Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action.

There is limited research on capacity building interventions that include theoretical foundations. The purpose of this systematic review is to identify underlying theories, models and frameworks used to support capacity building interventions relevant to public health practice. The aim is to inform and improve capacity building practices and services offered by public health organizations. Four search strategies were used: 1) electronic database searching; 2) reference lists of included papers; 3) key informant consultation; and 4) grey literature searching. Inclusion and exclusion criteria are outlined with included papers focusing on capacity building, learning plans, professional development plans in combination with tools, resources, processes, procedures, steps, model, framework, guideline, described in a public health or healthcare setting, or non-government, government, or community organizations as they relate to healthcare, and explicitly or implicitly mention a theory, model and/or framework that grounds the type of capacity building approach developed. Quality assessment were performed on all included articles. Data analysis included a process for synthesizing, analyzing and presenting descriptive summaries, categorizing theoretical foundations according to which theory, model and/or framework was used and whether or not the theory, model or framework was implied or explicitly identified. Nineteen articles were included in this review. A total of 28 theories, models and frameworks were identified. Of this number, two theories (Diffusion of Innovations and Transformational Learning), two models (Ecological and Interactive Systems Framework for Dissemination and Implementation) and one framework (Bloom’s Taxonomy of Learning) were identified as the most frequently cited. This review identifies specific theories, models and frameworks to support capacity building interventions relevant to public health organizations. It provides public health practitioners with a menu of potentially usable theories, models and frameworks to support capacity building efforts. The findings also support the need for the use of theories, models or frameworks to be intentional, explicitly identified, referenced and for it to be clearly outlined how they were applied to the capacity building intervention.

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Theories, models and frameworks used in capacity building interventions relevant to public health: a systematic review.

BACKGROUND: Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion. METHODS AND FINDINGS: Between September 9, 2013, and August 29, 2014, a randomised 2 × 2 × 3 factorial trial recruited 6- to 23-month-old children with MAM in Burkina Faso. The intervention comprised 12 weeks of food supplementation providing 500 kcal/day as LNS or CSB, each containing SI or DS, and 0%, 20%, or 50% of protein from milk. Fat-free mass (FFM) was assessed by deuterium dilution technique. By dividing FFM by length squared, the primary outcome was expressed independent of length as FFM index (FFMI) accretion over 12 weeks. Other outcomes comprised recovery rate and additional anthropometric measures. Of 1,609 children, 4 died, 61 were lost to follow-up, and 119 were transferred out due to supplementation being switched to non-experimental products. No children developed allergic reaction. At inclusion, 95% were breastfed, mean (SD) weight was 6.91 kg (0.93), with 83.5% (5.5) FFM. In the whole cohort, weight increased 0.90 kg (95% CI 0.88, 0.93; p 0.05). LNS compared to CSB resulted in 128 g (95% CI 67, 190; p < 0.01) greater weight gain if both contained SI, but there was no difference between LNS and CSB if both contained DS (mean difference 22 g; 95% CI -40, 84; p = 0.49) (interaction p = 0.017). Accordingly, SI compared to DS increased weight by 89 g (95% CI 27, 150; p = 0.005) when combined with LNS, but not when combined with CSB. A limitation of this and other food supplementation trials is that it is not possible to collect reliable data on individual adherence. CONCLUSIONS: Based on this study, children with MAM mainly gain fat-free tissue when rehabilitated. Nevertheless, LNS yields more fat-free tissue and higher recovery rates than CSB. Moreover, current LNSs with DS may be improved by shifting to SI. The role of milk relative to soy merits further research. TRIAL REGISTRATION: ISRCTN registry ISRCTN42569496.

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Effectiveness of food supplements in increasing fat-free tissue accretion in children with moderate acute malnutrition: A randomised 2 × 2 × 3 factorial trial in Burkina Faso.

Severe acute malnutrition (SAM) is currently defined by the WHO as either a low mid-upper arm circumference (i.e. MUAC <115 mm), a low weight-for-height z-score (i.e. WHZ <− 3), or bilateral pitting oedema. MUAC and WHZ do not always identify the same children as having SAM. This has generated broad debate, as illustrated by the recent article by Grellety & Golden (BMC Nutr. 2016;2:10). Regional variations in the proportion of children selected by each index seem mostly related to differences in body shape, including stuntedness. However, the practical implications of these variations in relation to nutritional status and also to outcome are not clear. All studies that have examined the relationship between anthropometry and mortality in representative population samples in Africa and in Asia have consistently showed that MUAC is more sensitive at high specificity levels than WHZ for identifying children at high risk of death. Children identified as SAM cases by low MUAC gain both weight and MUAC in response to treatment. The widespread use of MUAC has brought enormous benefits in terms of the coverage and efficiency of programs. As a large high-risk group responding to treatment, children with low MUAC should be regarded as a public health priority independently of their WHZ. While a better understanding of the mechanism behind the discrepancy between MUAC and WHZ is desirable, research in this area should not delay the implementation of programs aiming at effectively reducing malnutrition-related deaths by prioritising the detection and treatment of children with low MUAC.

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Low mid-upper arm circumference identifies children with a high risk of death who should be the priority target for treatment

The objectives of most treatment programs for severe acute malnutrition (SAM) in children focus on initial recovery only, leaving post-discharge outcomes, such as relapse, poorly understood and undefined. This study aimed to systematically review current literature and conduct secondary data analyses of studies that captured relapse rates, up to 18-month post-discharge, in children following recovery from SAM treatment. The literature search (including PubMed and Google Scholar) built upon two recent reviews to identify a variety of up-to-date published studies and grey literature. This search yielded 26 articles and programme reports that provided information on relapse. The proportion of children who relapsed after SAM treatment varied greatly from 0% to 37% across varying lengths of time following discharge. The lack of a standard definition of relapse limited comparability even among the few studies that have quantified post-discharge relapse. Inconsistent treatment protocols and poor adherence to protocols likely add to the wide range of relapse reported. Secondary analysis of a database from Malawi found no significant association between potential individual risk factors at admission and discharge, except being an orphan, which resulted in five times greater odds of relapse at 6 months post-discharge (95% CI [1.7, 12.4], P = 0.003). The development of a standard definition of relapse is needed for programme implementers and researchers. This will allow for assessment of programme quality regarding sustained recovery and better understanding of the contribution of relapse to local and global burden of SAM.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/mcn.12702

Relapse after severe acute malnutrition: A systematic literature review and secondary data analysis

BACKGROUND Global acute malnutrition (GAM) is the sum of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of different foods and protocols for MAM and SAM treatment can be cumbersome in emergency settings. OBJECTIVE Our objective was to determine the recovery and coverage rates for GAM of an integrated protocol with a single food product, ready-to-use therapeutic food (RUTF), compared with standard management. METHODS This was a cluster-randomized controlled trial in Sierra Leone conducted in 10 centers treating GAM in children aged 6-59 mo. The integrated protocol used midupper arm circumference (MUAC) as the criterion for admission and discharge, with a MUAC <12.5 cm defining malnutrition. The protocol included a decreasing ration of RUTF and health maintenance messages delivered by peers. Standard therapy treated MAM with a fortified blended flour and SAM with RUTF and used weight-for-height to determine admission to the treatment program. Coverage rates were the number of children who received treatment/number of children in the community eligible for treatment. RESULTS Most of the children receiving integrated management had MAM (774 of 1100; 70%), whereas among those receiving standard management, SAM predominated (537 of 857; 63%; P = 0.0001). Coverage was 71% in the communities served by integrated management and 55% in the communities served by standard care (P = 0.0005). GAM recovery in the integrated management protocol was 910 of 1100 (83%) children and was 682 of 857 (79%) children in the standard therapy protocol. CONCLUSION Integrated management of GAM in children is an acceptable alternative to standard management and provides greater community coverage. This trial was registered at clinicaltrials.gov as NCT01785680.

http://publichealth.wustl.edu/wp-content/uploads/2014/08/NnekaPubJN.pdf

Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone

Objectives This study aimed to examine individual barriers and supports to exclusive breastfeeding (EBF) and identify potential policy and programmatic interventions in Oman, where less than a quarter of Omani infants under six months are exclusively breastfed. Methods A cross-sectional barrier analysis (BA) was carried out among a purposive sample of Omani women who were selected and interviewed by trained enumerators in health clinics in various parts of the country. A BA tool, adapted for the Omani context, covered 12 common determinants of behaviour adoption using open-ended questions regarding participants’ perceptions about EBF including positive and negative consequences, self-efficacy and social norms. Qualitative analysis involved coding and tabulating as well as thematic analysis. Results This study included a total of 45 ‘doers’ (who exclusively breastfed their infants) and 52 ‘non-doers’ (who did not). Mothers reported that motivations for EBF include the perception that it leads to healthier children and is easy to do, readily available and therefore convenient, as well as that there is an high level of family support for breastfeeding. Barriers included perceived milk insufficiency and mother’s employment. Conclusion To achieve the EBF target of 50% for 2025, public health action should focus on emphasising the benefits and convenience of EBF and building women’s confidence in their ability to produce sufficient milk. These efforts will require increasing the knowledge and skills of community and healthcare workers and establishing monitoring mechanisms. Extended paid maternity leave and supportive workplace policies are necessary to encourage working women to exclusively breastfeed.

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Exclusive Breastfeeding

Objective There is a recognised need to strengthen capacity in the nutrition in emergencies sector and for greater clarity on the role of emergency nutritionists and the skills they require. Competency frameworks are an important tool for human resource development and have been developed for several other humanitarian sectors. We therefore developed a technical competency framework for practitioners in nutrition in emergencies. Design Existing competency frameworks were reviewed and interviews conducted to explore methods used in developing competency frameworks for other sectors. Competencies were identified through interviews with field experts, feedback from course trainees, academic course content and job specifications. Competencies were then categorised and behavioural indicators developed for each. The draft framework was then reviewed by members of the Global Nutrition Cluster and modified in an iterative process. Setting Global. Subjects Not applicable. Results A wide range of competencies were identified as essential for nutritionists working in emergencies, covering technical skills and general core competencies. The proposed framework contains twenty competency areas with 161 behavioural indicators categorised into three levels, corresponding to the requirements of progressively more senior roles. Many of the competencies are common across development and emergency nutrition. Conclusions The proposed technical competency framework should prove to be a valuable tool in creating standards within the sector and promoting effective capacity strengthening and professionalisation. Continued research is needed to validate the framework, optimise methods for assessment, develop approaches to integrate it within the sector and measure its impact on performance.

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Development of a competency framework for the nutrition in emergencies sector

There is a recognised need to strengthen capacity in the nutrition in emergencies sector and for greater clarity on the role of emergency nutritionists and the skills they require. Competency frameworks are an important tool for human resource development and have been developed for several other humanitarian sectors. We therefore developed a technical competency framework for practitioners in nutrition in emergencies.

Caroline Abla

Papers

Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone

Exclusive Breastfeeding

Development of a competency framework for the nutrition in emergencies sector

Development of a competency framework for the nutrition in emergencies sector.