This study shows that integrating food-assistance programs with routine health care in rural communities in the Dominican Republic can significantly improve the nutritional status of children. With collaborations between local physicians and the CHOP Global Health Program, the nutrition program was strengthened by focusing on high-risk children, modifying the food-package content to provide higher calories and nutritional value, and linking the program with mobile clinics that provide routine care to these rural communities. Working together, this program has increased access to nutritional assessment and management of these impoverished populations. The integration of a food-supplementation program with routine health care through mobile clinics may be an intervention that can be replicated in other rural areas.
In a seminal series of articles published in The Lancet
regarding maternal and child undernutrition, various nutrition-related interventions were reviewed and analyzed to determine standards for comparing effectiveness in terms of childhood survival.5
The authors subdivided interventions into major thematic groups. (1) interventions to improve general nutrient intake (both quality and quantity): breastfeeding promotion and complementary-feeding support nutritional education with or without food supplements; (2) micronutrient interventions: food fortification with micronutrients, supplements with iron, dispersible micronutrient preparation, vitamin A supplements, zinc supplements, iodine supplementation, and delayed cord clamping; (3) disease-prevention strategies: interventions that reduce malaria burden during pregnancy and reduce neglected tropical-disease burden and diarrheal diseases in childhood as well as improve hygiene and sanitation measures; (4) general nutrition-support strategies: conditional cash transfers and dietary diversification strategies. In respect to nutrition education with or without food supplementation, the authors conducted a meta-analysis in which countries were divided into food-insecure and food-secure nations. In populations with sufficient food, education about complementary feeding increased height for age Z
score by 0.25 (95% confidence interval = 0.01–0.49). However, provision of food supplements (with or without education) in populations with insufficient food increased the height for age Z
score by 0.41 (0.05–0.76). The authors of The Lancet
series consider that complementary-feeding counseling and support strategies in food-insecure populations could substantially reduce the burden of stunting and related disease.5
The CHOP Global Health program integrates health care through mobile clinics and food supplementation and provides a point of entry for rural and remote communities. This multidisciplinary approach in collaboration with local physicians may be a successful intervention in other remote areas.
The rural bateyes in the Dominican Republic are areas where food security is a major concern, and so, food-supplementation programs can address the burden of undernutrition. Significant reductions in the prevalence of acute and chronic undernutrition were seen in this study over a 1-year period. The magnitude of improvement among the children with acute undernutrition was greater than the improvement among the children with chronic undernutrition; the improvement in acute but not chronic undernutrition was likely related to the short time period over which this intervention was assessed. Although there was a trend of improvement in each of the undernutrition subcategories (mild, moderate, and severe), these rates were not statistically significant, perhaps because of small sample size. However, when the undernutrition variables were grouped into dichotomous categories (normal and undernourished), significant improvements were shown. There are also some interesting differences in rates of acute and chronic malnutrition in relation to sex and age. There was a non-statistical increase in acute malnutrition rates in the older age group; this effect may be related to the small sample size in the older subgroup (9% and 11% of total sample in 2005 and 2006, respectively) compared with the younger age groups. Increased rate of chronic malnutrition in the older age group and males is difficult to explain without further qualitative exploration and may represent selection bias rather than a true effect in the general population as well as a short time interval (1 year) to assess changes in chronic malnutrition.
Although the results of this program are favorable, there are limitations to this study. Evaluation of the program was done on a community level rather than on the individual level, and so, we were not able to account for migration between different bateyes. Because this is a take-home food program rather than a direct feeding program, the possibility of leakage exists. In one study, only 40–60% of foods in take-home programs went to the targeted child.6
The design of this study does not allow certainty that the improvement in anthropometric measurements of children after program implementation is solely a result of the food-supplementation program.
Although limitations to the study exist, strengths of this intervention may benefit other food-supplementation programs. First, linking the nutrition program with routine health-care visits may increase accessibility to the program for families as was previously reported by Beaton and Ghassemi.6
This integration of food distribution with routine health care through mobile clinics is a model that may be considered in other countries with rural regions. Second, community health workers were trained to identify high-risk children, collect proper anthropometrics, and counsel families on nutrition by the CHOP Global Health teams at least two times a year. These community health workers are trained by the CHOP Global Health teams on how to educate and support families to promote health and nutrition. These types of health-promotion activities have been shown to improve the nutritional status of children independent of food supplementation and are considered a key component in sustaining change.10
Collaborating with the local physicians and community health workers are important for building capacity and strengthening education for families in the bateyes to improve long-term health and nutrition. Lastly, the CHOP Global Health team worked in conjunction with the Dominican health workers and physicians to enhance the program and provide educational support to the Dominican team. Although funding for the food-supplementation program may be limited, educational outreach of the community health workers is an ongoing component of the program coordinated by Dominican physicians.
Although this program included treatment of undernourished children, preventative measures are crucial as well. A nutrition program in Haiti showed that a preventative model for delivering food assistance was more effective at reducing childhood undernutrition than the traditional treatment model of targeting underweight children.11
Preventative programs include education as well as development and support for community health workers. The CHOP Global Health program integrated these components to enhance the preventative strategy in conjunction with food supplementation. Program sustainability is also a concern, and whereas financial constraints and economic hardships may take time to address, families can be educated on breastfeeding practices and appropriate complementary foods as well as social marketing forces in the region. The CHOP Global Health program engaged in these preventative strategies by providing educational support to the community health workers to encourage healthy feeding practices; this aspect of the program is meant to provide avenues for long-standing change and improvement in the overall nutrition status of the community.
Achieving the MDG target of halving the proportion of undernourished children between 1990 and 2015 will require multifactorial and multilevel response and intervention. Unicef proposed a four-tier system. Micro-level interventions will empower families and communities to improve their health and feeding practices for pregnant women and children. Meso-level interventions will strength community efforts and improve sanitation and hygiene. Macro-level interventions will integrate child health and nutrition into national policies and budgets. Finally, global-level interventions will ensure sustainable improvements.12
This food-supplementation program linked with routine health care is a type of micro-level intervention that should be explored further as a means for improving the nutritional health of children in impoverished communities.