scholarly journals Evaluating malnutrition management through an intersectional lens: A case study of a community-based child malnutrition program in rural Uganda

2021 ◽  
Author(s):  
Marie-Catherine Gagnon-Dufresne ◽  
Geneviève Fortin ◽  
Kirsten Bunkeddeko ◽  
Charles Kalumuna ◽  
Kate Zinszer
Keyword(s):  
Gender Inequality ◽  
Acute Malnutrition ◽  
List Type ◽  
Structural Factors ◽  
Structural Determinants ◽  
Community Based ◽  
Middle Income ◽  
Middle Income Countries ◽  
Malnourished Children ◽  
Low And Middle Income

ABSTRACTBackgroundIn Uganda, almost half of children under 5 years old suffer from undernutrition. Community-based management of acute malnutrition (CMAM) is recognized as an effective strategy for tackling this important global health issue. However, evaluations of CMAM programs are inconsistent and largely based on biomedical and behavioral health models, failing to incorporate structural factors influencing malnutrition management. Using an intersectional lens would allow to investigate the complex social processes shaping children’s care in CMAM programs. The aim of this evaluation was to understand and describe factors influencing malnutrition management in a CMAM program in rural Uganda, situating its findings within their social contexts using an intersectional approach.MethodsThis evaluation used qualitative methods to identify determinants linked to caregivers (micro-level), healthcare (meso-level) and societal structures (macro-level) that can influence children’s outpatient care. Data were collected from September to December 2019 at a community clinic through observations and interviews with caregivers of malnourished children. Data were coded in NVivo using thematic analysis. Intersectionality informed the interpretation of findings.ResultsWe observed 14 caregiver-provider encounters and interviewed 15 caregivers to assess factors hindering outpatient malnutrition management. Findings showed that caregivers had limited understanding of malnutrition and its mechanisms. The counselling offered was inconsistent and information given to caregivers about treatment preparation at home was insufficient. Gender inequality and poverty limited caregivers’ access to healthcare and their ability to care of their children. Factors at the micro and meso levels intersected with structural factors to influence malnutrition management.ConclusionResults suggest that CMAM programs would benefit from expanding support to caregivers by providing holistic interventions tackling structural barriers to children’s care. Using an intersectional approach to program evaluation could support improvement efforts by moving beyond individual determinants to address the social dynamics shaping the outpatient management of malnutrition in low- and middle-income countries.KEY MESSAGEMost evaluations of community-based management of acute malnutrition programs adopt biomedical or behavioral health models, while determinants beyond caregivers’ choices, behaviors, and practices can influence the outpatient management of child malnutrition. Managers and evaluators of these programs in low- and middle-income countries should also consider healthcare and structural determinants of care, to offer holistic interventions tackling the multifaceted barriers to programmatic success.KEY MESSAGESKey FindingsPoverty and gender inequality limited caregivers’ access to healthcare and their ability to comply with community-based management of acute malnutrition (CMAM) outpatient protocol.Nutritional counseling provided to caregivers was inconsistent, often including contradictory information about the treatment prescribed to children.Caregivers of malnourished children had a limited understanding of malnutrition and its underlying mechanisms.Key ImplicationsCMAM program evaluators should look beyond individual and behavioral factors and consider how healthcare and structural determinants interact with caregivers’ behaviors in influencing children’s outpatient care.CMAM program managers should expand support offered to caregivers by implementing holistic interventions tackling the multilevel barriers to malnutrition management to maximize programmatic success.Policymakers in Uganda and other low- and middle-income countries should develop national guidelines to fight malnutrition that seek to address the underlying determinants of child undernutrition, such as food insecurity, poverty, and women’s access to education and employment.

scholarly journals Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review

2020 ◽  
Vol 17 (11) ◽  
pp. 3808
Author(s):  
Linda Campbell ◽  
Caroline Masquillier ◽  
Estrelle Thunnissen ◽  
Esther Ariyo ◽  
Hanani Tabana ◽  
...  
Keyword(s):  
Low Socioeconomic Status ◽  
Cultural Context ◽  
People Living With Hiv ◽  
Art Adherence ◽  
Structural Factors ◽  
Structural Determinants ◽  
Middle Income ◽  
Middle Income Countries ◽  
Household Members ◽  
Low And Middle Income

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH’s ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH’s ART adherence should take structural factors into account to have maximum impact.

scholarly journals Effectiveness of Breastfeeding Support Packages in Low- and Middle-Income Countries for Infants under Six Months: A Systematic Review

Nutrients ◽  
2021 ◽  
Vol 13 (2) ◽  
pp. 681
Author(s):  
Ritu Rana ◽  
Marie McGrath ◽  
Ekta Sharma ◽  
Paridhi Gupta ◽  
Marko Kerac
Keyword(s):  
At Risk ◽  
Severe Acute Malnutrition ◽  
Acute Malnutrition ◽  
World Health ◽  
Cochrane Library ◽  
Breastfeeding Support ◽  
Middle Income ◽  
Middle Income Countries ◽  
Breastfeeding Practices ◽  
Low And Middle Income

Small and nutritionally at-risk infants under six months, defined as those with wasting, underweight, or other forms of growth failure, are at high-risk of mortality and morbidity. The World Health Organisation 2013 guidelines on severe acute malnutrition highlight the need to effectively manage this vulnerable group, but programmatic challenges are widely reported. This review aims to inform future management strategies for small and nutritionally at-risk infants under six months in low- and middle-income countries (LMICs) by synthesising evidence on existing breastfeeding support packages for all infants under six months. We searched PubMed, CINAHL, Cochrane Library, EMBASE, and Global Health databases from inception to 18 July 2018. Intervention of interest were breastfeeding support packages. Studies reporting breastfeeding practices and/or caregivers’/healthcare staffs’ knowledge/skills/practices for infants under six months from LMICs were included. Study quality was assessed using NICE quality appraisal checklist for intervention studies. A narrative data synthesis using the Synthesis Without Meta-analysis (SWiM) reporting guideline was conducted and key features of successful programmes identified. Of 15,256 studies initially identified, 41 were eligible for inclusion. They were geographically diverse, representing 22 LMICs. Interventions were mainly targeted at mother–infant pairs and only 7% (n = 3) studies included at-risk infants. Studies were rated to be of good or adequate quality. Twenty studies focused on hospital-based interventions, another 20 on community-based and one study compared both. Among all interventions, breastfeeding counselling (n = 6) and education (n = 6) support packages showed the most positive effect on breastfeeding practices followed by breastfeeding training (n = 4), promotion (n = 4) and peer support (n = 3). Breastfeeding education support (n = 3) also improved caregivers’ knowledge/skills/practices. Identified breastfeeding support packages can serve as "primary prevention" interventions for all infants under six months in LMICs. For at-risk infants, these packages need to be adapted and formally tested in future studies. Future work should also examine impacts of breastfeeding support on anthropometry and morbidity outcomes. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO 2018 CRD42018102795).

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