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BACKGROUND: The cognitive processes involved in individuals' perceptions and prioritization of information, and how these change with experience or exposure to interventions, are rarely examined in the evaluation of nutrition interventions. Exclusive breastfeeding counseling is a common infant and young-child feeding intervention and is used to promote HIV-free survival in the prevention of mother-to-child transmission programs. However, it is often designed without adequate attention to the changes in mothers' perceptions over the course of their early breastfeeding experiences. OBJECTIVE: The aim of this study was to identify HIV-infected breastfeeding mothers' cognitive structure (their organization of messages and ideas) of infant feeding messages and to characterize whether their cognitive organization of infant feeding messages changed from pregnancy through the first 5 mo postpartum. METHODS: With the use of semistructured interviews and the cognitive mapping technique of pile sorting, we interviewed 30 HIV-infected breastfeeding mothers in Port-au-Prince, Haiti. We asked them to sort and rate 18 infant feeding messages 3 times (during pregnancy, 0- to 1-mo postpartum, and 3- to 5-mo postpartum). We analyzed their responses by using multidimensional scaling, property fitting, and partition analyses. RESULTS: At all 3 visits, we found consistency in women's cognitive mapping of messages. For example, mothers consistently differentiated messages pertinent for exclusive breastfeeding compared with those that pertained to other practices. However, subtle variations in mothers' cognition over time were also evident, particularly at 0- to 1-mo postpartum, when message proximity was tightly clustered compared with the earlier and later periods. CONCLUSIONS: We conclude that mothers share a common cognitive organization of infant feeding messages and that this organization changes over time. Attention to variations in cognition can support context-sensitive, patient-centered counseling by practitioners and improve the effectiveness of nutrition interventions. Pile sorting is an efficient, systematic technique to examine cognitive processes related to health and nutrition.
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Worldwide, mothers with young children receive many messages about infant feeding. Some messages are generated by health providers and others by the households, communities, and social contexts in which women live. We aimed to determine the scope of infant feeding messages in urban Haiti and to examine intracultural differences in salience of these messages and their alignment with international guidelines. We applied the method of free listing with 13 health workers and 15 human immunodeficiency virus (HIV)-infected and 15 HIV-uninfected mothers with infants 0-6 months old at Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti. Participants listed all messages women receive about infant feeding and specifically about HIV and infant feeding. Message salience was determined by frequency of mention and recall order; messages were coded for key themes. For all groups, the World Health Organization infant feeding recommendations were salient, especially those related to exclusive breastfeeding. Messages across all groups focused on infant health outcomes, with less emphasis on maternal outcomes. Cultural beliefs were also elicited and showed higher salience for mothers than health workers, particularly for consequences of poor maternal nutrition. Health workers' free lists were poorly correlated to those of mothers, whereas those of mothers were highly correlated, regardless of HIV status. Inasmuch as many salient messages were culturally generated, and differences existed between mothers and health workers, we conclude that it is important for health workers to acknowledge the broader infant feeding message environment, and discrepancies within that environment, to address successes and failures in the messages reaching mothers, given potential consequences for mothers' breastfeeding behaviours.
Asunto(s)
Lactancia Materna/estadística & datos numéricos , Infecciones por VIH/prevención & control , Conocimientos, Actitudes y Práctica en Salud , Alimentos Infantiles/estadística & datos numéricos , Fenómenos Fisiológicos Nutricionales del Lactante , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Adulto , Cultura , Femenino , Infecciones por VIH/transmisión , Haití , Humanos , Lactante , Recién Nacido , Madres , Población UrbanaRESUMEN
BACKGROUND: Antenatal care (ANC) is an important health service for women in developing countries, with numerous proven benefits. Global coverage of ANC has steadily increased over the past 30 years, in part due to increased community-based outreach. However, commensurate improvements in health outcomes such as reductions in the prevalence of maternal anemia and infants born small-for-gestational age have not been achieved, even with increased coverage, indicating that quality of care may be inadequate. Mobile clinics are one community-based strategy used to further improve coverage of ANC, but their quality of care delivery has rarely been evaluated. METHODS: To determine the quality of care of ANC in central Haiti, we compared adherence to national guidelines between fixed and mobile clinics by performing direct observations of antenatal care consultations and exit interviews with recipients of care using a multi-stage random sampling procedure. Outcome variables were eight components of care, and women's knowledge and perception of care quality. RESULTS: There were significant differences in the predicted proportion or probability of recommended services for four of eight care components, including intake, laboratory examinations, infection control, and supplies, iron folic acid supplements and Tetanus Toxoid vaccine provided to women. These care components were more likely performed in fixed clinics, except for distribution of supplies, iron-folic acid supplements, and Tetanus Toxoid vaccine, more likely provided in mobile clinics. There were no differences between clinic type for the proportion of total physical exam procedures performed, health and communication messages delivered, provider communication or documentation. Women's knowledge about educational topics was poor, but women perceived extremely high quality of care in both clinic models. CONCLUSIONS: Although adherence to guidelines differed by clinic type for half of the care components, both clinics had a low percentage of overall services delivered. Efforts to improve provider performance and quality are therefore needed in both models. Mobile clinics must deliver high-quality ANC to improve health and nutrition outcomes.
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Instituciones de Atención Ambulatoria/normas , Atención a la Salud/normas , Unidades Móviles de Salud/normas , Atención Prenatal/normas , Calidad de la Atención de Salud , Atención a la Salud/métodos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Haití , Humanos , EmbarazoRESUMEN
BACKGROUND: Nearly one-half of Guatemalan children experience growth faltering, more so in indigenous than in nonindigenous children. OBJECTIVES: On the basis of ethnographic interviews in Totonicapán, Guatemala, which revealed differences in maternal perceptions about food needs in infant girls and boys, we predicted a cumulative sex difference in favor of girls that occurred at â¼6 mo of age and diminished markedly thereafter. We examined whether the predicted differences in age-sex patterns were observed in the village, replicated the examination nationally for indigenous children, and examined whether the pattern in nonindigenous children was different. DESIGN: Ethnographic interviews (n = 24) in an indigenous village were conducted. Anthropometric measurements of the village children aged 0-35 mo (n = 119) were obtained. National-level growth patterns were analyzed for indigenous (n = 969) and nonindigenous (n = 1374) children aged 0-35 mo with the use of Demographic and Health Survey (DHS) data. RESULTS: Mothers reported that, compared with female infants, male infants were hungrier, were not as satisfied with breastfeeding alone, and required earlier complementary feeding. An anthropometric analysis confirmed the prediction of healthier growth in indigenous girls than in indigenous boys throughout the first year of life, which resulted in a 2.98-cm height-for-age difference (HAD) between sexes in the village and a 1.61-cm HAD (P < 0.001) in the DHS data between 6 and 17 mo of age in favor of girls. In both data sets, the growth sex differences diminished in the second year of life (P < 0.05). No such pattern was seen in nonindigenous children. CONCLUSIONS: We propose that the differences in the HAD that first favor girls and then favor boys in the indigenous growth patterns are due to feeding patterns on the basis of gendered cultural perceptions. Circumstances that result in differential sex growth patterns need to be elucidated, in particular the favorable growth in girls in the first year of life.
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Desarrollo Infantil , Trastornos de la Nutrición del Niño/fisiopatología , Métodos de Alimentación/efectos adversos , Trastornos del Crecimiento/etiología , Trastornos de la Nutrición del Lactante/fisiopatología , Relaciones Madre-Hijo , Sexismo , Estatura , Trastornos de la Nutrición del Niño/etnología , Preescolar , Etnopsicología/métodos , Femenino , Gráficos de Crecimiento , Trastornos del Crecimiento/etnología , Guatemala , Humanos , Indígenas Centroamericanos/psicología , Lactante , Trastornos de la Nutrición del Lactante/etnología , Recién Nacido , Masculino , Relaciones Madre-Hijo/etnología , Salud Rural/etnología , Factores Sexuales , Sexismo/etnologíaRESUMEN
The importance of early childhood development (ECD) is scientifically established and is increasingly recognized by governments and international organizations. However, progress in protecting and improving ECD is constrained by multisectoral influences on ECD, the multiple sectors and venues for delivering services, the lack of a common fiscal and policy space, and weak or fragmented data and monitoring systems. This paper describes two tools and strategies to strengthen multisectoral, system-wide policy environments for ECD. One is the Systems Approach for Better Education Results (SABER)-ECD framework for tracking progress toward an integrated ECD system. Developed by the World Bank, SABER-ECD assists governments and their partners to take stock of their existing ECD policies and programs, analyze strengths and areas for improvement using common metrics, and learn from international examples. The other tool is an Agenda-Setting and Commitments framework, based on research in global health and nutrition that can guide national-level actors in their advocacy and strategic efforts to strengthen the integrated ECD system. These represent practical and research-based tools to translate scientific evidence concerning ECD into effective and large-scale actions.
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Desarrollo Infantil , Fenómenos Fisiológicos Nutricionales Infantiles , Preescolar , Colombia , Prestación Integrada de Atención de Salud , Intervención Educativa Precoz , Intervención Médica Temprana , Salud Global , Política de Salud , Humanos , Kirguistán , Desnutrición/prevención & control , Tanzanía , Naciones UnidasRESUMEN
Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.
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Desnutrición/prevención & control , Formulación de Políticas , Bangladesh , Bolivia , Política de Salud , Promoción de la Salud/organización & administración , Humanos , Entrevistas como Asunto , Perú , VietnamRESUMEN
A number of multilateral and bilateral food security and nutrition initiatives have been launched in the wake of the 2008 food crisis, many with the explicit intention of fostering country ownership, multisectoral action, and harmonization among international partners. These bear some resemblance to the failed multisectoral nutrition planning initiatives that followed the 1974 world food crisis, raising the question of whether the current initiatives are doomed to experience the same fate. This paper explores these questions in one country by focusing on the policy sustainability of Bolivia's Zero Malnutrition Program (ZM), a multisectoral initiative that appeared at its initiation to be buttressed by political support and strengthened by design features that differed in important ways from similar efforts of the 1970s. Retrospective and prospective data collected through an action research and grounded methodology revealed, however, that the real struggle in Bolivia came after ZM was launched. ZM champions made undeniable progress in the first 2 years of the program with health-sector interventions, but they underestimated the challenges of building and sustaining the commitment of high-level political leaders, mid-level bureaucrats, and local-level implementers in the majority of other sectors. These initial experiences from Bolivia hold important lessons for several global initiatives to scale up nutrition actions, which are being launched in great haste and so far have given scant attention to strategies for managing the nutrition policy process and strengthening the capacities for implementation.
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Creación de Capacidad , Conducta Cooperativa , Servicios Dietéticos/organización & administración , Programas de Gobierno/organización & administración , Desnutrición/prevención & control , Política Nutricional , Condiciones Sociales , Bolivia , Servicios de Salud Comunitaria/organización & administración , Implementación de Plan de Salud , Promoción de la Salud/métodos , HumanosRESUMEN
Food security and nutrition are ascendant issues on global and national policy agendas in recent years, as a result of the global food crisis and growing recognition of the magnitude and consequences of these problems for human and economic development. The translation of this attention into effective action at the country level will require multistakeholder agreements concerning priority problems, interventions, delivery strategies, roles and responsibilities, and other matters, but this has proven to be a difficult and contentious process in many countries. This study explores stakeholders' perspectives on the characteristics of a good process in Guatemala, a country that has encountered difficulties deciding such matters in recent years, as well as their views on decision acceptance and the feasibility of implementing a good process. Semistructured interviews were conducted with 20 participants in earlier policy deliberations who were identified through snowball sampling. The constant comparative method was used for analysis. These participants attach great importance to the quality of decision processes, have strong support for decision principles derived from theory and experience elsewhere, would be willing to participate in such a process and accept the resulting decisions, and feel such a process would be challenging but feasible in the Guatemalan context. These findings, together with experiences elsewhere, suggest that countries would do well to seek agreement on the design of a multistakeholder decision-making process before they seek agreement on priority nutrition problems, target groups, interventions, delivery strategies, and other matters that have proven contentious in many settings.
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Consenso , Procesos de Grupo , Política Nutricional , Toma de Decisiones en la Organización , Programas de Gobierno , Guatemala , HumanosRESUMEN
80% of the world's undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions--eg, iodised salt and vitamin A supplementation--most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition.
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Protección a la Infancia , Promoción de la Salud/organización & administración , Desnutrición/prevención & control , Bienestar Materno , Política Nutricional , Adulto , África , Niño , China , Toma de Decisiones , Femenino , Alimentos/economía , Salud Global , Prioridades en Salud , Humanos , Evaluación Nutricional , Estado Nutricional , Política , Sector Privado , Desarrollo de Programa , Investigación , América del SurRESUMEN
Los modelos convencionales para la clasificacion de causas de defuncion indican que alrededor de 70 por ciento de las defunciones de ninos de 0 a 4 anos que ocurren en el mundo se deben a enfermedades diarreicas, infeccion respiratoria aguda, paludismo y enfermedades controlables por inmunizacion. Dichos metodos no revelan el papel que desempena la malnutricion en la mortalidad preescolar, pese al sinergismo, conocido desde hace mucho tiempo, entre la malnutricion y las enfermedades infecciosas. En este trabajo se decribe un metodo epidemiologico recien creado para estimar el porcentaje de las defunciones de ninos de 6 a 59 meses atribuible a los efectos potenciadores de la malnutricion en las enfermedades infecciosas. Los resultados obtenidos a partir de 53 paises en desarrollo que poseian datos representativos de alcance nacional sobre el peso para la edad en la infancia, indican que las defunciones infantiles se atribuyeron a los efectos potenciadores de la malnutricion en 56 por ciento de los casos, y que de estos, 83 por ciento se debieron a malnutricion leve o moderada, pero no grave. Cuando se examinaron los paises individualmente, los efectos potenciadores de la malnutricion en la mortalidad se observaron en un total de 13 a 66 por ciento de los casos, de los cuales por lo menos las tres cuartas partes correspondieron a malnutricion leve a moderada. Estos resultados demuestran que la malnutricion tiene un efecto mucho mas importante en la mortalidad preescolar de lo que se suele pensar y que las estrategicas basadas exclusivamente en la deteccion y tratamiento de ninos con malnutricion grave poco serviran para neutralizarlo. La metodologia presentada en este documento permite estimar los efectos de la malnutricion en la mortalidad preescolar de cualquier poblacion cuyos datos de prevalencia esten disponibles
Se publico en ingles en el Bull. WHO. Vol. 73(4), 1995