Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

Competency-based education and training for Community Health Workers: a scoping review

BACKGROUND

Community Health Workers (CHWs) play a critical role in supporting the delivery of health services globally. Competency-based learning programs can improve the transfer of learning to practice. This scoping review aims to characterize the published literature on competency-based education as an instructional and curricular strategy in community health worker training programs. We conducted a scoping review of the literature to identify how, by who, and in what ways CHWs are trained using competency-based education; and to characterize the extent of available evidence, as well as the gaps in that evidence.

METHODS

We conducted a review of the peer-reviewed literature on CHW competency-based education and training published between January 2010 to March 2023, drawing from four databases: EMBASE, OVID Medline, Web of Science, and CINAHL. We followed the PRISMA guidelines for scoping reviews. A total of 713 articles were reviewed and 236 were included for extraction based on the inclusion and exclusion criteria. Due to methodological heterogeneity, results were analyzed and synthesized only through a descriptive approach.

RESULTS

The literature on competency-based CHW education and training is most voluminous in high income contexts, primarily the USA. Overall, the included studies described very small-scale training interventions. Study types included observational (qualitative, quantitative, mixed methods, case studies) intervention or experimental studies, systematic or scoping reviews, and literature reviews. The most common practice area included was 'promotive and preventive services', whereas 'personal safety' was the rarest. Learning programs tailored to CHWs with low-literacy, content tailored to local cultural contexts, and curricula that were co-designed with CHWs were identified in the literature as effective strategies for converting learning to practice. Information on institutional support for CHWs was not provided in most of the articles reviewed. While the focus of our review was on education and training and not broader supports for CHWs, we still found it notable that training was usually discussed in isolation from other related supportive factors, including professionalization and career progression.

CONCLUSIONS

We found considerable academic interest in utilizing competency-based education to support CHWs and improve their work, yet this exploration was largely limited to smaller, ad hoc programs, in high income settings. Learning programs should be tailored to the realities and practice requirements of CHWs. Further work should illuminate the extent to which the design and delivery of education and training activities lead to acquiring and maintaining the requisite competencies.

Persistent Challenges of Micronutrient Deficiencies in Latin America Need Action

Micronutrient deficiencies affect growth and development and are critical for maintaining health at all ages. Their critical role in exacerbating complications of infections and chronic diseases continues to impact morbidity, mortality, and quality of life for many. Raising awareness and advocating for micronutrient deficiencies in Latin America is urgent to reduce this preventable burden. Globally, an estimated 372 million preschool-aged children and 1.2 billion non-pregnant women of reproductive age suffer deficiency from 1 or more micronutrient. Data is limited and often old, and the true burden of problem in the region remains unclear. There are also limited data on dietary intake and on the double burden of malnutrition. Latin America has been a leader in the design and implementation of innovative and effective actions to reduce excess energy intake and curb the consumption of unhealthy Actions to address deficiency have been implemented in many countries in the region over the years, but current evidence suggests that micronutrient deficiencies have fallen off the public health agenda in Latin America. Effective programming can be developed / appropriately adapted only with knowledge of the current burden. Such data can also help guide and predict future areas of risk and priorities to missing upcoming nutrition issues in the population. Renewed commitment to quantify and monitor micronutrient deficiencies in the region is essential. Abundant evidence and guidance exist to inform effective program selection, design and implementation to address this public health problem.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review

OBJECTIVES

Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia.

DESIGN

Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach.

DATA SOURCES

MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022.

ELIGIBILITY CRITERIA

We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators.

RESULTS

Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium.

CONCLUSION

Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions.

PROSPERO REGISTRATION NUMBER

CRD42021239143.

Young Child Undernutrition: Crucial to Prioritize Nutrition Interventions in the First 1000 Days of Life

The implications of young childhood undernutrition on health, development and productivity are grave. In the last two decades, global and Indian studies on undernutrition in under five years have concluded that stunting and underweight rate increases steadily between 0-24 mo, and then stabilises. The available evidence highlights the significance of concentrating interventions to tackle child undernutrition in the first 1000 d of life, which should aim at universal coverage of essential nutrition interventions (ENIs) and maternal-child health care package comprising maternal nutrition care, adoption of appropriate infant and young child feeding practices (IYCF), iron-folic acid supplementation, immunization, deworming, appropriate management of childhood illness etc. Additionally, it is critical to address context specific nutrition sensitive measures such as socio-economic empowerment of women, preventing domestic violence, adolescent conception, appropriate water -sanitation-hygiene and family planning services etc. Mapping of the 'at risk' households having a member falling in the 1000 d window needs special attention and is central to the ongoing efforts in India through the National Nutrition Mission/ POSHAN Abhiyaan. However, for effective implementation, there is an urgent need to consider to shift the lead responsibility of ENIs in the first 1000 d of life to the health care system in India and strategize to integrate maternal nutrition care interventions and establishing of IYCF practices by ensuring optimum use of contacts with antenatal care and routine child immunization services.

Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

BACKGROUND

The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists.

OBJECTIVES

This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences.

METHODS

We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring.

RESULTS

Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence.

CONCLUSION

A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India

Background

Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.

Objective

This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.

Methods

We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.

Results

For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.

Conclusion

Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts.

Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.

The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.

Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.

Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models.