Micronutrient supplementation in pregnancy.
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Birth Weight↗
Biomedical subjects
Jean-Pierre Habicht
Publications and source records attributed to Jean-Pierre Habicht.
Measuring the quality of child health care at first-level facilities.
Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.
Brazil↗
Predictors of improvement in hemoglobin concentration among toddlers enrolled in the Massachusetts WIC Program.
OBJECTIVE: Nutrition supplementation programs are generally targeted to those members of the population who are thought to be at risk of an undesirable outcome, but not all who participate in such programs respond to them. We sought to identify determinants of improvement in hemoglobin concentration among young children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: We conducted an observational study using data from 9,930 children who were enrolled in the Massachusetts WIC program and had data available on their hemoglobin values at both 1 and 2 years of age. Predictors of change in hemoglobin concentration between these ages were studied using multivariate statistical modeling. RESULTS: Overall, hemoglobin concentrations increased from age 1 to 2 years in those who had been breastfed 25 or more weeks (P < .0001) and were female (P < .01), and decreased with increasing weight at 1 year of age (P < .001). The determinants of change in hemoglobin concentration differed from the determinants of hemoglobin concentration at age 1 year. CONCLUSIONS: The analytical approach used here could be extended to identify subgroups of WIC participants likely to improve in other outcomes. If current efforts to increase the duration of breastfeeding among WIC participants are successful, the importance of WIC in improving hemoglobin concentration among young children also will increase.
Anemia, Iron-Deficiency↗
Context matters: interpreting impact findings in child survival evaluations.
Appropriate consideration of contextual factors is essential for ensuring internal and external validity of randomized and non-randomized evaluations. Contextual factors may confound the association between delivery of the intervention and its potential health impact. They may also modify the effect of the intervention or programme, thus affecting the generalizability of results. This is particularly true for large-scale health programmes, for which impact may vary substantially from one context to another. Understanding the nature and role of contextual factors may improve the validity of study results, as well as help predict programme impact across sites. This paper describes the experience acquired in measuring and accounting for contextual factors in the Multi-Country Evaluation of the IMCI (Integrated Management of Childhood Illness) strategy in five countries: Bangladesh, Brazil, Peru, Uganda and Tanzania. Two main types of contextual factors were identified. Implementation-related factors include the characteristics of the health systems where IMCI was implemented, such as utilization rates, basic skills of health workers, and availability of drugs, supervision and referral. Impact-related factors include baseline levels and patterns of child mortality and nutritional status, which affect the scope for programme impact. We describe the strategies used in the IMCI evaluation in order to obtain data on relevant contextual factors and to incorporate them in the analyses. Two case studies - from Tanzania and Peru - show how appropriate consideration of contextual factors may help explain apparently conflicting evaluation results.
Child Health Services↗
Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania.
OBJECTIVES: To assess the effect of Integrated Management of Childhood Illness (IMCI) relative to routine care on the quality and efficiency of providing care for sick children in first-level health facilities in Tanzania, and to disseminate the results for use in health sector decision-making. DESIGN: Non-randomized controlled trial to compare child health care quality and economic costs in two intervention (>90% of health care workers trained in IMCI) and two comparison districts in rural Tanzania. PARTICIPANTS: For quality measures, all sick children presenting for care at random samples of first-level health facilities; for costs, all national, district, facility and household costs associated with child health care, taking a societal perspective. RESULTS: IMCI training is associated with significantly better child health care in facilities at no additional cost to districts. The cost per child visit managed correctly was lower in IMCI than in routine care settings: $4.02 versus $25.70, respectively, in 1999 US dollars and after standardization for variations in population size. CONCLUSION: IMCI improved the quality and efficiency of child health care relative to routine child health care in the study districts. Previous study results indicated that the introduction of IMCI in these Tanzanian districts was associated with mortality levels that were 13% lower than in comparison districts. We can therefore conclude that IMCI is also more cost-effective than routine care for improving child health outcomes. The dissemination strategy for these results led to adoption of IMCI for nationwide implementation within 12 months of study completion.
Child Health Services↗
Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness.
OBJECTIVE: To summarize the expectations held by World Health Organization programme personnel about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would lead to improvements in child health and nutrition, to compare these expectations with what was learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and to discuss the implications of these findings for child survival policies and programmes. DESIGN: The MCE-IMCI study designs were based on an impact model developed in 1999-2000 to define how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies included: feasibility assessments documenting IMCI implementation in 12 countries (1999-2001); in-depth studies using compatible designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. RESULTS: The IMCI strategy was successfully introduced in the great majority of countries with moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-based evaluation, however, indicates that some of the basic expectations underlying the development of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in expanding the strategy at national level while maintaining adequate intervention quality. Technical guidelines on delivering interventions at family and community levels were slow to appear, and in their absence countries stalled in their efforts to increase population coverage with essential interventions related to care-seeking, nutrition, and correct care of the sick child at home. The full weight of health system limitations on IMCI implementation was not appreciated at the outset, and only now is it clear that solutions to larger problems in political commitment, human resources, financing, integrated or at least coordinated programme management, and effective decentralization are essential underpinnings of successful efforts to reduce child mortality. CONCLUSIONS: This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches. The focus on process within child health programmes must change to include greater accountability for intervention coverage at population level. Global strategies that expect countries to make massive adaptations must be complemented by country-level implementation guidelines that begin with local epidemiology and rely on tools developed for specific epidemiological profiles.
Child Health Services↗
Revisiting the independent effects of income on the risk of obesity.
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Brazil↗
Discussion: Targeting is making trade-offs.
The previous articles presented different aspects of targeting: the implicit political implications, the trade-offs in giving power to different stakeholders to decide and to implement targeting, perceptions of frontline workers in implementing a program, and a technical article about selecting a scale for targeting, which we review in greater detail. It is well recognized that targeting results in a trade-off between not serving those who should be served and including those who should not be served. Less well recognized are the trade-offs that are the consequences of deciding between using indicators of risk vs. using indicators that predict benefit.
Delivery of Health Care↗
Nutrition behavior change among EFNEP participants is higher at sites that are well managed and whose front-line nutrition educators value the program.
Effective programs to promote improved dietary practices among low-income families depend on the motivation and performance of front-line nutrition educators, yet little is known about the work context experienced by nutrition workers or how their perceptions of work context relate to program effectiveness. This research examined the perceived work context of nutrition educators, a multidimensional construct developed through formative research, in the Expanded Food and Nutrition Education Program (EFNEP) in New York State. We proposed that work context, program management, and program and educator characteristics would be related to program effectiveness (reported behavior change among participants). A state-wide survey of paraprofessional Community Nutrition Educators (CNEs) in 30 program sites was conducted and analyzed in relation to program monitoring data. Greater behavior change was reported by participants in sites whose CNEs gave positive ratings to the value of EFNEP (P < 0.02) and to the managerial practices of their supervisors (P < 0.001). To our knowledge, this is the first time that an association was demonstrated between perceived work context at the front lines and effectiveness of a nutrition program. Higher behavior change scores were also reported at sites in which a greater proportion of participants received individual rather than group instruction (P < 0.001). Associations between participants' reported behavior change and CNEs' perceptions of program value and program management suggest that improvements in these areas could enhance nutrition program success.
Attitude of Health Personnel↗
Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study.
CONTEXT: Malnutrition causes death and impaired health in millions of children. Existing interventions are effective under controlled conditions; however, little information is available on their effectiveness in large-scale programs. OBJECTIVE: To document the short-term nutritional impact of a large-scale, incentive-based development program in Mexico (Progresa), which included a nutritional component. DESIGN, SETTING, AND PARTICIPANTS: A randomized effectiveness study of 347 communities randomly assigned to immediate incorporation to the program in 1998 (intervention group; n = 205) or to incorporation in 1999 (crossover intervention group; n = 142). A random sample of children in those communities was surveyed at baseline and at 1 and 2 years afterward. Participants were from low-income households in poor rural communities in 6 central Mexican states. Children (N = 650) 12 months of age or younger (n = 373 intervention group; n = 277 crossover intervention group) were included in the analyses. INTERVENTION: Children and pregnant and lactating women in participating households received fortified nutrition supplements, and the families received nutrition education, health care, and cash transfers. MAIN OUTCOME MEASURES: Two-year height increments and anemia rates as measured by blood hemoglobin levels in participating children. RESULTS: Progresa was associated with better growth in height among the poorest and younger infants. Age- and length-adjusted height was greater by 1.1 cm (26.4 cm in the intervention group vs 25.3 cm in the crossover intervention group) among infants younger than 6 months at baseline and who lived in the poorest households. After 1 year, mean hemoglobin values were higher in the intervention group (11.12 g/dL; 95% confidence interval [CI], 10.9-11.3 g/dL) than in the crossover intervention group (10.75 g/dL; 95% CI, 10.5-11.0 g/dL) who had not yet received the benefits of the intervention (P =.01). There were no differences in hemoglobin levels between the 2 groups at year 2 after both groups were receiving the intervention. The age-adjusted rate of anemia (hemoglobin level <11 g/dL) in 1999 was higher in the crossover intervention group than in the intervention group (54.9% vs 44.3%; P =.03), whereas in 2000 the difference was not significant (23.0% vs 25.8%, respectively; P =.40). CONCLUSION: Progresa, a large-scale, incentive-based development program with a nutritional intervention, is associated with better growth and lower rates of anemia in low-income, rural infants and children in Mexico.
Anemia↗
Is breastfeeding best for HIV-positive mothers?
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Breast Feeding↗
Expert consultation on the optimal duration of exclusive breastfeeding: the process, recommendations, and challenges for the future.
In March, 2001 The World Health Organization (WHO) convened an Expert Consultation to recommend to WHO an optimal duration of exclusive breastfeeding. WHO formulated the specific questions to be addressed, selected the membership for the meeting, prepared background documents, and provided the venue for the meeting. After the meeting WHO formally accepted the recommendations and began to implement them. The Consultation recommended that WHO change its recommendation on exclusive breastfeeding from four-to-six months to a recommendation to promote exclusive breastfeeding for six months. This recommendation was contingent upon WHO also accepting and implementing other recommendations to deal with possible detrimental side effects, and to support mothers who did not exclusively breastfeed for six months. The amount of scientific evidence available was more than is often available for policy decisions in health, but much less than desirable to address issues of generalizability across and within populations. The evidence for the contingent recommendations was also less than desirable and raises a number of important research questions that now need to be addressed.
Age Factors↗
An in vitro digestion/Caco-2 cell culture system accurately predicts the effects of ascorbic acid and polyphenolic compounds on iron bioavailability in humans.
We developed a rapid in vitro digestion/Caco-2 cell culture model for assessing relative bioavailabilities of iron in foods and meals. The objective of the present study was to determine how closely our Caco-2 model reflects the human response. Meals described in published reports of studies on effects of varying levels of ascorbic acid (AA) and tannic acid (TA) on iron absorption by human subjects were carefully replicated. Iron absorption ratios (iron absorption from meals containing AA or TA divided by iron absorption from identical meals without these enhancers or inhibitors) were determined using the Caco-2 model. Ferritin formation by the Caco-2 cells was used as an indicator of iron absorption. Response patterns of effects of AA and TA on absorption ratios (AR) calculated from Caco-2 and human data were very similar: AA increased ARs in a dose-response manner and TAs decreased AR. The natural logs of the ARs determined in Caco-2 and human studies were correlated: R = 0.935 (P = 0.012) and 0.927 (P = 0.007) for AA and TA, respectively. When results from meals with AA and TA were pooled, a linear relation between the natural logs of ARs from Caco-2 and human studies was observed (R = 0.968, P < 0.001). We conclude that our Caco-2 model accurately predicts the human response to AA and TA in the meals we tested. If future work reproduces the precision and accuracy shown in this paper for predicting iron bioavailability to humans, then the implications for saving time and resources in iron bioavailability measurements are considerable.
Ascorbic Acid↗
Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition.
Physician behavior and caregiver retention of nutrition advice were examined as potential mediating factors in the success of a nutrition counseling efficacy trial in Pelotas, Brazil, which reduced growth faltering in children 12-24 mo old. After pair-matching on socioeconomic status and nutrition indicators, municipal health centers were randomly assigned to an intervention group, in which physicians were trained with an IMCI-derived (Integrated Management of Childhood Illness) nutrition counseling protocol, or to a control group, without continuing education in nutrition. In a substudy of the larger trial, direct observation of consultations, followed by home interviews with mothers, provided data on physician counseling behavior and mothers' retention of nutrition advice. Trained providers were more likely to engage in nutrition counseling (P < 0.013) and to deliver more extensive advice (P < 0.02). They also used communication skills designed to improve rapport and ensure that mothers understood the advice (P < 0.01). Mothers who received advice from trained providers had high rates of recalling the messages on specific foods (95 vs.27%; P < 0.01) and feeding practice and food preparation recommendations (90 vs. 20%; P < 0.01), whereas the proportions of the messages recalled on breast-feeding (60% vs. 30%) did not differ significantly (P < 0.20). The training course contained several elements that may explain why intervention group mothers were better able to recall nutrition advice. These include locally appropriate messages, tools for assessing individual problems, and counseling skills.
Brazil↗
Mechanisms of power within a community-based food security planning process.
A community food security movement has begun to address problems of hunger and food insecurity by utilizing a community-based approach. Although various models have been implemented, little empirical research has assessed how power operates within community-based food security initiatives. The purpose of this research was to determine how power influenced participation in decision-making, agenda setting, and the shaping of perceived needs within a community-based food security planning process, with particular reference to disenfranchised stakeholders. Power influenced participation in decision-making, agenda setting, and the shaping of perceived needs through managing 1) problem framing, 2) trust, 3) knowledge, and 4) consent. To overcome these mechanisms of power, practitioners need to address individual-, community-, and institutional-level barriers to participation in community-based food security planning processes. Practitioners and researchers can work with disenfranchised groups to determine which agents have the power to create desired changes by utilizing theory-based methods and strategies that focus on changing external determinants at multiple levels.
Adult↗
Community-based school feeding during Indonesia's economic crisis: implementation, benefits, and sustainability.
The Indonesian Government initiated a community-based national school-feeding program in 1996. Implementation was decentralized and involved multiple participants. In 1998 we evaluated the implementation of the program and the perceived benefits for community stakeholders using a survey of principals in 143 randomly selected schools and follow-up with in-depth interviews and observations in a subsample of 16 communities. The evaluation covered the period of the 1998 Asian economic crisis, affording the opportunity to assess its impact on the program. The program was implemented in all targeted schools, with excellent community participation. Feeding was sustained through the crisis, in spite of a dramatic escalation in food costs. The families of schoolchildren, farmers, and those who prepared food received economic benefits. The snacks replaced those sold at schools and were of better nutritional value. The children benefited because the snacks compensated for losses in the home diet resulting from the economic crisis. Characteristics of the program that may be important in explaining its success include the involvement of a range of community stakeholders, engagement with existing village administrative structures, scope for local community adaptation and innovation, and the use of local foods that dispersed benefits and ensured sustained implementation during the crisis.
Adolescent↗
Evidence-based public health: moving beyond randomized trials.
Randomized controlled trials (RCTs) are essential for evaluating the efficacy of clinical interventions, where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other settings. However, causal chains in public health interventions are complex, making RCT results subject to effect modification in different populations. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility designs. For evaluating large-scale interventions, studies with plausibility designs are often the only feasible option and may provide valid evidence of impact. There is an urgent need to develop evaluation standards and protocols for use in circumstances where RCTs are not appropriate.
Causality↗