Correction to: Optima nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

It has been highlighted that the original manuscript [1] contains a typesetting error in the name of Meera Shekar. This had been incorrectly captured as Meera Shekhar in the original article which has since been updated.

Optima Nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

BACKGROUND: Child stunting due to chronic malnutrition is a major problem in low- and middle-income countries due, in part, to inadequate nutrition-related practices and insufficient access to services. Limited budgets for nutritional interventions mean that available resources must be targeted in the most cost-effective manner to have the greatest impact. Quantitative tools can help guide budget allocation decisions. METHODS: The Optima approach is an established framework to conduct resource allocation optimization analyses. We applied this approach to develop a new tool, 'Optima Nutrition', for conducting allocative efficiency analyses that address childhood stunting. At the core of the Optima approach is an epidemiological model for assessing the burden of disease; we use an adapted version of the Lives Saved Tool (LiST). Six nutritional interventions have been included in the first release of the tool: antenatal micronutrient supplementation, balanced energy-protein supplementation, exclusive breastfeeding promotion, promotion of improved infant and young child feeding (IYCF) practices, public provision of complementary foods, and vitamin A supplementation. To demonstrate the use of this tool, we applied it to evaluate the optimal allocation of resources in 7 districts in Bangladesh, using both publicly available data (such as through DHS) and data from a complementary costing study. RESULTS: Optima Nutrition can be used to estimate how to target resources to improve nutrition outcomes. Specifically, for the Bangladesh example, despite only limited nutrition-related funding available (an estimated $0.75 per person in need per year), even without any extra resources, better targeting of investments in nutrition programming could increase the cumulative number of children living without stunting by 1.3 million (an extra 5%) by 2030 compared to the current resource allocation. To minimize stunting, priority interventions should include promotion of improved IYCF practices as well as vitamin A supplementation. Once these programs are adequately funded, the public provision of complementary foods should be funded as the next priority. Programmatic efforts should give greatest emphasis to the regions of Dhaka and Chittagong, which have the greatest number of stunted children. CONCLUSIONS: A resource optimization tool can provide important guidance for targeting nutrition investments to achieve greater impact.

The costs of stunting in South Asia and the benefits of public investments in nutrition.

South Asia is home to the largest number of stunted children worldwide: 65 million or 37% of all South Asian children under 5 were stunted in 2014. The costs to society as a result of stunting during childhood are high and include increased mortality, increased morbidity (in childhood and later as adults), decreased cognitive ability, poor educational outcomes, lost earnings and losses to national economic productivity. Conversely, investing in nutrition provides many benefits for poverty reduction and economic growth. This article draws from analyses conducted in four sub-Saharan countries to demonstrate that investments in nutrition can also be very cost-effective in South Asian countries. Specifically, the analyses demonstrate that scaling up a set of 10 critical nutrition-specific interventions is highly cost-effective when considered as a package. Most of the interventions are also very cost-effective when considered individually. By modelling cost-effectiveness of different scale-up scenarios, the analysis offers insights into ways in which the impact of investing in nutrition interventions can be maximized under budget constraints. Rigorous estimations of the costs and benefits of nutrition investments, similar to those reported here for sub-Saharan countries, are an important next step for all South Asian countries in order to drive political commitment and action and to enhance allocative efficiency of nutrition resources.

Training and technical assistance for compliance with beverage and physical activity components of New York City's regulations for early child care centers.

INTRODUCTION: In 2006, the New York City Department of Health and Mental Hygiene (DOHMH) passed regulations for child care centers that established standards for beverages provided to children and set a minimum amount of time for daily physical activity. DOHMH offered several types of training and technical assistance to support compliance with the regulations. This article analyzes the association between training and technical assistance provided and compliance with the regulations in a sample of 174 group child care centers. METHODS: Compliance was measured by using a site inventory of beverages stored on premises and a survey of centers' teachers regarding the amount of physical activity provided. Training and technical assistance measures were based on the DOHMH records of training and technical assistance provided to the centers in the sample and on a survey of center directors. Ordinal logistic regression was used to assess the association between training and technical assistance measures and compliance with the regulations. RESULTS: Measures of training related to physical activity the center received: the number of staff members who participated in Sport, Play and Active Recreation for Kids (SPARK) and other training programs in which a center participated were associated with better compliance with the physical activity regulations. Neither training nor technical assistance were associated with compliance with the regulations related to beverages. CONCLUSION: Increased compliance with regulations pertaining to physical activity was not related to compliance with beverage regulations. Future trainings should be targeted to the specific regulation requirements to increase compliance.

Relationship between child care centers' compliance with physical activity regulations and children's physical activity, New York City, 2010.

INTRODUCTION: Physical activity may protect against overweight and obesity among preschoolers, and the policies and characteristics of group child care centers influence the physical activity levels of children who attend them. We examined whether children in New York City group child care centers that are compliant with the city's regulations on child physical activity engage in more activity than children in centers who do not comply. METHODS: A sample of 1,352 children (mean age, 3.39 years) served by 110 group child care centers in low-income neighborhoods participated. Children's anthropometric data were collected and accelerometers were used to measure duration and intensity of physical activity. Multilevel generalized linear regression modeling techniques were used to assess the effect of center- and child-level factors on child-level physical activity. RESULTS: Centers' compliance with the regulation of obtaining at least 60 minutes of total physical activity per day was positively associated with children's levels of moderate to vigorous physical activity (MVPA); compliance with the regulation of obtaining at least 30 minutes of structured activity was not associated with increased levels of MVPA. Children in centers with a dedicated outdoor play space available also spent more time in MVPA. Boys spent more time in MVPA than girls, and non-Hispanic black children spent more time in MVPA than Hispanic children. CONCLUSION: To increase children's level of MVPA in child care, both time and type of activity should be considered. Further examination of the role of play space availability and its effect on opportunities for engaging in physical activity is needed.

Compliance with New York City's beverage regulations and beverage consumption among children in early child care centers.

INTRODUCTION: This article examines the association between the New York City regulations on beverages served in child care centers and beverage consumption among enrolled children. The regulations include requirements related to beverages served to children throughout the day. METHODS: Beverage consumption data were collected on 636 children enrolled in 106 group child care centers in New York City. Data on compliance with the regulations were collected through direct observation, interviews with center staff, and a site inventory. Logistic regression for rare events was used to test associations between compliance with the regulations and beverage consumption. RESULTS: Compliance with the regulations was associated with lower odds of children consuming milk with more than 1% fat content and sugar-sweetened beverages during meals and snacks. There was not a significant relationship between compliance with the regulations and children's consumption of water. CONCLUSION: The findings suggest a strong, direct relationship between what a center serves and what a child consumes, particularly regarding consumption of higher-fat milk and sugar-sweetened beverages. Therefore, policies governing the types of beverages served in child care centers may increase children's consumption of more healthful beverages and reduce the consumption of less healthful ones.

Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Measurement of compliance with New York City's regulations on beverages, physical activity, and screen time in early child care centers.

INTRODUCTION: Policy interventions designed to change the nutrition environment and increase physical activity in child care centers are becoming more common, but an understanding of the implementation of these interventions is yet to be developed. The objective of this study was to explore the extent and consistency of compliance with a policy intervention designed to promote nutrition and physical activity among licensed child care centers in New York City. METHODS: We used a multimethod cross-sectional approach and 2 independent components of data collection (Center Evaluation Component and Classroom Evaluation Component). The methods were designed to evaluate the impact of regulations on beverages served, physical activity, and screen time at child care centers. We calculated compliance scores for each evaluation component and each regulation and percentage agreement between compliance in the center and classroom components. RESULTS: Compliance with certain requirements of the beverage regulations was high and fairly consistent between components, whereas compliance with the physical activity regulation varied according to the data collection component. Compliance with the regulation on amount and content of screen time was high and consistent. CONCLUSION: Compliance with the physical activity regulation may be a more fluid, day-to-day issue, whereas compliance with the regulations on beverages and television viewing may be easier to control at the center level. Multiple indicators over multiple time points may provide a more complete picture of compliance - especially in the assessment of compliance with physical activity policies.

Funding and expenditure of a sample of community-based organizations in Kenya, Nigeria, and Zimbabwe.

Over the last decade, international donors, technical specialists, and governments have come to recognize the potential of community-based organizations (CBOs) in the fight against HIV/AIDS. Recent empirical studies suggest that community engagement, including the involvement of CBOs, adds value to the national response to HIV/AIDS. With the emerging evidence of the effectiveness of engaging communities in the fight against AIDS, it is crucial to understand the economic dimension of community engagement. This article provides an analysis of funding and expenditure data collected from CBOs in three African countries: Kenya, Nigeria, and Zimbabwe. It presents descriptive information regarding CBO funding and expenditure and examines the factors associated with the total amount of funds received and with the proportions of the funds allocated to programmatic activities and program management and administration. An average CBO in the sample received US$29,800 annually or about US$2480 per month. The highest percentage of CBO funding (37%) came from multilateral organizations. CBOs in the sample spent most of their funds (71%) on programmatic activities including provision of treatment, support, care, impact mitigation, and treatment services.

Evaluating the effects of community-based organization engagement on HIV and AIDS-related risk behavior in Kenya.

International donors have increasingly shifted AIDS funding directly to community-based organizations (CBOs) with the assumption that responding to the epidemic is best achieved at the community level. The World Bank, ICF Macro, and the National Council for Population and Development in Kenya, conducted a study to evaluate the community response in Kenya. The study used a quasi-experimental design comparing seven study communities and seven comparison communities in Nyanza Province and Western Province. We examined the impact of CBO activity on individual and community-level outcomes, including HIV knowledge, awareness and perceptions, sexual risk behavior, and social transformation (gender ideology and social capital). The study consisted of two components: a household survey conducted in all 14 communities, and qualitative data collected in a subset of communities. Individuals in communities with higher CBO engagement were significantly more likely to have reported consistent condom use. Higher CBO engagement was associated with some measures of social capital, including participation in local and national elections, and participation in electoral campaigns. CBOs provide added value in addressing the HIV and AIDS epidemic in very targeted and specific ways that are closely tied to the services they provide (e.g., prevention education); thus, increasing CBO engagement can be an effective measure in scaling up prevention efforts in those areas.

It takes a village: community-based organizations and the availability and utilization of HIV/AIDS-related services in Nigeria.

Community-based organizations (CBOs) have emerged as a vital part of the response to HIV/AIDs in Nigeria. The evaluation, on which this article is based, conducted in 28 communities in 6 states and the Federal capital Territory in Nigeria, assessed the effects of the CBO engagement on a set of outcomes related to HIV/AIDS knowledge, attitudes, beliefs, and practices, stigma, service availably and utilization and social capital. It consisted of three components: a household survey conducted in all 28 communities, qualitative data collected from CBO staff and key informants (KIs), and a funding allocation study (qualitative interviews and the funding allocation study were conducted in a subset of 14 communities). This article focuses on the association between CBO engagement and reported availability and utilization of HIV/AIDS-related services. It shows that CBO engagement has a potential to add value to the national response to HIV/AIDS by increasing the awareness, availability, and utilization of HIV/AIDS-related services, especially in the area of prevention, care and support. The CBOs in the evaluation communities focused on prevention activities as well as on providing support for people living with HIV/AIDS (PLWHA) and prevention and care and support were the highest expenditure categories reported by CBOs. Respondents in communities with a stronger CBO engagement were more likely to: (1) be aware of any HIV/AIDs-related services, (2) report that prevention and care services were available in their communities, and (3) have used any HIV/AIDS related services, prevention-related and care-related services than respondents in communities where CBO engagement was weaker. The association between service awareness and service use and CBO engagement was stronger in rural than in urban areas.

Healthcare service disruption in 14 Latin American and Caribbean countries during the COVID-19 pandemic: Analysis of household phone surveys, 2020-2021.

Background: The coronavirus 2019 (COVID-19 pandemic) and associated responses have significantly disrupted healthcare. We aimed to estimate the magnitude of and reasons for households reporting healthcare disruption in 14 Latin America and the Caribbean (LAC) region countries from mid-2020 to mid-2021, and its relationship with country contextual factors. Methods: We used COVID-19 high-frequency phone surveys (HFPS) conducted in 14 LAC countries in three rounds in 2020 and one in 2021. We classified the reasons reported for healthcare disruption into four groups: concerns about contracting COVID-19, healthcare supply constraints, financial reasons, and public health measures (PHMs). We used bivariate and multivariate regressions to examine correlates of reported healthcare disruption with the above groups and country context as control variables. Results: On average, 20% of households reported a disruption in May-June 2020 (45% to 10% at country level), dropping to 9% in June-July 2020 (31% to 3%) and July-August 2020 (26% to 3%), and declining to 3% in May-July 2021 (11% to 1%). The most common reason reported for disruption was healthcare supply constraints, followed by concerns about contracting COVID-19, PHM, and financial reasons. In multivariable regression analyses, we found that a higher incidence of new COVID-19 cases (regression coefficient (ß) = 0.018, P < 0.01), stricter PHM (ß = 0.002, P < 0.01), fewer hospital beds per population (ß = -0.011, P < 0.01), and lower out-of-pocket health spending (ß = -0.0008, P < 0.01) were associated with higher levels of disrupted care. A higher care disruption was associated with a lower gross domestic product (GDP) per person (ß = -0.00001, P < 0.01) and lower population density (ß = -0.056, P < 0.01). Conclusions: Healthcare services for households in LAC were substantially disrupted during the COVID-19 pandemic. Findings about supply and financial constraints can inform the recovery of postponed healthcare services, while public health and contextual factors findings can inform future health system resilience efforts in LAC and elsewhere.

How prevalent is COVID-19 vaccine hesitancy in low-income and middle-income countries and what are the key drivers of hesitancy? Results from 53 countries.

OBJECTIVES: This study aims to estimate the levels of COVID-19 vaccine hesitancy in 53 low-income and middle-income countries, differences across population groups in hesitancy, and self-reported reasons for being hesitant to take the COVID-19 vaccine. METHODS: This paper presents new evidence on levels and trends of vaccine hesitancy in low-income and middle-income countries based on harmonised high-frequency phone surveys from more than 120 000 respondents in 53 low-income and middle-income countries collected between October 2020 and August 2021. These countries represent a combined 53% of the population of low-income and middle-income countries excluding India and China. RESULTS: On average across countries, one in five adults reported being hesitant to take the COVID-19 vaccine, with the most cited reasons for hesitancy being concerns about the safety of the vaccine, followed by concerns about its efficacy. Between late 2020 and the first half of 2021, there tended to be little change in hesitancy rates in 11 of the 14 countries with available data, while hesitancy increased in Iraq, Malawi and Uzbekistan. COVID-19 vaccine hesitancy was higher among female, younger adults and less educated respondents, after controlling for selected observable characteristics. CONCLUSIONS: Country estimates of vaccine hesitancy from the high-frequency phone surveys are correlated with but lower than those from earlier studies, which often relied on less representative survey samples. The results suggest that vaccine hesitancy in low-income and middle-income countries, while less prevalent than previously thought, will be an important and enduring obstacle to recovery from the pandemic.

Foregone healthcare during the COVID-19 pandemic: early survey estimates from 39 low- and middle-income countries.

In addition to the direct health effects of the Coronavirus disease (COVID-19) pandemic, the pandemic has increased the risks of foregone non-COVID-19 healthcare. Likely, these risks are greatest in low- and middle-income countries (LMICs), where health systems are less resilient and economies more fragile. However, there are no published studies on the prevalence of foregone healthcare in LMICs during the pandemic. We used pooled data from phone surveys conducted between April and August 2020, covering 73 638 households in 39 LMICs. We estimated the prevalence of foregone care and the relative importance of various reported reasons for foregoing care, disaggregated by country income group and region. In the sample, 18.8% (95% CI 17.8-19.8%) of households reported not being able to access healthcare when needed. Financial barriers were the most-commonly self-reported reason for foregoing care, cited by 31.4% (28.6-34.3%) of households. More households in wealthier countries reported foregoing care for reasons related to COVID-19 [27.2% (22.5-31.8%) in upper-middle-income countries compared to 8.0% (4.7-11.3%) in low-income countries]; more households in poorer countries reported foregoing care due to financial reasons [65.6% (59.9-71.2%)] compared to 17.4% (13.1-21.6%) in upper-middle-income countries. A substantial proportion of households in LMICs had to forgo healthcare in the early months of the pandemic. While in richer countries this was largely due to fear of contracting COVID-19 or lockdowns, in poorer countries foregone care was due to financial constraints.

Recommended community strategies and measurements to prevent obesity in the United States.

Approximately two thirds of U.S. adults and one fifth of U.S. children are obese or overweight. During 1980--2004, obesity prevalence among U.S. adults doubled, and recent data indicate an estimated 33% of U.S. adults are overweight (body mass index [BMI] 25.0-29.9), 34% are obese (BMI >or=30.0), including nearly 6% who are extremely obese (BMI >or=40.0). The prevalence of being overweight among children and adolescents increased substantially during 1999-2004, and approximately 17% of U.S. children and adolescents are overweight (defined as at or above the 95% percentile of the sex-specific BMI for age growth charts). Being either obese or overweight increases the risk for many chronic diseases (e.g., heart disease, type 2 diabetes, certain cancers, and stroke). Reversing the U.S. obesity epidemic requires a comprehensive and coordinated approach that uses policy and environmental change to transform communities into places that support and promote healthy lifestyle choices for all U.S. residents. Environmental factors (including lack of access to full-service grocery stores, increasing costs of healthy foods and the lower cost of unhealthy foods, and lack of access to safe places to play and exercise) all contribute to the increase in obesity rates by inhibiting or preventing healthy eating and active living behaviors. Recommended strategies and appropriate measurements are needed to assess the effectiveness of community initiatives to create environments that promote good nutrition and physical activity. To help communities in this effort, CDC initiated the Common Community Measures for Obesity Prevention Project (the Measures Project). The objective of the Measures Project was to identify and recommend a set of strategies and associated measurements that communities and local governments can use to plan and monitor environmental and policy-level changes for obesity prevention. This report describes the expert panel process that was used to identify 24 recommended strategies for obesity prevention and a suggested measurement for each strategy that communities can use to assess performance and track progress over time. The 24 strategies are divided into six categories: 1) strategies to promote the availability of affordable healthy food and beverages), 2) strategies to support healthy food and beverage choices, 3) a strategy to encourage breastfeeding, 4) strategies to encourage physical activity or limit sedentary activity among children and youth, 5) strategies to create safe communities that support physical activity, and 6) a strategy to encourage communities to organize for change.

Determinants of the Global Prices of Ready-to-Use Therapeutic Foods.

BACKGROUND: A therapy based on ready-to-use therapeutic food (RUTF) in outpatient settings is considered the gold standard in the treatment of severe acute malnutrition in children younger than 5 years. The price of RUTF is the key cost driver of the therapy. However, no studies to date have systematically examined the determinants of RUTF prices. OBJECTIVE: This article presents the first analysis of factors associated with the prices of RUTF, focusing on the impact of competition and tendering. METHODS: This article examines data on the prices of RUTF purchased by UNICEF Supply Division from 2006 through 2015 (90% of RUTF purchased globally). To assess the association between price, competition, and tender introduction, controlling for potential confounding factors, regression analysis using a generalized estimating equation was used. RESULTS: Competition, measured as the number of suppliers, was negatively associated with RUTF price. On the other hand, no statistically significant association was found between RUTF price tendering. Quantities sold were also significantly associated with RUTF prices. CONCLUSIONS: Significant price reductions have been achieved by increasing competition in the RUTF market. In contrast, introduction of tendering did not result in decreases in prices. Tendering is an effective price-lowering mechanism because it awards the bidder(s) with the lowest price with market exclusivity. However, the current tender system promotes market fragmentation and reduces the incentives for price reductions. Further reduction in RUTF prices can likely be achieved by modifying the current tendering procedures and putting a greater emphasis on price competition.

Reaching the global target to reduce stunting: an investment framework.

Childhood stunting, being short for one's age, has life-long consequences for health, human capital and economic growth. Being stunted in early childhood is associated with slower cognitive development, reduced schooling attainment and adult incomes decreased by 5-53%. The World Health Assembly has endorsed global nutrition targets including one to reduce the number of stunted children under five by 40% by 2025. The target has been included in the Sustainable Development Goals (SDG target 2.2). This paper estimates the cost of achieving this target and develops scenarios for generating the necessary financing. We focus on a key intervention package for stunting (KIPS) with strong evidence of effectiveness. Annual scale-up costs for the period of 2016-25 were estimated for a sample of 37 high burden countries and extrapolated to all low and middle income countries. The Lives Saved Tool was used to model the impact of the scale-up on stunting prevalence. We analysed data on KIPS budget allocations and expenditure by governments, donors and households to derive a global baseline financing estimate. We modelled two financing scenarios, a 'business as usual', which extends the current trends in domestic and international financing for nutrition through 2025, and another that proposes increases in financing from all sources under a set of burden-sharing rules. The 10-year financial need to scale up KIPS is US$49.5 billion. Under 'business as usual', this financial need is not met and the global stunting target is not reached. To reach the target, current financing will have to increase from US$2.6 billion to US$7.4 billion a year on average. Reaching the stunting target is feasible but will require large coordinated investments in KIPS and a supportive enabling environment. The example of HIV scale-up over 2001-11 is instructive in identifying the factors that could drive such a global response to childhood stunting.

You've got male: internet use, rural residence, and risky sex in men who have sex with men recruited in 12 U.S. cities.

This study assessed whether the relationship between using the Internet to meet sex partners and unprotected anal intercourse (UAI) differs for men who have sex with men (MSM) living in rural and urban areas. Data on Internet use, residence and UAI were collected from MSM attending Gay Pride events in 12 U.S. cities. Rural MSM who used the Internet to meet sex partners were more likely to report any UAI (adjusted odds ratio[AOR]: 1.89 [1.12-3.19]) and insertive UAI (AOR: 2.16 [1.13-4.10]) with the last sex partner than those who did not use the Internet. For urban MSM, UAI was not more commonly reported by men who used the Internet to meet sex partners. The association between using the Internet to meet sex partners and UAI depended on whether MSM resided in rural or urban areas. Rural MSM may have different patterns of risk behavior from urban MSM. The Internet may offer new prevention opportunities for rural MSM.

Promoting undergraduate interest, preparedness, and professional pursuit in the sciences: An outcomes evaluation of the SURE program at Emory University.

We report on an outcomes assessment of the Summer Undergraduate Research Experience (SURE) Program at Emory University in Atlanta, GA. Using follow-up survey data and academic transcripts, we gauge SURE's impact on levels of interest in, preparedness for, and actual pursuit of graduate study and professional careers in the sciences for the program's first 15 summer cohorts (1990-2004). Our follow-up survey indicated significant increases in all research preparedness skills considered, notably in ability to give a poster research presentation, to discuss research at a graduate school interview, and to apply research ethics principles. About a third of SURE graduates went on to complete a graduate degree >90% considered SURE as important or very important in their academic development. Respondents reported postprogram increases in the level of interest in academic and research careers, and reported high levels of employment in science careers and job satisfaction. Regression analyses of Emory SURE participant transcripts revealed that participants take significantly more science courses as seniors and earn higher grades in those courses than nonparticipants. This trend held after correcting for indicators of prior interest (first-year course work, GPA, and math SAT scores), gender, and minority status. We also report on an external survey completed by SURE participants.