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).

Malnutrition and morbidity trends in Somalia between 2007 and 2016: results from 291 cross-sectional surveys.

BACKGROUND: More than two decades of conflict and natural disasters in Somalia have resulted in one of the longest running humanitarian crises in the world. Nutrition data have been collected over the years despite challenges to inform programmatic action. This paper explores malnutrition and morbidity trends in Somalia during the last decade, disaggregated by geographical zone and livelihood system. METHODS: We used data from 291 cross-sectional surveys conducted in children aged 6-59 months between 2007 and 2016 in Somalia. Wasting, morbidity and stunting prevalences over time were analysed by geographic area, livelihood system and season. Logistic regressions were used to test trends. RESULTS: The wasting trends show a striking peak in 2011, more marked in southern and central Somalia and coinciding with the famine declaration. The trend declines slightly thereafter although not consistently across all zones and livelihoods, and it raises again in 2016 especially among internally displaced persons (IDPs). Stunting declined for all groups and in all zones but with more consistent patterns in northern Somalia.Morbidity also showed a declining trend, although with multiple peaks depicting disease outbreaks.Pastoralist showed the lowest stunting estimates overall, while agrarian populations showed the lowest prevalence of wasting and morbidity. IDPs were the most affected by all outcomes. Seasonality affected the three outcomes differently by livelihood system. Stunting rates increased after the 2011 famine for all age groups within children under 5 years. CONCLUSIONS: Despite the continuous complex situation in Somalia, there has been a sustained decline in stunting and morbidity in the last decade. Wasting trends have remained at very high levels especially in north-east and the south zones of Somalia. The findings support the importance of performing trend analyses disaggregated by zone and livelihood groups within countries to better identify priorities for programme intervention.

Maternal exposure to intimate partner violence and breastfeeding practices in 51 low-income and middle-income countries: A population-based cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) against women is a major global health issue, particularly in low- and middle-income countries (LMICs), that is associated with poor physical and mental health, but its association with breastfeeding practices is understudied. Both the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life. Breastfeeding within the first hour of birth is critical to newborn survival, and exclusive breastfeeding for 6 months is recognised to offer significant health benefits to mothers and their infants. We examined the association of maternal exposure to IPV with early initiation of breastfeeding (within 1 hour of birth) and exclusive breastfeeding in the first 6 months. METHODS AND FINDINGS: We assessed population-based cross-sectional Demographic and Health Surveys (DHS) from 51 LMICs. Data from the most recent DHS in each country (conducted between January 2000 and January 2019) with data available on IPV and breastfeeding practices were used. By WHO region, 52.9% (27/51) were from Africa, 11.8% (6/51) from the Americas, 7.8% (4/51) from the Eastern Mediterranean, 11.8% (6/51) from Europe, 11.8% (6/51) from South-East Asia, and 3.9% (2/51) from the Western Pacific. We estimated multilevel logistic regression models for any IPV and each type of IPV separately (physical violence, sexual violence, and emotional violence), accounting for demographic and socioeconomic factors. Depending on specification, the sample size varied between 95,320 and 102,318 mother-infant dyads. The mean age of mothers was 27.5 years, and the prevalence of any lifetime exposure to IPV among mothers was 33.3% (27.6% for physical violence, 8.4% for sexual violence, and 16.4% for emotional violence). Mothers exposed to any IPV were less likely to initiate breastfeeding early (adjusted odds ratio [AOR]: 0.88 [95% CI 0.85-0.97], p < 0.001) and breastfeed exclusively in the first 6 months (AOR: 0.87 [95% CI 0.82-0.92], p < 0.001). The associations were similar for each type of IPV and were overall consistent across infant's sex and WHO regions. After simultaneously adjusting for all 3 types of IPV, all 3 types of IPV were independently associated with decreased likelihood of early breastfeeding initiation, but only exposure to physical violence was independently associated with a decreased likelihood of exclusively breastfeeding in the first 6 months. The main limitations of this study included the use of cross-sectional datasets, the possibility of residual confounding of the observed associations by household wealth, and the possibility of underreporting of IPV experiences attenuating the magnitude of observed associations. CONCLUSIONS: Our study indicates that mothers exposed to any form of IPV (physical, sexual, or emotional violence) were less likely to initiate breastfeeding early and breastfeed exclusively in the first 6 months. These findings may inform the argument for antenatal screening for IPV in LMICs and the provision of services to not only improve mothers' safety and well-being, but also support them in adopting recommended breastfeeding practices.

Dietary patterns and nutritional status of HIV-infected children and adolescents in El Salvador: A cross-sectional study.

INTRODUCTION: The present study aimed to assess the nutritional status, the dietary patterns and its associated factors in the HIV-infected population of children and adolescents on antiretroviral treatment at the El Salvador reference center for pediatric HIV care (CENID). METHODS: A cross-sectional survey was carried out between December 2010 and December 2011. Socio-demographic and clinical characteristics were collected from 307 children and adolescents aged 2-18 years and receiving antiretroviral therapy. Nutritional status was assessed by height-for-age, weight-for-height and body mass index-for-age. Dietary data was collected through a 24 hour recall, and through a weekly food frequency questionnaire. Dietary patterns were identified by principal component analysis. Bivariate and multivariable statistical methods were used to assess the factors associated with "high adherence" to the "healthy diet" pattern. RESULTS: More than a third of the study group (33.2%) were stunted, 3.3% were identified as being wasted, and 10% were overweight or obese. Their diets were predominantly based on a high consumption of cereals, beans, eggs and processed foods and a low consumption of fruits, vegetables and dairy products. Three dietary patterns were identified: "healthy diet", "high fat/sugar diet" and "low diversity diet". Being female (OR: 1.63; 95%CI: 0.97-2.75), younger (OR: 2.37; 95%CI: 1.28-4.36) and institutionalized (OR: 14.5; 95%CI: 5.35-39.50) increased the odds to adhere to the "healthy diet" pattern. CONCLUSION: Our findings reveal a high prevalence of stunting and overweight in HIV-infected children in El Salvador. Institutionalized children were more likely to adhere to a healthy dietary pattern whereas children in poverty were more likely to have less varied and healthy diets. These results highlight the need to assess the dietary patterns of HIV-infected children and adolescents in order to guide public policies to design healthy life style interventions for this population at risk.

MUAC-for-age more useful than absolute MUAC for nutritional surveillance in Somalia: results from nineteen cross-sectional surveys (2007-2016).

BACKGROUND: Somalia is affected by a civil war and a protracted humanitarian crisis for more than two decades. The international community has put in place nutrition surveillance systems to monitor the situation and inform decisions. However, the indicators commonly used to identify acute malnutrition, weight-for-height Z-score (WHZ) and mid upper arm circumference (MUAC), do not always converge in their estimations of acute malnutrition, creating challenges for decision making. Furthermore, the divergences are not consistent across livelihood populations within the country. We explored the MUAC-for-age Z-score (MUACAZ) as an alternative indicator in Somalia to minimize the discrepancy. METHODS: We analyzed data from nineteen cross-sectional surveys conducted in Somalia between 2007 and 2016. We compared the acute malnutrition prevalence estimates by each of the indicators and the degree of overlap in the individual diagnosis of acute malnutrition between the WHZ and the MUAC-based indicators. We performed multivariate regression analysis with sex, age and stunting as independent variables and acute malnutrition as the dependent outcome, defined by WHZ, MUAC or MUACAZ. We performed all the analysis in the population overall and in each of the livelihood populations separately. RESULTS: A total 255,623 measurements of children 6-59 months of age were analyzed. The overall prevalence of global acute malnutrition by MUACAZ (15.8%) was similar to the one obtained using WHZ (16%), whereas prevalence based on MUAC was much lower (7.8%). These patterns of divergence were sustained throughout the nineteen surveys and the livelihoods studied, with only few exceptions. However, the proportion of overlap in the individual diagnosis of children as acutely malnourished was low between WHZ and absolute MUAC diagnosis (18.1%) and also between WHZ and MUACAZ (28.3%). Results show that age, sex and stunting status of the child affected the likelihood of being diagnosed as acutely malnourished to varying degrees, depending on the indicator used. CONCLUSIONS: The MUAC-for-age (MUACZ) indicator yielded acute malnutrition prevalence estimates convergent with those obtained by WHZ indicator. However, the degree of overlap between these two indicators for individual diagnosis of acute malnutrition is low. Further studies of MUACAZ as an alternative indicator for nutrition surveillance are needed.

Dyslipidemia, Diet and Physical Exercise in Children on Treatment With Antiretroviral Medication in El Salvador: A Cross-sectional Study.

BACKGROUND: Dyslipidemias are common in HIV-infected children, especially if treated with protease inhibitors, but there are few data on how to treat dyslipidemias in this population. We estimated the dyslipidemia prevalence and its association with treatment, diet and physical exercise in children on antiretroviral treatment at the El Salvador reference center for pediatric HIV care (CENID). METHODS: Information was gathered regarding socio-demographic characteristics, treatment, diet and physical activity of 173 children aged 5-18 years and receiving antiretroviral therapy. Triglycerides, total cholesterol, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), viral load and CD4 T-lymphocytes were measured. Abnormal concentrations were defined as triglycerides ≥130 mg/dL in 10- to 18-year olds and ≥100 mg/dL in <10-year olds; total cholesterol ≥200 mg/dL; LDL-C ≥130 mg/dL and HDL-C ≤35 mg/dL. We adjusted 4 different multivariate models to assess the independent association of each type of dyslipidemia with protease inhibitors, diet and physical exercise. RESULTS: Of the 173 children, 83 (48%) had hypertriglyceridemia and 25 (14.5%) hypercholesterolemia. High LDL-C concentrations were observed in 17 children (9.8%) and low HDL-C in 38 (22%). Treatment with protease inhibitors was significantly associated with hypertriglyceridemia [prevalence ratio (PR) 2.8; 95% confidence interval (CI): 2.0-3.8] and hypercholesterolemia (PR 9.0; 95% CI: 3.6-22.2). Higher adherence to a "high fat/sugar diet" was associated with hypercholesterolemia (PR 1.6; 95% CI: 1.1-2.3) and high LDL-C (PR 1.7; 95% CI: 1.0-2.9). Compared with those exercising <3 times/week, children exercising ≥7 times were less likely to have low HDL-C (PR = 0.4; 95% CI: 0.2-0.7). CONCLUSIONS: These results suggest that a healthy diet and exercise habits can contribute to controlling some aspects of the lipid profile in this population.