Friday, November 11, 2011

How Innovative Fortification Strategies Can Reduce Iron Deficiency Anemia in the Developing World

Micronutrient deficiencies and their associated medical consequences are among the greatest threats to public health in developing countries. Iron deficiency is extremely prevalent throughout the developing world, and iron deficiency anemia (IDA) affects two billion people worldwide – over 30% of the global population.[1] Women and children are particularly vulnerable to IDA: 42% of pregnant women and 47% of preschool-age children worldwide are anemic.[2] It has long been recognized that iron deficiency impedes physical and economic development, and that reducing the prevalence of IDA is necessary for economic growth and prosperity. However, unlike certain widely accepted global health strategies such as vitamin A supplementation, there is no universally accepted intervention addressing iron deficiency. Long term, sustainable strategies aimed at reducing poverty and inequality are necessary to eliminate malnutrition, but micronutrient interventions, specifically, have the potential for immediate results.

Two new methods of reducing the prevalence of IDA are documented to be showing promise. The first is a home fortification strategy called “Sprinkles,” and the second is the technology of double fortified salt combined with iodine and iron.

Sprinkles, developed by the Sprinkles Global Health Initiative, are micronutrient powders that come in small sachets, each containing enough powder to provide a child with his or her daily micronutrient requirements.[3] Sprinkles can be mixed with food prepared in the home, and the powder does not change the taste, color, or texture of the food once mixed. One version of the Sprinkles formula is specially designed to reduce the prevalence of IDA, and contains a highly absorbable form of iron. There have been many community-based studies on the safety, efficacy, and acceptability of Sprinkles conducted in various regions around the world.[4] [5] Overall, results show that Sprinkles are an effective strategy to reduce IDA, and anemia reduction rates have ranged from 49-91%, depending on the area.[6] Currently, seventeen countries worldwide have ongoing Sprinkles programs.

The second, more widespread method of addressing iron deficiency is salt fortification technology. Salt is an optimal product to fortify, as it is widely available, consumed regularly throughout the year, and is affordable even in many low-income households. For these reasons, salt has become a typical household commodity, allowing fortification efforts to reach a diverse range of people in areas of endemic iron deficiency and IDA.

One unique benefit of salt fortification programs is that they can also be used to address iodine deficiency, which is another prevalent health problem in the developing world. In fact, universal salt iodization was adopted in 1993 to prevent iodine deficiency disorders, and it has been incredibly successful in many countries.[7] Since salt can be used to supply populations with iodine or iron, current technologies can allow for double fortification of salt, so that it becomes a carrier for both iodine and iron. Existing encapsulation technology allows double fortified salt to look and taste exactly like ordinary salt, making it culturally acceptable. A randomized, double-blind controlled trial of double fortified salt in southern India indicated that it could reduce the prevalence of anemia and iron deficiency among school-aged children by about 10% in ten months.[8] India represents a large proportion of iron deficient women and children worldwide, and the country has proposed the introduction of double fortified salt into public health policy due to its demonstrated success.

Micronutrient powders and iron fortification strategies have great potential to make an impact on public health. Salt fortification is far-reaching and is particularly relevant in countries like India, where iron deficiency is widespread. Targeted interventions, such as Sprinkles and nutrition education programs that are tailored to vulnerable groups, can complement dual salt fortification, making an even larger improvement in global nutrition.

Although evidence-based research is available for both the Sprinkles and salt fortification intervention strategies, a significant scale-up will be necessary to gain recognition in the field of global health practice. Iron and iodine deficiencies have been a burden to the public health sector for decades; fortunately, quality research and innovative ideas have the power to create lasting change.

[1] WHO (2011). Micronutrient Deficiencies: Iron Deficiency Anemia. Retrieved October 28^th, 2011, from http://www.who.int/nutrition/topics/ida/en/index.html

[2] Black, R.E., Allen, L.H., Bhutta, Z.A, Caulfield, L.E., de Onis, M., Ezzati, M. et al. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371: 243-260.

[3] Sprinkles Global Health Initiative. (2011). About Sprinkles. Retrieved October 28^th, 2011, from http://www.sghi.org/index.html

[4] Adu-Afarwuah, S., Lartey, A., Brown, K.H., Zlotkin, S., Briend, A. & Dewey, K.G. (2008). Home fortification of complementary foods with micronutrient supplements is well accepted and has proven effects on infant iron status in Ghana. American Clinical Journal of Nutrition, 87: 929-938.

[5] Lundeen, E., Schueth, T., Toktobaev, N., Zlotkin, S., Hyder, S.M., & Houser, R. (2010). Daily use of Sprinkles micronutrient powder for 2 months reduces anemia among children 6-36 months of age in Kyrgyz Republic: a cluster-randomized trial. Food Nutrition Bulletin, 31(3): 446-460.

[6] Sprinkles Global Health Initiative. (2011). About Sprinkles. Retrieved October 28^th, 2011, from http://www.sghi.org/index.html

[7] WHO (2011). Micronutrient Deficiencies: Iodine Deficiency Disorders. Retrieved October 28^th, 2011, from http://www.who.int/nutrition/topics/idd/en/index.html

[8] Anderson, M., Thankachan, P., Muthayya, S., Goud, R.B., Kurpad, A.V., Hurrell, R.F., et al. (2008). Dual fortification of salt with iodine and iron: a randomized, double-blind, controlled trial of micronized ferric pyrophosphate and encapsulated ferrous fumarate in southern India. American Journal of Clinical Nutrition, 88: 1378-1387.

Tuesday, October 4, 2011

Ben Goldacre Battles “Bad Science” and the Stresses The Importance of Unbiased Research

In a TED Talk presentation, Ben Goldacre – a doctor turned epidemiologist – addresses the troublesome issue of using “bad science” (a term used to describe poor quality research methods) to produce and support scientific publications[1]. Usually, qualified scientific researchers pride themselves on keeping the integrity of science alive by using the best methods for acquiring and analyzing data. Goldacre, however, argues that not all scientific papers being published are based on the gold standard of evidence, and that readers should be wary of misguided results. This is especially true when coming across the many health claims that are popularly publicized in the media today. Some examples of these health claims that Goldacre mentions include coffee being advertised, separately, as both a cause and a preventative measure for cancer, and that housework prevents breast cancer for women, while shopping could make men impotent. It would be easy for the public to take these claims as truth, but it is important to think critically, explore the science behind them, and to decide whether there are any political or private industry interests related to them.

One of Goldacre’s main points is that the pharmaceutical industry benefits from manipulating data so that reporting is in favor of whichever new drug they are marketing. It has been shown that drug studies that are funded by pharmaceutical companies are associated with outcomes that are flattering to the funder, with most of the reasoning due to research bias[2]. Clearly this poses a problem to progress in healthcare since poor quality publications can convince a doctor to use a newer, more expensive drug than its predecessor, while there may be no real advantages to doing so. The gold standard of evidence when testing the efficacy of a drug is using randomized controlled trials, which include a control group (either a placebo or a competing drug) for comparing the intervention trial[3]. Goldacre explains that there are many tricks that can be used to make a new drug look better, including having different sample sizes, administering the competing drug in a dose that is either too high or too low, or by simply withholding some of the data. All of these practices are unacceptable research methods.

The Cochrane Collaboration is an international network of professionals that produces a library of Cochrane Reviews, a database of systemic reviews which scrutinize the results of medical and healthcare research[4]. Their hope is plainly that “healthcare decision-making throughout the world will be informed by high-quality, timely research evidence”[5]. Having a publication go through the peer review process is like having a signature of approval, and is something doctors and medical professionals should look for when trying to compare drugs. Having public access to the Cochrane library is a huge asset to the field of public health. However, there is no easy solution to the problem of scientific misinformation.

To learn more about quality research practices visit Unite for Sight’s Certificate in Global Health Research curriculum at http://www.uniteforsight.org/global-health-university/research-certificate

[1] TED: Ideas Worth Spreading. (2011). Ben Goldacre: Battling Bad Science. Retrieved October 3, 2011, from http://www.ted.com/talks/ben_goldacre_battling_bad_science.html

1167.abstract

[3] Kaptchuk, T.J. (2001). The double-blind, randomized, placebo-controlled trial: Gold standard or golden calf? Journal of Clinical Epidemiology, 54(6), 541-549.

[4] The Cochrane Collaboration. (2011). About Us. Retrieved October 3, 2011, from http://www.cochrane.org/about-us

[5] Ibid.

Thursday, September 29, 2011

What Do Willingness-to-Pay Studies on Health Services in Developing Countries Reveal?

Low-income individuals in a developing country face numerous barriers to health care such as financial constraints, distance to health providers, transportation costs, and loss of work time. In developing countries, most poor people are unable to pay for even basic health care services to prevent or treat life-threatening diseases, and they therefore experience higher risk of mortality from treatable and preventable diseases[1]. With scarce health services and resources, low-cost health insurance may be a feasible option to improve health, even for low-income groups[2]. How do we measure how much people in developing countries are willing to pay for health services?

Without real-world experience, willingness to pay (WTP) for health services in developing countries is measured through contingent valuation (CV) methods. CV is a survey-based research technique that elicits direct responses from consumers on how much they are willing to pay for a proposed improvement of a good or service[3]. In the health field, WTP approaches evaluate the value people place on health services, and this has become increasingly used and applied in recent years to health care services and health insurance[4]. The CV technique has been used in a few countries to predict the demand of health services:

Wuhan, China: Informal sector workers had a WTP that was greater than the estimated cost of insurance based on past health expenditures with workers willing to pay the equivalent of around 4 US dollars per member each month[5].
Burkino Faso: A community-based health insurance package was “feasible if health service utilization did not increase by more than 28%”[6].
Ghana: A study found that 64% were willing to pay for health insurance[7].
Iran: A study found that it is feasible to expand the existing urban health insurance system into rural areas based on WTP from consumers[8].
Tanzania: A study on WTP for cataract surgeries found that higher-income individuals reported a higher WTP for cataract surgery, and individuals who owned one or more items were 5.1 times more likely. Those with two or more items were 11.8 times more likely to be willing to pay for cataract surgery than those who did not own items[9].
Ethiopia: A study found that it is feasible to have a community-based health care insurance system[10].
India: A study conducted with more than 3,000 households reported that the rich have a higher WTP than the poor, the young have a higher WTP than the old, and males have a higher WTP than females[11]. Case studies of 16 voluntary organizations in India found that people are less willing to pay for preventive and promotive health care services. A study by the National Institute of Health and Family Welfare of New Delhi found that the majority of consumers are willing to pay for government health care services. A total of 80.3 percent of 811 households interviewed from rural and urban areas were willing to pay for health care services provided by the government[12].

WTP for health services is largely dependent on respondents’ perception of the relevance of the health service to a specific health need, and also the extent of value they place on the health service[13].The number of studies in the area of WTP for health insurance and health services is increasing and provides a consistent trend: while each of these schemes are different among countries and health services, evidence through CV studies demonstrate that individuals from multiple different low-income countries would be willing to pay for low-cost health insurance[14].

[1] Fleba, Steffen. "Costing of Health Care Services in ..." Challenges in Public Health. Peter Lang, 2009. Web. 19 Sept. 2011. <http://books.google.com/books?id=yqmwrwonJgAC>.

[2] Asfaw, Abay, Emily Gustafsson-Wright, and Jacques Van Der Gaag. "Willingness to Pay for Health Insurance: An Analysis of the Potential Market for New Low Cost Health Insurance Products in Namibia." Center for Disease Control and Prevention. National Institute for Occupational Health & Safety (USA). Web. 19 Sept. 2011. <http://www.aiid.org/conference/uploads/File/Research%20Papers/WTPpaperAsfaw_et_al_AIID_RS_08-01%202.pdf>.

[3] Mitchell, R. Cameron. "Using Surveys to Value Public Goods ..." Google Books. Web. 19 Sept. 2011. <http://books.google.com/books?id=1R75c1UxVE0C>.

[4] Ibid

[5] Ibid

[6] Lofgren, Curt. "CERA | Full Text | People's Willingness to Pay for Health Insurance in Rural Vietnam." Cost Effectiveness and Resource Allocation. 11 Aug. 2008. Web. 20 Sept. 2011. <http://www.resource-allocation.com/content/6/1/16>.

[7] Ibid

[8] Ibid

[9] Lewallen, S., and R. Geneau. "Willingness to Pay for Cataract Surgery in Two Regions of Tanzania." British Journal of Ophthalmology, 2 Sept. 2005. Web. 20 Sept. 2011. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856885/>.

[10] Ibid

[11] Ibid

[12] Bir, T. "USER CHARGE: A POLICY OPTION FOR HEALTH SERVICE DEVELOPMENT IN DEVELOPING COUNTRIES LIKE INDIA." Health and Population - Perspectives and Issues 23(2): 71-84, 2000 USER, 2000. Web. 19 Sept. 2011.

[13] "Health Economics for Developing Countries: A Survival Kit: Chapter 12: Sources of Finance for the Health Sector." Health Library for Disasters. Web. 19 Sept. 2011. <http://helid.digicollection.org/en/d/Jh0197e/15.html>.

[14] Asfaw, Abay, Emily Gustafsson-Wright, and Jacques Van Der Gaag. "Willingness to Pay for Health Insurance: An Analysis of the Potential Market for New Low Cost Health Insurance Products in Namibia." Center for Disease Control and Prevention. National Institute for Occupational Health & Safety (USA). Web. 19 Sept. 2011. <http://www.aiid.org/conference/uploads/File/Research%20Papers/WTPpaperAsfaw_et_al_AIID_RS_08-01%202.pdf>.

Thursday, September 22, 2011

Grassroots Fundraising - Why Do People Give?

A great model for nonprofits is grassroots fundraising, in which the organization and its volunteers generate charitable contributions from their social and business networks. Through this peer-to-peer fundraising method, organizations base their strength on having an expanded network of community support and not needing to depend on the support of a small number of financial resources. This diversified fundraising approach allows organizations to stay true to their original missions and avoid collapsing from volatile changes in giving trends. As a result, organizations engaged in grassroots fundraising are able to continue working towards the goals of the communities they serve.

A major motivation for giving is affinity for a cause due to personal connection with the mission of a nonprofit organization. Donors tend to give to organizations that hold shared ideals and values, and they are most excited to donate to organizations that are admired and supported by their own friends and family members.

Donors oftentimes feel more compelled to give when moved by empathy when they are told the story of a single person rather than provided with statistics and information about a group of people. Furthermore, individuals are more inclined to give for public benefit when they are convinced that they will make a lasting and tangible change as a result of their contribution.[1] A study found that potential donors’ top priorities were to “see an organization’s missions, goals, objectives and work” and “how the charity uses their donations and contributions”.[2]

It is critical for organizations to clearly communicate their mission statement and provide easy-to-understand results to individuals in order to convince them that their contribution will make a direct impact. For example, Unite For Sight annually engages hundreds of volunteers who each fundraise more than $2,000 to provide eye care to patients living in extreme poverty. The volunteers tell their story to their family and friends, and they explain why fundraising for Unite For Sight is important to them. The volunteers also emphasize that 100% of all donations to Unite For Sight provide eye care, and 0% is used for any other purpose. Additionally, Unite for Sight’s volunteers inform donors that each cataract surgery costs $50 on average, so every dollar donated makes a tremendous impact on the lives of children and adults.

Unite For Sight welcomes new volunteers to become engaged in our grassroots fundraising movement. If you are interested, please contact us at ufs@uniteforsight.org

[1] Sims, Sandra. "Why Do People Donate to Charitable Causes?" Fundraiser Ideas for Non Profit Organizations | Step by Step Fundraising Ideas. Step-by-Step Fundraising, 15 Aug. 2007. Web. 29 Aug. 2011. <http://stepbystepfundraising.com/why-do-people-donate-to-charitable-causes>.

[2] "Grants & Resources From Chapel & York." Chapel & York Online. Chapel & York, Feb. 2011. Web. 29 Aug. 2011. <http://www.chapel-york.com/latest_gandr/april09.html>.