SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
May, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Caregivers’ feeding practices for children are influenced by different factors that include social and cultural issues. One method that can help overcome these issues is nutrition training of health workers. This is done through in service training, continuing professional education, short courses, or seminars.
People making decisions concerning child health.
Sunguya B, Poudel K, Mlunde L, et al. Effectiveness of nutrition training of health workers toward improving caregivers’ feeding practices for children aged six months to two years: a systematic review. Nutrition J 2013; 12:66
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Under nutrition is responsible for one third of child deaths worldwide, mainly in low and middle income countries. Nutrition training of relevant health workers can help in reducing this problem mainly through providing frequent nutrition counseling to caregivers. Nutrition training is defined as “any formal nutrition course provided to health workers in the form of in service training, continuing professional education, short courses, or seminars, aimed at improving the nutrition knowledge or practices of health workers.”
| Review objectives: To examine the effectiveness of nutrition training for health workers on child feeding practices among children aged 6 months to 2 years. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials and cluster randomised trials of interventions in which health workers received nutrition trainings targeting caregivers’ feeding practices. |
Ten randomised trials and cluster randomised trials of interventions in which health workers received nutrition training targeting caregivers’ feeding practices. |
| Participants | Health workers including doctors; nurses and nurse midwives; midlevel providers including assistant medical officers, clinical officers, assistant nurses, or assistant physicians; community health workers including village health workers. |
Nutritionists (2); doctors (1); health workers (6); community health workers (2); auxiliary nurse midwives (1) |
| Settings | Health facilities |
Health facilities in low and middleincome countries: India (4), Brazil (1), Peru (1), Pakistan (1), China (1), Bangladesh (1), Vietnam (1) |
| Outcomes | Three outcome variables: feeding frequency measured in the number of times the child was fed in the previous 24 hours; energy intake in kilojoules (kJ) per day; and dietary diversity, defined as the variety of food items that was fed to a child |
Feeding frequency (5), energy intake (6); dietary diversity: consumption of targeted food items (7) |
| Date of most recent search: October 2012 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Sunguya B, Poudel K, Mlunde L, et al. Effectiveness of nutrition training of health workers toward improving caregivers’ feeding practices for children aged six months to two years: a systematic review. Nutrition J 2013; 12:66.
Sunguya B, Poudel K, Mlunde L, et al. Effectiveness of nutrition training of health workers toward improving caregivers’ feeding practices for children aged six months to two years: a systematic review. Nutrition J 2013; 12:66
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 10 studies conducted in low and middle income countries. The studies found that health workers receiving nutrition training for caregivers:
Health workers who received nutrion training versus health workers who did not receive nutrition training |
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| People: Health workers: nutritionists; doctors; health workers; community health workers; auxiliary nurse midwives. Settings: Health facilities in low and middle income countries: India, Brazil, Peru, Pakistan, China, Bangladesh, Vietnam. Intervention: Nutrition training. Comparison: No nutrition training. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
Comments | |
| Energy intake in kilo joules (kJ) per day |
Standardized mean difference +0.76 (95% CI 0.63 to 0.88) |
High |
The effect was expressed in units of standard deviations. The results indicate a moderate beneficial effect of the intervention on energy intake | |
| Feeding frequency (number of times the child was fed in the previous 24 hours) |
Standardized mean difference +0.48 (95% CI 0.38 to 0.58)Relative risk of being fed: 0.99 (0.87 to 1.13) |
High |
The results indicate a moderate beneficial effect of the intervention on feeding frequency. | |
| Consumption of targeted food items |
High |
There were consistent findings among all included studies showing that children whose caregivers were counseled by trained health workers had a higher consumption of targeted food items compared to their counterparts. | ||
| Cost of training | No included studies | |||
| Health outcomes, such as the proportion of undernourished children or children with adverse health outcomes | No included studies | |||
| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| The interventions were conducted in healthcare facilities in low and middle income countries. |
The results are likely applicable in low income country settings with accessible health facilities that are utilized by caregivers.
|
| EQUITY | |
| The systematic review did not address equity issues. |
Training targeted at disadvantaged and underserved populations would likely reduce inequities. However, training health workers serving less disadvantaged populations might increase inequities relative to more disadvantaged populations with out access to trained health workers. |
| ECONOMIC CONSIDERATIONS | |
| The review did not include studies that reported economic evaluations. |
There may be some additional costs involved in providing nutrition training to health workers, as well as potentially increased costs associated with providing counseling to the caregivers. Future studies should include economic evaluations, and local costing would be important prior to implementation. |
| MONITORING & EVALUATION | |
| The certainty of the evidence was high for feeding frequency and energy intake. |
Delivery of the intervention and performance of health workers should be monitored when implementing a new nutrition training program. Consideration should also be given to monitoring the impact of the training on caregivers’ behaviors. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgments were made see: www.supportsummaries.org/methods |
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Kulwa KB, Verstraeten R, Bouckaert KP, et al. Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial. BMC Public Health 2014; 14.
Sunguya BF, Poudel KC, Mlunde LB, et al. Nutrition training improves health workers' nutrition knowledge and competence to manage child undernutrition: a systematic review. Frontiers Public Health 2013; 1:37.
Andrea Darzi, MD, MPH, Clinical Research institute AUB GRADE Centre at the American University of Beirut, Leba non; and Nour Hemadi, MPH, K2P, American University of Beirut, Lebanon
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Agustin Ciapponi and Samar ElFeky. We did not receive any comments from the review authors.
Sunguya B, Poudel K, Mlunde L, et al. Effectiveness of nutrition training of health workers toward improving caregivers’ feeding practices for children aged six months to two years: a systematic review. Nutrition J 2013; 12:66.
Darzi A, Hemadi N. Is nutrition training of health workers effective in improving caregivers’ feeding practices for children aged six months to two years. A SUPPORT Summary of a systematic review. May 2017. www.supportsummaries.org
Evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, nutrition training, health workers, feeding frequency, energy intake
