Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review

Biofortification as a food-based strategy to improve nutrition in high-income countries: a scoping review

Biofortification (increasing the micronutrient content of food before harvest) has been successfully used to nutritionally improve staple foods in low- and middle-income countries. This approach could also help address micronutrient shortfalls in at-risk populations in high-income countries (HICs), however, the potential of biofortification interventions in this context is not well understood. The aim of this scoping review is to assess the nature and extent of available research evidence on biofortified foods in relation to human consumption in HICs. Literature searches were conducted in MEDLINE, WoS, ProQuest, CINAHL, AGRIS and Epistemonikos. Forty-six peer-reviewed articles were included. Most research was conducted in the USA (n = 15) and Italy (n = 11), on cereal crops (n = 14) and vegetables (n = 11), and on selenium (n = 12) and provitamin A (n = 11). Seven research domains were identified in the literature: bioavailability (n = 17); nutrient stability (n = 11); opinions and attitudes (n = 9); functionality (n = 9); sensory properties (n = 2); safety (n = 1); and modeling (n = 1). Evidence from HICs in each domain is limited. There is a need for more research particularly in areas sensitive to the cultural and socio-economic context.

Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal

Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.

Preventing chronic malnutrition in children under 2 years in rural Angola (MuCCUA trial): protocol for the economic evaluation of a three-arm community cluster randomised controlled trial

INTRODUCTION

Chronic malnutrition is a serious problem in southern Angola with a prevalence of 49.9% and 37.2% in the provinces of Huila and Cunene, respectively. The MuCCUA (Mother and Child Chronic Undernutrition in Angola) trial is a community-based randomised controlled trial (c-RCT) which aims to evaluate the effectiveness of a nutrition supplementation plus standard of care intervention and a cash transfer plus standard of care intervention in preventing stunting, and to compare them with a standard of care alone intervention in southern Angola. This protocol describes the planned economic evaluation associated with the c-RCT.

METHODS AND ANALYSIS

We will conduct a cost-efficiency and cost-effectiveness analysis nested within the MuCCUA trial with a societal perspective, measuring programme, provider, participant and household costs. We will collect programme costs prospectively using a combined calculation method including quantitative and qualitative data. Financial costs will be estimated by applying activity-based costing methods to accounting records using time allocation sheets. We will estimate costs not included in accounting records by the ingredients approach, and indirect costs incurred by beneficiaries through interviews, household surveys and focus group discussions. Cost-efficiency will be estimated as cost per output achieved by combining activity-specific cost data with routine data on programme outputs. Cost-effectiveness will be assessed as cost per stunting case prevented. We will calculate incremental cost-effectiveness ratios comparing the additional cost per improved outcome of the different intervention arms and the standard of care. We will perform sensitivity analyses to assess robustness of results.

ETHICS AND DISSEMINATION

This economic evaluation will provide useful information to the Angolan Government and other policymakers on the most cost-effective intervention to prevent stunting in this and other comparable contexts. The protocol was approved by the República de Angola Ministério da Saúde Comité de Ética (27C.E/MINSA.INIS/2022). The findings of this study will be disseminated within academia and the wider policy sphere.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05571280).

Projecting the long-term economic benefits of reducing Shigella-attributable linear growth faltering with a potential vaccine: a modelling study

BACKGROUND

Linear growth is an important outcome of child development with implications for economic productivity. Enteric infections, particularly Shigella, have been linked to linear growth faltering (LGF). However, benefits from potential reductions in LGF are rarely included in economic analyses of enteric infections. We aimed to quantify the economic benefits of vaccination related to reduced Shigella-attributable disease and associated LGF compared with the net costs of a vaccine programme.

METHODS

In this benefit-cost analysis, we modelled productivity benefits in 102 low-income and middle-income countries that had recent stunting estimates available, at least one Shigella-attributable death annually, and available economic data, particularly on gross national income and growth rate projections. We modelled benefits strictly related to linear growth improvements and no other benefits associated with reducing diarrhoeal burden. The effect size in each country was calculated as shifts in height-for-age Z score (HAZ), representing population average changes for preventing Shigella-attributable less-severe diarrhoea and moderate-to-severe diarrhoea separately for children younger than 5 years. Benefits data were calculated per country and combined with estimated net costs of the vaccine programme in the form of benefit-cost ratios (BCRs); BCRs above parity, or $1 in benefits per $1 in costs (with a 10% margin representing borderline results: 1·10:1), were considered cost-beneficial. Countries were aggregated for analysis by WHO region, World Bank income category, and eligibility for support from Gavi, the Vaccine Alliance.

FINDINGS

In the base-case scenario, all regions exhibited cost-beneficial results, with the South-East Asia region and Gavi-eligible countries exhibiting the highest BCRs (21·67 for the South-East Asia region and 14·45 for Gavi-eligible countries), and the Eastern Mediterranean region yielding the lowest BCRs (2·90). All regions exhibited cost-beneficial results from vaccination, except in more conservative scenarios (eg, those assuming early retirement ages and higher discount rates). Our findings were sensitive to assumed returns for increased height, assumptions about vaccine efficacy against linear growth detriments, the anticipated shift in HAZ, and discount rate. Incorporating the productivity benefits of LGF reduction into existing cost-effectiveness estimates resulted in longer-term cost-savings in nearly all regions.

INTERPRETATION

LGF is a secondary outcome of Shigella infection and reduction in LGF is not often quantified as a health or economic benefit of vaccination. However, even under conservative assumptions, a Shigella vaccine only moderately effective against LGF could pay for itself from productivity gains alone in some regions. We recommend that LGF be considered in future models assessing the economic and health impacts of interventions preventing enteric infections. Further research is needed on vaccine efficacy against LGF to inform such models.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust.

Barriers and Opportunities for Clinical Nutritionists in 13 Latin American Countries: A Qualitative Study

A clinical nutritionist (CN) is a university-educated professional trained to perform preventive and recovery functions in the health of patients. The actions of these professionals, both worldwide and in Latin America, may face barriers and opportunities that require careful identification and examination. The main objective of this study is to identify the most important barriers and opportunities for the clinical nutritionist in 13 Latin American countries. A qualitative study was carried out; the initial phase involved conducting in-depth individual interviews with 89 informants, experienced CNs from 13 Latin American countries. After calculating the mean and standard deviation, we ranked the top 10 most frequently reported barriers by assigning a score ranging from 1 to 10. Additionally, 3 opportunities were identified with a lower score from 1 to 3. Means and standard deviation were calculated to sort the responses. Results: the most important barrier was the absence of public policies that regulate and/or monitor compliance with the staffing of CNs according to the number of hospital beds, while the most important opportunity was the advances in technology such as software, body analysis equipment and other tools used in Nutritional Care. The identified barriers can interfere with the professional performance of CNs and, moreover, make it difficult to monitor the good nutritional status of patients. It is recommended to consider the barriers identified in this study, as well as the opportunities, with a view to improving the quality of hospital services with an adequate supply of nutritionists.