Impact of financial assistance on stunting: Syrian refugee children under 5 in Türkiye.

Despite the global decrease over the last two decades, stunting, also called 'chronic malnutrition', remains a public health issue affecting almost 150 million children under the age of 5 years globally. Defined by height-for-age, stunting is the consequence of poor nutrition, repeated infection, and inadequate psychosocial stimulation. Programmes and policies target undernutrition globally, and humanitarian and development actors invest great efforts to prevent stunting. This study uses multivariate analysis to examine the impact of financial assistance on the reduction of stunting in a refugee context, focusing on Syrian refugee children under the age of 5 years in Türkiye. Using a unique dataset, the 2018 Turkey Demographic and Health Survey Syrian Migrant Sample (2018 TDHS-SR), the findings indicate that financial assistance significantly reduces the incidence of stunting among refugee children under the control of economic, mother and children, environmental, health-related and nutritional and breastfeeding characteristics. However, having household members generate income is found to be another stronger predictor to reduce stunting. The paper also argues that the nutritional well-being of refugee children might improve if forced migration occurs towards a stable host country/region. In addition, adaptation over time also seems to have a positive influence.

Comparison of treatment adherence outcome among PLHIV enrolled in economic strengthening program with community control.

Economic strengthening (ES) interventions are increasingly promoted to support the economic well-being and food security of people living with HIV (PLHIV) in resource poor settings. This study aims to assess the impact of ES interventions in Ethiopia designed to address poverty and food insecurity on antiretroviral treatment (ART) adherence. A comparative cross-sectional design was employed to compare treatment adherence between food insecure PLHIV benefitting from the ES project of WFP Ethiopia to food insecure PLHIV not participating in ES. Using the visual analogue scale (VAS) to measure ART adherence, only 9.9% of the ES group reported less than 95% adherence compared to 25.9% of the comparison group. Controlling for socio-economic and demographic variables using logistic regression models, engagement in ES activities increased the likelihood of having 95% or greater ART adherence by a factor of 2.4 and 5.6 respectively (as measured by VAS and ACTG approaches) compared to those PLHIV that were not engaged in ES. The findings of the study suggest that engagement in ES contributes to improved ART adherence among food insecure PLHIV. If further studies validate this result, ES should be adopted as a key strategy to improve HIV treatment adherence in resource poor settings where adherence is an issue of concern.

Changes in Health and Antiretroviral Adherence Among HIV-Infected Adults in Kenya: Qualitative Longitudinal Findings from a Livelihood Intervention.

This longitudinal qualitative study sought to understand how and why a livelihood intervention affected the health and health behaviors of HIV-infected Kenyan adults. The intervention included a microfinance loan, agricultural and financial training, and a human-powered water pump. In-depth interviews were conducted at two time points with intervention and control participants and program staff. We double coded interviews (n = 117) and used thematic content analysis of transcripts following an integrative inductive-deductive approach. Intervention participants described improvements in HIV health, including increased CD4 counts and energy, improved viral suppression, and fewer HIV-related symptoms. Better health was linked to improved clinic attendance and ART adherence through several mechanisms: (1) reductions in food insecurity and abject hunger; (2) improved financial stability; (3) improved productivity which enhanced social support; (4) better control over work situations; and, (5) renewed desire to prioritize their own health. Livelihood interventions may improve health by influencing upstream determinants of health behavior including food security and poverty.

Preferences for food and nutritional supplements among adult people living with HIV in Malawi.

OBJECTIVE: To elucidate the factors influencing food intake and preferences for potential nutritional supplements to treat mild and moderate malnutrition among adult people living with HIV (PLHIV). DESIGN: Qualitative research using in-depth interviews with a triangulation of participants and an iterative approach to data collection. SETTING: The study was conducted in a health clinic of rural Chilomoni, a southern town of Blantyre district, Malawi. SUBJECTS: Male and female participants, aged 18-49 years (n 24), affected by HIV; health surveillance assistants of Chilomoni clinic (n 8). RESULTS: Six themes emerged from the in-depth interviews: (i) PLHIV perceived having a poor-quality diet; (ii) health challenges determine the preferences of PLHIV for food; (iii) liquid-thick, soft textures and subtle natural colours and flavours are preferred; (iv) preferred organoleptic characteristics of nutritional supplements resemble those of local foods; (v) food insecurity may contribute to intra-household sharing of nutritional supplements; and (vi) health surveillance assistants and family members influence PLHIV's dietary behaviours. No differences by sex were found. The emergent themes were corroborated by health surveillance assistants through participant triangulation. CONCLUSIONS: In this setting, a thickened liquid supplement, slightly sweet and sour, may be well accepted. A combination of quantitative and qualitative methods for data collection should follow to further develop the nutritional supplement and to fine tune the organoleptic characteristics of the product to the taste and requirements of PLHIV. Results of the present study provide a first approach to elucidate the factors influencing food intake and preferences for potential nutritional supplements among adult PLHIV.

Food Insecurity is Longitudinally Associated with Depressive Symptoms Among Homeless and Marginally-Housed Individuals Living with HIV.

Depression and food insecurity are prevalent among people with HIV (PLHIV) and contribute to poor HIV outcomes. Longitudinal data can help clarify the effect of food insecurity on depression among PLHIV in the United States. We assessed the longitudinal association of food insecurity with symptoms of depression using validated measures among participants living with HIV from the Research on Access to Care in the Homeless cohort in San Francisco. We followed 346 participants for a median of 28 months. Over half of participants (55.0 %) were food insecure and 35.8 % had symptoms of depression. In adjusted models, severe food insecurity in the previous period was associated with increased depressive symptom severity (b = 1.22; p < 0.001). The association remained statistically significant in models including participant fixed effects. Severe food insecurity was also longitudinally associated with a binary variable indicating probable depression. Efforts to increase access to and participation in food security safety net programs for PLHIV could improve depression.

Integrating food poverty and minimum cost diet methods into a single framework: a case study using a Nepalese household expenditure survey.

BACKGROUND: Current tools assessing affordability of nutritious diets are incomplete. "Food poverty" uses expenditure data to identify households unable to acquire a diet adequate in energy but does not consider other nutrients. The "minimum cost of a nutritious diet" method provides a threshold for purchasing a nutritious diet but must rely on other data to identify "nutrient-poor" households. OBJECTIVE: Integrating both methods into a single framework using a common data source, we sought to jointly estimate the proportions of a population that are food and nutrient poor. METHODS: Household expenditure data from the 2010/11 Nepal Living Standards Survey were used, focusing on representative samples of households from the mountain region (n = 401) and Kathmandu (n = 857). Food poverty thresholds were set at the cost for a low-income household to purchase a basket of foods providing adequate energy following the Cost of Basic Need method. Linear optimization was used to calculate a "nutrient poverty" threshold. Household expenditures were used to determine food and nutrient poverty rates. RESULTS: The food and nutrient poverty thresholds were 13,294 and 18,628 rupees/person/year, respectively, in the mountain region and 14,610 and 22,945 rupees/ person/year, respectively, in Kathmandu. In the mountain region, 34% of households were both food and nutrient poor and 24% were just nutrient poor. In Kathmandu the percentages were 7% and 14%, respectively. CONCLUSIONS: This approach, integrating two commonly used tools, provides a more nuanced interpretation of economic access to a nutritious diet and an opportunity to improve the design and targeting of nutrition and food security interventions.

Economic and social factors are some of the most common barriers preventing women from accessing maternal and newborn child health (MNCH) and prevention of mother-to-child transmission (PMTCT) services: a literature review.

Support to health programming has increasingly placed an emphasis on health systems strengthening. Integration of prevention of mother-to-child transmission (PMTCT) and maternal and newborn child health (MNCH) services has been one of the areas where there has been a shift from a siloed to a more integrated approach. The scale-up of anti-retroviral therapy has made services increasingly available while also bringing them closer to those in need. However, addressing supply side issues around the availability and quality of care at the health centre level alone cannot guarantee better results without a more explicit focus on access issues. Access to PMTCT care and treatment services is affected by a number of barriers which influence decisions of women to seek care. This paper reviews published qualitative and quantitative studies that look at demand side barriers to PMTCT services and proposes a categorisation of these barriers. It notes that access to PMTCT services as well as eventual uptake and retention in PMTCT care starts with access to MNCH in general. While poverty often prevents women, regardless of HIV status, from accessing MNCH services, women living with HIV who are in need of PMTCT services face an additional set of PMTCT barriers. This review proposes four categories of barriers to accessing PMTCT: social norms and knowledge, socioeconomic status, physiological status and psychological conditions. Social norms and knowledge and socioeconomic status stand out. Transport is the most frequently mentioned socioeconomic barrier. With regard to social norms and knowledge, non-disclosure, stigma and partner relations are the most commonly cited barriers. Some studies also cite physiological barriers. Barriers related to social norms and knowledge, socioeconomic status and physiology can all be affected by the mental and psychological state of the individual to create a psychological barrier to access. Increased coverage and uptake of PMTCT services can be achieved if policy makers and programme managers better understand the barriers that may prevent their potential target population from taking up and adhering to their services. The categorisation presented in this review provides further insight into the type of barriers that may exist .

Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level?

This paper reviews evidence on social and economic costs of tuberculosis. Key socio-economic consequences include stigma, social isolation, increased out-of-pocket expenditures for medical and non-medical costs and reduced income. Many of the financing methods that households use have long-term negative impacts and the poor are most vulnerable to these costs. Together, these negative consequences adversely affect TB control, in terms of delayed diagnosis, delayed initiation of treatment, suboptimal adherence and failure to complete treatment, as well as the coping and well being of the individual and household. There are two ways to reduce treatment costs for the patient; one can either reduce the direct and indirect costs of seeking a diagnosis and obtaining treatment and/or provide income transfers to offset some of those costs incurred. Social transfers in the form of food, cash or vouchers can mitigate the negative effects by enabling the individual to seek a diagnosis, protecting minimum food expenditures, reducing the need to accumulate debt and reduce productive assets and reducing the negative impacts on other household members, particularly young children and school-age children.

The enabling effect of food assistance in improving adherence and/or treatment completion for antiretroviral therapy and tuberculosis treatment: a literature review.

Socioeconomic costs of HIV and TB and the difficulty of maintaining optimal treatment are well documented. Social protection measures such as food assistance may be required to offset some of the treatment related costs as well as to ensure food security and maintain good health of the affected individual and household. Programmes have started placing greater emphasis on treatment adherence and are looking for proven interventions that can optimize it. This paper looks at the effect of food assistance for enabling treatment adherence and reviews studies that used food assistance to promote adherence. Eight of ten studies found that provision of food can improve adherence and/or treatment completion for HIV care and treatment, ART and TB-DOTS. This indicates that food provision is not only a biological, but also a behavioural intervention, and underscores that unresolved food insecurity can be an impediment to treatment adherence and consequently to good treatment outcomes.

Measuring food and nutrition security: tools and considerations for use among people living with HIV.

As an increasing number of countries implement integrated food and nutrition security (FNS) and HIV programs, global stakeholders need clarity on how to best measure FNS at the individual and household level. This paper reviews prominent FNS measurement tools, and describes considerations for interpretation in the context of HIV. There exist a range of FNS measurement tools and many have been adapted for use in HIV-endemic settings. Considerations in selecting appropriate tools include sub-types (food sufficiency, dietary diversity and food safety); scope/level of application; and available resources. Tools need to reflect both the needs of PLHIV and affected households and FNS program objectives. Generalized food sufficiency and dietary diversity tools may provide adequate measures of FNS in PLHIV for programmatic applications. Food consumption measurement tools provide further data for clinical or research applications. Measurement of food safety is an important, but underdeveloped aspect of assessment, especially for PLHIV.

Retention in care and adherence to ART are critical elements of HIV care interventions.

Retention in care and adherence to antiretroviral treatment (ART) are critical elements of HIV care interventions and are closely associated with optimal individual and public health outcomes and cost effectiveness. This literature review was conducted to analyse how the roles of clients in HIV care and treatment are discussed, from terminology used to measurement methods to consequences of a wide range of patient-related factors impacting client adherence to ART and retention in care. Unfortunately, data suggests that clients find it hard to follow recommended behaviour. For HIV, the greatest loss to follow-up occurs before starting treatment, though each step of the continuum of care is affected. Measurement approaches can be divided into 'direct' and 'indirect' methods; in practice, a combination is often considered the best strategy. Inadequate retention and adherence lead to decreased health outcomes (morbidity, mortality, drug resistances, risk of transmission) and cost effectiveness (increased costs and lower productivity).

Food security in the context of HIV: towards harmonized definitions and indicators.

Integration of HIV and food security services is imperative to improving the health and well-being of people living with HIV. However, consensus does not exist on definitions and measures of food security to guide service delivery and evaluation in the context of HIV. This paper reviews definitions and indicators of food security used by key agencies; outlines their relevance in the context of HIV; highlights opportunities for harmonized monitoring and evaluation indicators; and discusses promising developments in data collection and management. In addition to the commonly used dimensions of food availability, access, utilization and stability, we identify three components of food security-food sufficiency, dietary quality, and food safety-that are useful for understanding and measuring food security needs of HIV-affected and other vulnerable people. Harmonization across agencies of food security indicators in the context of HIV offers opportunities to improve measurement and tracking, strengthen coordination, and inform evidence-based programming.

Cost of the Diet (CoD) tool: first results from Indonesia and applications for policy discussion on food and nutrition security.

BACKGROUND: The Minimum Cost of a Nutritious Diet (MCNut) is the cost of a theoretical diet satisfying all nutrient requirements of a family at the lowest possible cost, based on availability, price, and nutrient content of local foods. A comparison with household expenditure shows the proportion of households that would be able to afford a nutritious diet. OBJECTIVE: To explore using the Cost of Diet (CoD) tool for policy dialogue on food and nutrition security in Indonesia. METHODS: From October 2011 to June 2012, market surveys collected data on food commodity availability and pricing in four provinces. Household composition and expenditure data were obtained from secondary data (SUSENAS 2010). Focus group discussions were conducted to better understand food consumption practices. Different types of fortified foods and distribution mechanisms were also modeled. RESULTS: Stark differences were found among the four areas: in Timor Tengah Selatan, only 25% of households could afford to meet the nutrient requirements, whereas in urban Surabaya, 80% could. The prevalence rates of underweight and stunting among children under 5 years of age in the four areas were inversely correlated with the proportion of households that could afford a nutritious diet. The highest reduction in the cost of the child's diet was achieved by modeling provision of fortified blended food through Social Safety Nets. Rice fortification, subsidized or at commercial price, can greatly improve nutrient affordability for households. CONCLUSIONS: The CoD analysis is a useful entry point for discussions on constraints on achieving adequate nutrition in different areas and on possible ways to improve nutrition, including the use of special foods and different distribution strategies.

What linear programming contributes: world food programme experience with the "cost of the diet" tool.

BACKGROUND: Linear programming has been used for analyzing children's complementary feeding diets, for optimizing nutrient adequacy of dietary recommendations for a population, and for estimating the economic value of fortified foods. OBJECTIVE: To describe and apply a linear programming tool ("Cost of the Diet") with data from Mozambique to determine what could be cost-effective fortification strategies. METHODS: Based on locally assessed average household dietary needs, seasonal market prices of available food products, and food composition data, the tool estimates the lowest-cost diet that meets almost all nutrient needs. The results were compared with expenditure data from Mozambique to establish the affordability of this diet by quintiles of the population. RESULTS: Three different applications were illustrated: identifying likely "limiting nutrients," comparing cost effectiveness of different fortification interventions at the household level, and assessing economic access to nutritious foods. The analysis identified iron, vitamin B2, and pantothenic acid as "limiting nutrients." Under the Mozambique conditions, vegetable oil was estimated as a more cost-efficient vehicle for vitamin A fortification than sugar; maize flour may also be an effective vehicle to provide other constraining micronutrients. Multiple micronutrient fortification of maize flour could reduce the cost of the "lowest-cost nutritious diet" by 18%, but even this diet can be afforded by only 20% of the Mozambican population. CONCLUSIONS: Within the context of fortification, linear programming can be a useful tool for identifying likely nutrient inadequacies, for comparing fortification options in terms of cost effectiveness, and for illustrating the potential benefit of fortification for improving household access to a nutritious diet.

Changes in food insecurity, nutritional status, and physical health status after antiretroviral therapy initiation in rural Uganda.

OBJECTIVE: To investigate whether time on antiretroviral therapy (ART) is associated with improvements in food security and nutritional status, and the extent to which associations are mediated by improved physical health status. DESIGN: The Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of HIV-infected adults newly initiating ART in Mbarara, Uganda. METHODS: Participants initiating ART underwent quarterly structured interview and blood draws. The primary explanatory variable was time on ART, constructed as a set of binary variables for each 3-month period. Outcomes were food insecurity, nutritional status, and PHS. We fit multiple regression models with cluster-correlated robust estimates of variance to account for within-person dependence of observations over time, and analyses were adjusted for clinical and sociodemographic characteristics. RESULTS: Two hundred twenty-eight ART-naive participants were followed for up to 3 years, and 41% were severely food insecure at baseline. The mean food insecurity score progressively declined (test for linear trend P < 0.0001), beginning with the second quarter (b = -1.6; 95% confidence interval: -2.7 to -0.45) and ending with the final quarter (b = -6.4; 95% confidence interval: -10.3 to -2.5). PHS and nutritional status improved in a linear fashion over study follow-up (P < 0.001). Inclusion of PHS in the regression model attenuated the relationship between ART duration and food security. CONCLUSIONS: Among HIV-infected individuals in Uganda, food insecurity decreased and nutritional status and PHS improved over time after initiation of ART. Changes in food insecurity were partially explained by improvements in PHS. These data support early initiation of ART in resource-poor settings before decline in functional status to prevent worsening food insecurity and its detrimental effects on HIV treatment outcomes.

Rice fortification: its potential for improving micronutrient intake and steps required for implementation at scale.

BACKGROUND: Micronutrient deficiencies affect over 2 billion people worldwide, with profound implications for health, cognitive development, education, economic development, and productivity. Fortification of staple foods is a cost-effective strategy to increase vitamin and mineral intake among the general population. Rice is consumed by billions of people (> 440 million MT/year) but is as yet rarely fortified. OBJECTIVE: To discuss the untapped opportunity of rice fortification. METHODS: Review literature and experience with rice fortification and compare to fortification of other staple foods. RESULTS: Most technologies used to fortify rice first produce the fortified kernels and then blend them with regular, polished rice. Technologies differ with regard to how nutrients are added to the rice kernels, required investment, production cost, and degree of resemblance to unfortified rice. There are, so far, limited success stories for rice fortification. Some of the main roadblocks appear to be high initial investment and associated cost; lack of government leadership; and consumer hesitation to accept variations in the characteristics of rice, or a higher price, without good understanding of the benefits. CONCLUSIONS: In countries with a large centralized rice milling industry, starting rice fortification is easier than in countries with many small mills. Countries with large safety nets that supply rice to the poorest, for free or subsidized, have a good channel to reach those most in need. Furthermore, key players from the public and private sectors should establish a coalition to support the use of fortified rice and address some of the barriers to its implementation.

Food insecurity in the context of HIV/AIDS: a framework for a new era of programming.

BACKGROUND: Food insecurity can be both a consequence and a driver of HIV/AIDS. It is often difficult to disentangle these two roles of food insecurity, since the HIV epidemic has different drivers in different settings. The advent of antiretroviral treatment in resource-limited settings adds an additional layer of complexity. This paper seeks to organize current thinking by reviewing the existing literature on food insecurity and HIV/AIDS and describing the complex interactions between them. OBJECTIVE: Based on literature review, the paper proposes a framework to understand the linkages, distinguishing four types of interventions to address them. It is hoped that the model, albeit simplified as is any framework, will help to structure research, policy, and programming in the field of HIV/AIDS and food insecurity. Finally, the paper intends to widen the lens to regard food not just as a means to provide calories or an income transfer but also as a carrier of adequate nutrition in the context of HIV. RESULTS AND CONCLUSIONS: An adequate response to HIV/AIDS and food insecurity must be tailored to specific settings. Interventions distinguished in this paper are aimed at both promoting food security and providing antiretroviral treatment and nutrition support. The four types of interventions are containing HIV and preventing AIDS through comprehensive treatment regimes that include nutritional support; mitigating the effects of AIDS through support; providing HIV-sensitive, but not HIV-exclusive, safety nets at the individual, household, and community levels; and limiting the exposure to risk through HIV prevention activities.

Food insecurity in the context of HIV/AIDS: a framework for a new era of programming.

BACKGROUND: Food insecurity can be both a consequence and a driver of HIV/AIDS. It is often difficult to disentangle these two roles of food insecurity, since the HIV epidemic has different drivers in different settings. The advent of antiretroviral treatment in resource-limited settings adds an additional layer of complexity. This paper seeks to organize current thinking by reviewing the existing literature on food insecurity and HIV/AIDS and describing the complex interactions between them. OBJECTIVE: Based on literature review, the paper proposes a framework to understand the linkages, distinguishing four types of interventions to address them. It is hoped that the model, albeit simplified as is any framework, will help to structure research, policy, and programming in the field of HIV/AIDS and food insecurity. Finally, the paper intends to widen the lens to regard food not just as a means to provide calories or an income transfer but also as a carrier of adequate nutrition in the context of HIV. RESULTS AND CONCLUSIONS: An adequate response to HIV/AIDS and food insecurity must be tailored to specific settings. Interventions distinguished in this paper are aimed at both promoting food security and providing antiretroviral treatment and nutrition support. The four types of interventions are containing HIV and preventing AIDS through comprehensive treatment regimes that include nutritional support; mitigating the effects of AIDS through support; providing HIV-sensitive, but not HIV-exclusive, safety nets at the individual, household, and community levels; and limiting the exposure to risk through HIV prevention activities.