RESUMO
The objective of this study was to test whether adding a text message campaign about the importance of eating eggs and other nutrition-related behaviours to an on-going package of large-scale, diverse social and behaviour change interventions would improve four types of nutrition-related knowledge and behaviour outcomes: child diets (egg consumption as the primary outcome), maternal diets, maternal nutrition knowledge, and maternal participation in additional interventions. The cluster-randomized controlled trial involved a repeat cross-sectional design, recruiting families with children 12-23 months of age at baseline and endline in one plains district of Nepal. Throughout the 1000-day period, 51 text messages were sent to each household at specific time points to reinforce ideal diets and other nutrition-related practices and promote engagement with community health workers and other intervention platforms. The primary outcome was egg consumption and dietary diversity among young children. We found no population-level effect. Some evidence supports that for those who received and opened the SMS intervention, it improved child egg consumption (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.03-1.93), child minimum dietary diversity (OR: 1.36, 95% CI: 1.07-1.73), child dietary diversity scores (ß: 0.15, 95% CI: 0.01-0.24), as well as maternal IYCF knowledge (ß: 0.21, 95% CI: 0.08-0.35), participation in health mothers' group meetings (OR: 3.03, 95% CI: 1.91-4.84) and Bhanchhin Aama listenership (OR: 1.36, 95% CI: 1.07-1.73). This study highlights the importance of more research to understand the effectiveness of emerging digital interventions for behaviour change among specific populations, to facilitate nuanced targeting to those who can best benefit from these investments. Registered at clinicaltrials.gov with identifier NCT03926689.
RESUMO
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.
RESUMO
Maternal and child undernutrition remain major public health problems in Nepal. Suaahara is a USAID-funded multi-sectoral nutrition programme aiming to strengthen local nutrition governance to reduce maternal and child undernutrition, among other objectives. The purpose of this study is to present findings from a recent qualitative evaluation of Suaahara II's influence on the decentralised implementation of Nepal's Multi-sectoral Nutrition Plan (MSNP) and identifying gaps and areas for improvement at the federal, provincial, and local levels to strengthen nutrition governance. This study employed multiple qualitative methods, engaging over 100 multi-sectoral nutrition stakeholders across three levels of government and eight districts. Thematic qualitative analysis was employed to identify emergent and salient themes, which were triangulated with other secondary data sources. Suaahara II had a positive influence on strengthening horizontal coordination for implementing the MSNP and effectively leveraged existing networks to strengthen implementation of nutrition-focused activities at the municipal level. Although there was an observable increased demand for nutrition budgets attributable to Suaahara II activities, sufficient allocation and utilisation, particularly in non-health sectors, did not meet these levels. Nepal's shift to federalism hindered vertical coordination of MSNP implementation. Some formal coordination mechanisms were strengthened, but variation in their effectiveness to strengthen horizontal and vertical coordination to implement MSNP activities continues. Finally, limited government ownership over nutrition activities and facilitating multi-sector coordination to implement the MSNP threatened sustainability of Suaahara II's outcomes on nutrition governance. Future programmes should continue to build on the progress made under Suaahara II, and specifically aim to address challenges in vertical coordination to strengthen nutrition governance in Nepal.
RESUMO
Background: Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality. Objectives: This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings. Methods: SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff). Results: Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation. Conclusions: Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.
RESUMO
BackgroundQuarantine of healthcare workers (HCWs) exposed to COVID -19 confirmed cases is a well-known strategy for limiting the transmission of infection. However, there is need of evidence-based guidelines for quarantine of HCWs in COVID -19. MethodsWe describe our experience of contact tracing and risk stratification of 3853 HCWs who were exposed to confirmed COVID-19 cases in a tertiary health care institution in India. We developed an algorithm, on the basis of risk stratification, to rationalize quarantine among HCWs. Risk stratification was based on the duration of exposure, distance from the patient, and appropriateness of personal protection equipment (PPE) usage. Only high-risk contacts were quarantined for 14 days. They underwent testing for COVID-19 after five days of exposure, while low-risk contacts continued their work with adherence to physical distancing, hand hygiene, and appropriate use of PPE. The low-risk contacts were encouraged to monitor for symptoms and report for COVID-19 screening if fever, cough, or shortness of breath occurred. We followed up all contacts for 14 days from the last exposure and observed for symptoms of COVID-19 and test positivity. Results and interpretationOut of total 3853 contacts, 560 (14.5%) were categorized as high-risk contacts, and 40 of them were detected positive for COVID-19, with a test positivity rate of 7.1% (95% CI = 5.2 - 9.6). Overall, 118 (3.1%) of all contacts tested positive. Our strategy prevented 3215 HCWs from being quarantined and saved 45,010 person-days of health workforce until June 8, 2020, in the institution. We conclude that exposure-based risk stratification and quarantine of HCWs is a viable strategy to prevent unnecessary quarantine, in a healthcare institution. SummaryO_ST_ABSWhat is already known about this subject?C_ST_ABSO_LIQuarantine of HCWs is a well-known strategy for community and HCWs to prevent the transmission of COVID-19. C_LIO_LIThough success stories of prompt contact tracing and quarantine to control COVID-19 are available from countries like South Korea, Singapore, and Hong Kong, there is a scarcity of evidence that could guide targeted quarantine of HCWs exposed to COVID -19 in India. C_LI What does this study add?O_LIOnly 14.5% HCWs exposed to COVID-19 cases were stratified "high risk" contacts, and the most common reason for high-risk contacts was non-formal workplace interactions such as having meals together. C_LIO_LIThe overall test positivity rate among the high-risk contacts was 7.1%, while it was higher in symptomatic high-risk contacts as compared to those who were asymptomatic (10.2% vs. 6.3%). C_LI How might this impact on clinical practice?O_LIContact tracing and risk stratification can be used to minimize unnecessary quarantine of COVID-19 exposed health care workers and prevent the depletion of healthcare workers amidst the pandemic to continue the healthcare services optimally. C_LI
RESUMO
OBJECTIVES: Maternal health-seeking behaviors are critical to improving maternal and child health in low-income countries. This study investigates associations between maternal decision-making input and their health-seeking behaviors in the first 1000-day period between pregnancy and a child's second birthday in Nepal. METHODS: We used data from a cross-sectional survey conducted in 2018 in 16 districts of Nepal. Among the 3648 households surveyed, 1910 mothers of a child 0 to 24 months with complete data were included for analyses. Logistic regression was used to examine associations between decision-making input and the utilization of antenatal, delivery and postnatal care services, and attendance at health mothers' group (HMG) meetings. We also used negative binomial regression to assess the relationship between her decision-making input and participation in growth monitoring and promotion (GMP) in the 6 months prior to the survey. For each relationship examined, we adjusted for clustering, as well as potentially confounding factors at individual and household levels. RESULTS: After adjusting for confounders, maternal decision-making input had a small but positive and significant association with receiving at least 4 antenatal care visits (OR = 1.09, 95% CI 1.02, 1.17), attendance at GMP in the 6 months prior to the survey (IRR = 1.02, 95% CI 1.00, 1.04), and HMG attendance (OR = 1.10, 95% CI 1.03, 1.17), but not with receiving at least 3 postnatal care visits or delivering in a health institution. CONCLUSIONS FOR PRACTICE: Our findings indicated that empowering women and mothers in household decision-making might warrant greater attention when developing future policies and programs in Nepal.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Tomada de Decisões , Comportamentos Relacionados com a Saúde , Serviços de Saúde/estatística & dados numéricos , Mães/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Criança , Estudos Transversais , Feminino , Humanos , Saúde Materna/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Mães/estatística & dados numéricos , Nepal , Gravidez , Fatores SocioeconômicosRESUMO
The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal's 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII's 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2-5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6-24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2-5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2-5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.
Assuntos
Transtornos da Nutrição Infantil/epidemiologia , Dieta , Fenômenos Fisiológicos da Nutrição do Lactente , Estado Nutricional/fisiologia , Adolescente , Adulto , Criança , Transtornos da Nutrição Infantil/fisiopatologia , Pré-Escolar , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Masculino , Mães , Nepal/epidemiologia , Gravidez , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: Suaahara, a large-scale integrated program, aimed to improve diets and nutritional status among women and children, in part by facilitating enhanced homestead food production (EHFP). OBJECTIVE: This study examines associations between EHFP and maternal and child dietary diversity and variations by season and agroecological zone (AEZ): mountains and terai. METHODS: We used data from household monitoring surveys (n = 2101 mothers; n = 994 children, 6-23 months), which included a 7-day dietary recall and maternal report on participation in 5 EHFP activities-received vegetable seeds, chicks, and technical support and participated in training and EHFP groups. We constructed binary variables for each activity and a scale (0-5) summing participation. For dietary diversity, we used the Women's Dietary Diversity Score using 10 food groups and 7 food groups for child diets. Multivariable linear regression analyses were used to assess associations between EHFP participation and dietary diversity by season and AEZ, controlling for potential confounders and clustering. RESULTS: In adjusted models, we found positive associations between dietary diversity and chicks, technical support, and EHFP beneficiary groups; the magnitude of the associations varied by season and AEZ. The degree of participation in 5 EHFP activities was positively associated with maternal dietary diversity in the terai (ß = .24, P < .001) and mountains (ß = .12, P = .01) and child dietary diversity in the terai (ß = .35, P < .001) during the winter. No associations were found in the rainy season. CONCLUSION: Our findings highlight the potential for EHFP to address dietary diversity constraints among this population. Variation by subnational setting and seasonality suggest that policies and programs should be contextualized.