibit initiation, exclusivity and duration. There is insufficient evidence on how to strengthen health providers’ competencies to address breastfeeding challenges in low- and middle-income countries. The objectives of this study were to 1) assess EBF challenges, from the perspectives of health providers and mothers; 2) ascertain the quality of health provider counseling to address EBF challenges; and 3) gain an understanding of the usefulness of job aids to improve counseling within routine health contact points in Nampula, Mozambique.

Methods

This implementation science study was conducted in Meconta and Mogovolas districts, Nampula province, Mozambique from July-November 2018. In Phase 1, 46 in-depth interviews with mothers and providers, and 11 observations of counseling sessions were conducted. In Phase 2, health providers were trained to use three job aids (i.e., facility, community or maternity contacts) to identify and address EBF problems during routine health services. In Phase 3, 30 in-depth interviews with mothers and providers were conducted to assess the experience with job aid use. In both Phase 1 and 3, we conducted a thematic analysis using a grounded theory approach involving a step-wise coding process.

Results

Poor latch and positioning, perceived insufficient breastmilk and breast engorgement emerged as barriers to EBF. Providers often lacked the knowledge, skillset, and self-efficacy to manage EBF problems, with little counseling provided at community or facility levels. Following job aid rollout, providers reported improved assessment of breastfeeding technique, and increased self-efficacy and motivation to identify and resolve EBF problems.

Conclusions

Integration of job aids, with clear lactation management guidance, into maternal and child health training curricula and supportive supervision is critical to building providers’ skillsets and competencies to provide quality lactation counseling and support.

Strengthening nutrition services within integrated community case management (iCCM) of childhood illnesses in the Democratic Republic of Congo: Evidence to guide implementation

In the Democratic Republic of Congo, 43% of children under 5 years of age suffer from stunting, and the majority (60%) of children, 6–59 months of age, are anaemic. Malaria, acute respiratory infections, and diarrheal diseases are common among children less than 5 years of age, with 31% of children 6–59 months affected by malaria. This qualitative implementation science study aimed to identify gaps and opportunities available to strengthen service delivery of nutrition within integrated community case management (iCCM) at the health facility and community level in Tshopo Province, Democratic Republic of Congo, through the following objectives: (a) examine cultural beliefs and perceptions of infant and young child feeding (IYCF) and child illness, (b) explore the perspectives and knowledge of facility‐based and community‐based health providers on nutrition and iCCM, and (c) gain an understanding of the influence of key family and community members on IYCF and care‐seeking practices. This study involved in‐depth interviews with mothers of children under 5 years of age (n = 48), grandmothers (n = 20), fathers (n = 21), facility‐based providers (n = 18), and traditional healers (n = 20) and eight focus group discussions with community health workers. Study findings reveal most mothers reported diminished quantity and quality of breastmilk linked to child/maternal illness, inadequate maternal diet, and feedings spaced too far apart. Mothers' return to work in the field led to early introduction of foods prior to 6 months of age, impeding exclusive breastfeeding. Moreover, children's diets are largely limited in frequency and diversity with small quantities of foods fed. Most families seek modern and traditional medicine to remedy child illness, dependent on type of disease, its severity, and cost. Traditional healers are the preferred source of information for families on certain child illnesses and breastmilk insufficiency. Community health workers often refer and accompany families to the health centre, yet are underutilized for nutrition counselling, which is infrequently given. Programme recommendations are to strengthen health provider capacity to counsel on IYCF and iCCM while equipping health workers with updated social and behavior change communication (SBCC) materials and continued supportive supervision. In addition, targeting key influencers to encourage optimal IYCF practices is needed through community and mother support groups. Finally, exploring innovative ways to work with traditional healers, to facilitate referrals for sick/malnourished children and provide simple nutrition advice for certain practices (i.e., breastfeeding), would aid in strengthening nutrition within iCCM.

Integrating nutrition services into health care systems platforms: Where are we and where do we go from here

Integrating maternal-child nutrition into health care services is a desirable but complex task that requires implementation research studies. This special supplement, entitled "How to Strengthen Nutrition into the Health Platform: Programmatic Evidence and Experience from Low- and Middle-Income Countries" presents a collection of mixed-methods research and case studies mostly conducted in sub-Saharan Africa that help us gain a better understanding of the barriers and facilitators for this integration to happen. Collectively, the evidence confirms that integrating nutrition services as part of health care systems and other platforms is feasible, but for that to be successful, there is a need to address strong barriers related to all six key health care systems building blocks identified by the World Health Organization. These include financing, health information systems, health workforce, supplies and technology, governance, and service delivery. Moving forward, it is crucial that more robust implementation science research is conducted within the rough and tumble of real-world programming to better understand how to best integrate and scale up nutrition services across health care systems and other platforms based on dynamic complex adaptive systems frameworks. This research can help better understand how the key health care systems building blocks need to interlock and communicate with each other to improve the policymakers' ability to integrate and scale up nutrition services in a more timely and cost-effective way.

Who are the real community health workers in Tshopo Province, Democratic Republic of the Congo?

Recent years have seen increasing momentum towards task shifting of basic health services, including using community health workers (CHW) to diagnose and treat common childhood illnesses. Yet few studies have examined the role of traditional healers in meeting families’ and communities’ health needs and liaising with the formal health system. We examine these issues in Tshopo Province in the Democratic Republic of the Congo, a country with high rates of child mortality (104 deaths per 1000 live births). We conducted 127 in-depth interviews and eight focus group discussions with a range of community members (mothers, fathers and grandmothers of children under 5 years of age) and health providers (CHWs, traditional healers, doctors and nurses) on topics related to care seeking and case management for childhood illness and malnutrition, and analysed them iteratively using thematic content analysis. We find significant divergence between biomedical descriptions of child illness and concepts held by community members, who distinguished between local illnesses and so-called ‘white man’s diseases.’ Traditional healers were far less costly and more geographically accessible to families than were biomedical health providers, and usually served as families’ first recourse after home care. Services provided by traditional healers were also more comprehensive than services provided by CHWs, as the traditional medicine sphere recognised and encompassed care for ‘modern’ diseases (but not vice versa). Meanwhile, CHWs did not receive adequate training, supervision or supplies to provide child health services. Considering their accessibility, acceptability, affordability and ability to recognise all domains of illness (biomedical and spiritual), traditional healers can be seen as the de facto CHWs in Tshopo Province. National and international health policymakers should account for and involve this cadre of health workers when planning child health services and seeking to implement policies and programmes that genuinely engage with community health systems.