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Micronutrient powder (MNP) can reduce iron deficiency in young children, which has been well established in efficacy trials. However, the cost of different delivery platforms has not been determined. We calculated the cost and cost‐efficiency of distributed MNP through community‐based mechanisms and in health facilities in a primarily rural district in Uganda. An endline survey (n = 1072) identified reach and adherence. During the 9‐month pilot, 37,458 (community platform) and 12,390 (facility platform) packets of MNP were distributed. Each packet consisted of 30 MNP sachets. In 2016, total costs were $277,082 (community platform, $0.24/sachet) and $221,568 (facility platform, $0.59/sachet). The cost per child reached was lower in the community platform ($53.24) than the facility platform ($65.97). The cost per child adhering to a protocol was $58.08 (community platform) and $72.69 (facility platform). The estimated cost of scaling up the community platform pilot to the district level over 3 years to cover approximately 17,890 children was $1.23 million (scale‐up integrated into a partner agency program) to $1.62 million (government scale‐up scenario). Unlike previous estimates, these included opportunity costs. Community‐based MNP delivery costs were greater, yet more cost‐efficient per child reached and adhering to protocol than facility‐based delivery. However, total costs for untargeted MNP delivery under program settings are potentially prohibitive., This study estimates costs based on programmatic elements using two delivery platforms in a single rural site in Uganda: (1) delivery by community health workers (community‐based platform) and (2) delivery using facility‐based health providers (facility‐based platform). We calculated the cost of micronutrient powders (MNP) provision from start‐up to the “last mile”— the final leg in product and service delivery when MNP reaches beneficiaries. We compared costs and cost‐efficiency across delivery platforms using several indicators of outcomes and estimated the costs of scaling up, extending the pilot program, and integrating MNP delivery activities into existing infant and young child feeding programs.

Significance Language discordance has been shown to contribute to social disparities in healthcare. Contact tracing is essential to combating COVID-19, but language differences between contact tracers and patients have hindered its efficacy. We demonstrate a general method for leveraging machine learning and administrative data to maximize the impact of bilingual contact tracers and level language differences. We evaluate in a randomized controlled trial the impact of language matching on high-volume contact tracing in Santa Clara County, CA, and show that it reduces time spent and improves engagement with contact tracers. These results illustrate the advantages of utilizing bilingual personnel over third-party interpreters in improving social services., Contact tracing is a pillar of COVID-19 response, but language access and equity have posed major obstacles. COVID-19 has disproportionately affected minority communities with many non–English-speaking members. Language discordance can increase processing times and hamper the trust building necessary for effective contact tracing. We demonstrate how matching predicted patient language with contact tracer language can enhance contact tracing. First, we show how to use machine learning to combine information from sparse laboratory reports with richer census data to predict the language of an incoming case. Second, we embed this method in the highly demanding environment of actual contact tracing with high volumes of cases in Santa Clara County, CA. Third, we evaluate this language-matching intervention in a randomized controlled trial. We show that this low-touch intervention results in 1) significant time savings, shortening the time from opening of cases to completion of the initial interview by nearly 14 h and increasing same-day completion by 12%, and 2) improved engagement, reducing the refusal to interview by 4%. These findings have important implications for reducing social disparities in COVID-19; improving equity in healthcare access; and, more broadly, leveling language differences in public services.

Key Points Question What are effective mechanisms to identify and reach vulnerable populations and equalize access to COVID-19 testing resources in the presence of substantial demographic disparities? Findings In this cohort study of 756 participants, a door-to-door program with community-based health workers was associated with a substantial increase in the proportion of Latinx and elderly individuals undergoing testing, relative to neighborhood testing sites. The protocol associated with the greatest increase in testing at-risk individuals was uncertainty sampling, followed by local knowledge, and then targeting households in areas with a high number of index cases. Meaning These findings suggest that community-based testing programs that allocate resources using uncertainty sampling might effectively reduce COVID-19 testing disparities., Importance Overcoming social barriers to COVID-19 testing is an important issue, especially given the demographic disparities in case incidence rates and testing. Delivering culturally appropriate testing resources using data-driven approaches in partnership with community-based health workers is promising, but little data are available on the design and effect of such interventions. Objectives To assess and evaluate a door-to-door COVID-19 testing initiative that allocates visits by community health workers by selecting households in areas with a high number of index cases, by using uncertainty sampling for areas where the positivity rate may be highest, and by relying on local knowledge of the health workers. Design, Setting, and Participants This cohort study was performed from December 18, 2020, to February 18, 2021. Community health workers visited households in neighborhoods in East San Jose, California, based on index cases or uncertainty sampling while retaining discretion to use local knowledge to administer tests. The health workers, also known as promotores de salud (hereinafter referred to as promotores) spent a mean of 4 days a week conducting door-to-door COVID-19 testing during the 2-month study period. All residents of East San Jose were eligible for COVID-19 testing. The promotores were selected from the META cooperative (Mujeres Empresarias Tomando Acción [Entrepreneurial Women Taking Action]). Interventions The promotores observed self-collection of anterior nasal swab samples for SARS-CoV-2 reverse transcriptase–polymerase chain reaction tests. Main Outcomes and Measures A determination of whether door-to-door COVID-19 testing was associated with an increase in the overall number of tests conducted, the demographic distribution of the door-to-door tests vs local testing sites, and the difference in positivity rates among the 3 door-to-door allocation strategies. Results A total of 785 residents underwent door-to-door testing, and 756 were included in the analysis. Among the 756 individuals undergoing testing (61.1% female; 28.2% aged 45-64 years), door-to-door COVID-19 testing reached different populations than standard public health surveillance, with 87.6% (95% CI, 85.0%-89.8%) being Latinx individuals. The closest available testing site only reached 49.0% (95% CI, 48.3%-49.8%) Latinx individuals. Uncertainty sampling provided the most effective allocation, with a 10.8% (95% CI, 6.8%-16.0%) positivity rate, followed by 6.4% (95% CI, 4.1%-9.4%) for local knowledge, and 2.6% (95% CI, 0.7%-6.6%) for index area selection. The intervention was also associated with increased overall testing capacity by 60% to 90%, depending on the testing protocol. Conclusions and Relevance In this cohort study of 785 participants, uncertainty sampling, which has not been used conventionally in public health, showed promising results for allocating testing resources. Community-based door-to-door interventions and leveraging of community knowledge were associated with reduced demographic disparities in testing., This cohort study compares 3 protocols for allocating health workers to deliver COVID-19 tests door-to-door within East San Jose, California, including index area selection, uncertainty sampling, and local knowledge of the health workers.

Micronutrient powders (MNP) have the potential to increase micronutrient intake, yet documentation of implementation lessons remains a gap. This paper presents results of a pilot in Uganda comparing community‐ and facility‐based delivery of MNP and documenting experiences of caregivers and distributors. The pilot's mixed method evaluation included a cross‐sectional endline survey, monthly household visits, and midline and endline interviews. Primary outcomes were ever‐covered (received ≥1 MNP packet), repeat‐coverage (received ≥2 MNP packets), and adherence (consumed no more than 1 MNP sachet per day, consumed MNP with food, and consumed MNP 3+ days in past week). An adjusted Wald chi‐square test compared differences in programme outcomes between arms, and logit regression identified predictors to adherence. Key informant interviews were coded thematically. Most programme outcomes in the endline survey were statistically significantly higher in the community arm, although in both arms, adherence was lower than other outcomes (adherence 31.4% in facility vs. 58.3% in community arm). Counselling, receipt of communication materials, perceived positive effects, MNP knowledge, and child liking MNP were consistent predictors of adherence in both arms. Qualitative findings corroborated survey results, revealing that social encouragement and advocacy facilitated use and that forgetting to give MNP was a barrier. Facility arm caregivers also cited distance, time, and transportation cost as barriers. Distributors had positive experiences with training and supervision but experienced increased workloads in both arms. MNP programme design is context‐specific but could benefit from strengthened community sensitization, continued and more effective counselling for caregivers, and increased support for distributors.

Background: In 2010, Uganda began developing its first multisectoral nutrition plan, the Uganda Nutrition Action Plan (UNAP), to reduce malnutrition. While the UNAP signals high-level commitment to addressing nutrition, knowledge gaps remain about how to successfully implement such a plan. Objective: We tracked the UNAP’s influence on the process of priority setting and funding for nutrition from 2013 to 2015. Methods: This study used a longitudinal mixed methods design to track qualitative and budgetary changes related to UNAP processes nationally as well as in 2 study districts. Qualitative changes were assessed through interviews, news content, and meeting notes. Changes in allocations and expenditures were calculated based on budget documents, work plans, and validation interviews. Results: Important enabling factors named by stakeholders included identity, human resources, sustainable structures, coordination, advocacy, and adaptation of the UNAP to local needs. Evidence suggests that the UNAP facilitated improvements in the last 3 factors. We found no systematic increases in planned nutrition activities, nor did we find increases in allocations or expenditures for nutrition between fiscal years 2013-2014 and 2014-2015. Expenditure data were not always available for all funding mechanisms. In the 2 study districts, there was little flexibility within financing structures to allow for additional nutrition activities. Conclusions: Results suggest the UNAP has played an important role in strengthening the enabling environment for nutrition action. The next UNAP will need to translate these improvements into a greater number of nutrition activities and higher levels of funding at the national and subnational levels.

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

The proportion of pregnant women receiving 4 or more antenatal care (ANC) visits has no necessary relationship with the actual content of those visits. We propose a simple alternative to measure program performance that aggregates key services that are common across countries and measured in Demographic and Health Surveys, such as blood pressure measurement, tetanus toxoid vaccination, first ANC visit before 4 months gestation, urine testing, counseling about pregnancy danger signs, and iron–folate supplementation., Background: The proportion of pregnant women receiving 4 or more antenatal care visits (ANC 4+) is used prominently as a global benchmark indicator to track maternal health program performance. This has contributed to an inappropriate focus on the number of contacts rather than on the content and process of care. This paper presents analysis of specific elements of care received among women reporting 4 or more ANC visits. Methods: We conducted secondary analysis using Demographic and Health Survey data from 41 countries to determine coverage for specific elements of antenatal care. The analysis was conducted for: (1) women who delivered during the 2 years preceding the survey and who reported receiving 4 or more ANC visits, and (2) all women who delivered during the preceding 2 years. The specific ANC services that we assessed were: blood pressure measurement, tetanus toxoid vaccination, first ANC visit at less than 4 months gestation, urine testing, counseling about danger signs, HIV counseling and testing, iron–folate supplementation (≥ 90 days), and at least 2 doses of sulfadoxine/pyramethamine for malaria prevention. The difference between expected (100%) and actual coverage (the quality–coverage gap) was calculated for each service across the 41 surveys. Results: Coverage for specific elements of care among women reporting 4 or more ANC visits was generally low for most of the specific elements assessed. Blood pressure and tetanus toxoid performed best, with median quality–coverage gaps of 5% and 18%, respectively. The greatest gaps were for iron–folate supplementation (72%) and malaria prevention (86%). Coverage for specific interventions was generally much lower among all pregnant women (reflecting population effective coverage) than among only those who had received ANC 4+ visits. Although ANC 4+ and average coverage across the elements of care correlated relatively well (Pearson r2 = 0.56), most countries had lower average coverage for the content of care than for ANC 4+ (among all pregnant women). Conclusion: We argue for the adoption of a summary indicator that better reflects the content of antenatal care than does the current ANC 4+ indicator. We propose, as an alternative, the simple average of a set of ANC content indicators available through surveys and routine health information systems.

ObjectiveThe prevalence of maternal anaemia remains unacceptably high in developing countries. At the same time, the percentage of women who consume one or more Fe+folic acid (IFA) tablets during pregnancy remains persistently low. The objective of the present study was to identify where, within antenatal care (ANC) programmes, pregnant women falter in obtaining and consuming an ideal minimum of 180 IFA tablets.DesignData from Demographic and Health Surveys were used to develop a schematic which identifies four sequential ‘falter points’ to consuming 180 IFA tablets: ANC attendance, IFA receipt or purchase, IFA consumption and the number of tablets consumed.SettingTwenty-two countries with high burdens of undernutrition.SubjectsA sample of 162 958 women, 15 to 49 years of age, with a live birth in the past 5 years.ResultsAcross all countries, 83 % of all pregnant women had at least one ANC visit, 81 % of whom received IFA tablets. Of those receiving IFA tablets, 95 % consumed at least one. Overall adherence to the ideal supplementation regimen, however, was extremely low: only 8 % consumed 180 or more IFA tablets. There were only two countries in which the percentage of pregnant women consuming 180 or more tablets exceeded 30 %.ConclusionsWhile most women receive and take some IFA tablets, few receive or take enough. The analysis identifies where ANC-based distribution of IFA falters in each country. It enables policy makers to design and prioritize follow-up activities to more precisely identify barriers, an essential next step to improving IFA distribution through ANC.