Background
Broad objective
Methods
Inclusion criteria
Types of studies
Types of participants
Study setting
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Countries with high levels of institutional and social fragility, identified based on publicly available indicators that measure the quality of policy and institutions and manifestations of fragility.
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Countries affected by violent conflict, identified based on a threshold number of conflict-related deaths relative to the population [9].
Interventions
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Promotion of exclusive breastfeeding in the first 6 months
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Promotion of appropriate, adequate and safe complementary feeding for children aged 6–23 months
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Vitamin A supplementation for children aged 6–59 months
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Zinc supplementation for diarrhea management
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Deworming for children from 12 to 59 months
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Iron-folic acid supplementation for pregnant women
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Food fortification of staple foods
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Salt iodization
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Multiple Micronutrient Supplementation (MNPs) for under5s
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Prevention and treatment of moderate acute under-nutrition
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Prevention and treatment of severe acute malnutrition
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Dietary diversity among pregnant and lactating mothers
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Adolescent health and preconception nutrition
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Agriculture and food security
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Social protection (social safety nets programs such as CVAs, Food Donations/Aids, NHIF, CT)
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Early childhood development and education (ECDE) (This will include child stimulation play and responsiveness, Nutrition)
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Maternal mental health
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Women’s empowerment
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Child protection
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Water and sanitation (WASH)
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Health and family planning services
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Schooling
Comparison group
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The programme start year, location(s) & duration;
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Level of programme integration at which implemented I.e. primary care, secondary care, tertiary care, and quaternary care (teaching and referral hospitals), public / private sector;
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Whether the integration covers specific groups e.g. adults’ vs children, pregnant and lactating women, under-fives, adolescents etc...
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Types of services /intervention integrated.
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What were the components of the integration process? i.e. was it joint programme where clients were seen for example on the same day, or was it just referral pathways between the services.2.Programme integration: We will assess how the approach to integration was developed and designed i.e.
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How the integration of nutrition sensitive and specific interventions was executed;
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Challenges and barriers linked to the programme integration;
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Facilitators of programme integration.3.Programme results
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-What is the impact of integration broadly categorized as;
Type of nutrition outcomes
Exclusion criteria
Search methods for identification of studies
Data collection and analysis
Data extraction and management
Risk of bias (quality) assessment
Subgroup analysis
Assessment of heterogeneity
Data synthesis
Quality assessments
Results
Results of the search
Study ID | Country | Study design | Duration of intervention | Integration program | Nutrition Interventions Included |
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Arifeen et al. 2009 [14] | Bangladesh | Cluster RCT | 2 years | Nutrition into IMCI/iCCM | Counselling of mothers on breastfeeding and appropriate complementary feeding, local feeding practices, growth monitoring, supplementary nutrition, vitamin A supplementation, and screening, management and referral for malnutrition. |
Armstrong et al. 2004 [15] | Tanzania | Cross-sectional study | Not stated | ||
Bhandari et al. 2012 [16] | India | Cluster RCT | 3 years and 4 months | ||
Bryce et al. 2005 [17] | Tanzania | Non-RCT | 1 year | ||
El Arifeen et al. 2004 [18] | Bangladesh | Cluster RCT | 2 years | ||
Friedman & Wolfheim 2014 [19] | Multi-countries | Mixed studies | Not stated | ||
Masanja et al. 2005 [20] | Tanzania | Cross-sectional study | Not stated | ||
Mazumder et al. 2014 [21] | India | Cluster RCT | 3 years and 4 months | ||
Miller et al. 2014 [22] | Ethiopia | Cross-sectional study | 1 year | ||
Rasanathan et al. 2014 [23] | Sub-Saharan countries | Cross-sectional study | Not stated | ||
Schellenberg et al. 2004 [24] | Tanzania | Cross-sectional study | Not stated | ||
Taneja et al. 2015 [25] | India | Cluster RCT | 1 year | ||
Aguayo et al. 2013 [26] | India | Cross-sectional study | 1 year | SAM/MAM into Health Services | Community and facility-based management of SAM and MAM. |
Amadi et al. 2016 [27] | Zambia | Cohort study | 3 years | ||
Brits et al. 2017 [28] | South Africa | Cohort study | 1 year | ||
Deconinck et al. 2016 [29] | Niger | Qualitative study | Not stated | ||
Kouam et al. 2014 [30] | Bangladesh | Qualitative study | Not stated | ||
Puett et al. 2015 [31] | Bangladesh | Qualitative study | Not stated | ||
Puett et al. 2013 [32] | Bangladesh | Mixed study | Not stated | ||
Sadler et al. 2011 [33] | Bangladesh | Cross-sectional study | Not stated | ||
Tadesse et al. 2017 [34] | Ethiopia | Cohort study | 14 weeks | ||
Doherty et al. 2010 [35] | Ethiopia, Madagascar, Tanzania, Uganda, Zambia, Zimbabwe | Cross-sectional study | 6 months | Nutrition into Child Health Days | Vitamin A supplementation and nutrition screening. |
Palmer et al. 2013 [36] | Multi-countries | Cross-sectional study | Not stated | ||
Anand et al. 2012 [37] | 28 sub-Saharan African countries | Cross-sectional study | Not stated | Nutrition into Immunization | Vitamin A supplementation, early and exclusive breastfeeding, infant and young child feeding practices and growth monitoring. |
Baqui et al. 2008 [38] | India | Quasi-experimental | 3 years | ||
Ching et al. 2000 [39] | Philippines and Vietnam | Cross-sectional study | Not stated | ||
Hodges et al. 2015 [40] | Sierra Leone | Quasi-experimental | 6 months | ||
Klemm et al. 1996 [41] | Philippines | Cross-sectional study | 6 months | ||
Ropero-Álvarez et al. 2012 [42] | Multi-countries | Cross-sectional study | Not stated | ||
Fernandez-Rao et al. 2014 [43] | India | RCT | 1 year | Nutrition into ECD | Home/preschool fortification with multiple micronutrient powder, responsive stimulation, early nutrition interventions, monitoring of child nutrition and growth promotion. |
Gowani et al. 2014 [44] | Pakistan | RCT | 2 years and 7 months | ||
Yousafzai et al. 2014 [45] | India | RCT | 1 year | ||
Grellety et al. 2017 [46] | Congo | RCT | 6 months | Nutrition into Cash Transfer Programs | Treatment of SAM according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. |
Berti et al. 2010 [47] | Ethiopia, Ghana, Malawi & Tanzania | Cross-sectional survey | 10 years | Nutrition into Other Programs | Infant and young child feeding practices and micronutrient supplementation. |
Fagerli et al. 2017 [48] | Kenya | Cross-sectional study | 1 year | ||
Grossmann et al. 2015 [49] | Guatamala | Before and after study | 3 months | ||
Guyon et al. 2009 [50] | Madagascar | Before and after study | 5 years | ||
Nguyen et al. 2017 [51] | Bangladesh | Cluster-RCT | 2 years | ||
Parikh et al. 2010 [52] | Dominican Republic | Cross-sectional study | 1 year | ||
Saiyed & Seshadri 2000 [53] | India | Cross-sectional study | Not stated | ||
Singh et al. 2017 [54] | India | Quasi experimental | 18 months | ||
Sivanesan et al. 2016 [55] | India | Cross-sectional study | Not stated | ||
Tandon, 1989 [56] | India | Cross-sectional study | Not stated | ||
Head Jeniffer 1999 [57] | Ethiopia | Cross-sectional study | Not stated |
Study description and geographical location
Nutrition integration platform
Risk of bias
Impact of integration models or approaches on nutrition integration following nutrition interventions
Integrated nutrition intervention and IMCI/iCCM programmes
Integrated nutrition intervention and immunisation programmes
Best practices, drivers and bottlenecks to integration with applicability to fragile context
Study ID/Country | Integration program/ Intervention | Key findings/ Recommendations | Barriers and opportunities for improvement |
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Armstrong et al. 2004 [15] Tanzania | Nutrition into IMCI/ICCM Intervention: Counselling of mothers on breastfeeding and appropriate complementary feeding, local feeding practices, growth monitoring, supplementary nutrition, vitamin A supplementation, and screening, management and referral for malnutrition | There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. | Opportunities: IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource poor countries and can lead to rapid gains in the quality of case-management. |
Bhandari et al. 2012 [16] India | Implementation of the IMNCI resulted in substantial improvement in infant survival and in neonatal survival in those born at home. | Opportunities: High quality training, ensuring adequate supervision, timely supplies, and task based incentives to community health workers was critical for the observed effect. | |
Aguayo et al. 2013 [26] India | SAM/MAM into Health Services Intervention: Community and facility-based management of SAM and MAM. | The survival rates in the integrated model for the management of SAM (IM-SAM) program were very high | Opportunities: Existing health systems can be strengthened with feasible adjustments i.e. integrated model that comprises facility- and community-based therapeutic care |
Amadi et al. 2016 [27] Zambia | Comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality | Opportunities: Community-based screening may seem like a resource-intensive approach but the result is justified | |
Brits et al. 2017 [28] South Africa | Half of the children improved from severe malnutrition to underweight or exited at target weight | Barriers observed include; obstacles in implementing the guidelines correctly and lack of monitoring of the integrated program. | |
Deconinck et al. 2016 [29] Niger | Key hindering factors identified were not fully understanding severity, causes and consequences of the problem | Barriers: lack of information on burden of acute malnutrition, recognition of the public health priority, leadership for policy adaptations and implementation, technical and financial resources, effectiveness of the intervention and capabilities and motivation of health actors. | |
Baqui et al. 2008 [38] India | Nutrition into Immunization Intervention: Vitamin A supplementation, early and exclusive breastfeeding, infant and young child feeding practices and growth monitoring. | Most of the reduction in mortality was in the group who were visited within the first 3 days of birth | Opportunities: Reaching newborn babies at the community level is crucial in settings where the availability and utilization of facility-based care is low. Systems must also be put in place to ensure that these workers visit neonates at home during the first hours and days after birth and provide a link to competent health services Barriers: Workers’ competency in the new neonatal component of the programme, their workload and inadequate management and supervision were possible barriers to higher coverage. |
Fagerli et al. 2017 [48] Kenya | Nutrition into Other Programs Intervention: Infant and young child feeding practices and micronutrient supplementation. | The study shows multi-sectoral integration including hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women. | Barriers: low education level, distance from health facilities, and poor socioeconomic status. |
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Broad context: political readiness, interest, and support and progress monitoring for resilience and development initiatives
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Nature of the problem: knowledge of causes and consequences of illness and prevention and treatment pathways, accurate information on the burden of disease, and political and social environment to recognize the problem and initiate change
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Intervention: skill development; decentralised care to increase staff exposure to the breadth of the health care system, access, utilization and involvement; quality of care showing effectiveness and increasing awareness and user satisfaction; and clinical, organizational and management capacities in successful sites
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Adoption system: compatibility with personal, professional and institutional goals, values and principles; collaborative support, engagement and involvement; learning and career development opportunities; and support for problem solving
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Health system characteristics: policy adaptation and translation; expanded, regulated and aligned partnerships; expanded health workforce; and decentralised care
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Broad context: demographic pressure and multi-sectoral approach diverting a sectoral focus
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There is lack of evidence on the nature of the problem
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Intervention: clinical, organizational and management capacity gaps in certain sites, interventions substituted by partners and limited community awareness and involvement reinforcing mistrust
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Adoption system: partner support favouring evading responsibility; lack of interest or motivation or collaboration in care and learning, feeling of curtailed career development, and high workload
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Health system characteristics: multiple health information systems; underfunded health budget; short-term emergency funding; high staff turnover and attrition; limited logistic capacity for bulky, expensive supplies; and limited community and patient/ care giver involvement and empowerment