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OBJECTIVE We aimed to identify the main barriers to integrated care (IC) as reported by healthcare stakeholders from various linguistic regions and health system specificities, according to their reality of practice. METHODS Information was gathered through an open-ended question from a national survey conducted in Switzerland in 2019. Responses were analysed qualitatively with the IRaMuTeQ software. RESULTS Answers from 410 respondents were obtained. Respondents reported barriers at two levels: the system and professional level. Threat to financial benefits, concerns for patient data sharing and tensions between quality of care and benefits for patients versus costs were mentioned at the professional level, in their activity and in patient care. At the system level, limitations at the political level due to federalism and the lack of support and training for professionals were important barriers, in addition to the lack of recognition and compensation for professionals and the fragmented functioning of the health care system. CONCLUSION Our study underlines the importance of implementing innovative funding strategies and reimbursement schemes, as well as political willingness to move towards IC. The alignment between federal policies and cantonal specificities also appears as necessary to achieve involvement of professionals, promote integration of services and coordination of professionals for continuous and efficient care.

Introduction: Interprofessional collaboration (IPC) is becoming more widespread in primary care due to the increasing complex needs of patients. However, its implementation can be challenging. We aimed to identify barriers and facilitators of IPC in primary care settings. Methods: An overview of reviews was carried out. Nine databases were searched, and two independent reviewers took part in review selection, data extraction and quality assessment. A thematic synthesis was carried out to highlight the main barriers and facilitators, according to the type of IPC and their level of intervention (system, organizational, inter-individual and individual). Results: Twenty-nine reviews were included, classified according to six types of IPC: IPC in primary care (large scope) (n = 11), primary care physician (PCP)-nurse in primary care (n = 2), PCP-specialty care provider (n = 3), PCP-pharmacist (n = 2), PCP-mental health care provider (n = 6), and intersectoral collaboration (n = 5). Most barriers and facilitators were reported at the organizational and inter-individual levels. Main barriers referred to lack of time and training, lack of clear roles, fears relating to professional identity and poor communication. Principal facilitators included tools to improve communication, co-location and recognition of other professionals’ skills and contribution. Conclusions: The range of barriers and facilitators highlighted in this overview goes beyond specific local contexts and can prove useful for the development of tools or guidelines for successful implementation of IPC in primary care.

Introduction: Interprofessional collaboration (IPC) is increasingly used but diversely implemented in primary care. We aimed to assess the effectiveness of IPC in primary care settings. Methods: An overview (review of systematic reviews) was carried out. We searched nine databases and employed a double selection and data extraction method. Patient-related outcomes were categorized, and results coded as improvement (+), worsening (–), mixed results (?) or no change (0). Results: 34 reviews were included. Six types of IPC were identified: IPC in primary care (large scope) (n = 8), physician-nurse in primary care (n = 1), primary care physician (PCP)-specialty care provider (n = 5), PCP-pharmacist (n = 3), PCP-mental healthcare provider (n = 15), and intersectoral collaboration (n = 2). In general, IPC in primary care was beneficial for patients with variation between types of IPC. Whereas reviews about IPC in primary care (large scope) showed better processes of care and higher patient satisfaction, other types of IPC reported mixed results for clinical outcomes, healthcare use and patient-reported outcomes. Also, reviews focusing on interventions based on pre-existing and well-defined models, such as collaborative care, overall reported more benefits. However, heterogeneity between the included primary studies hindered comparison and often led to the report of mixed results. Finally, professional- and organizational-related outcomes were under-reported, and cost-related outcomes showed some promising results for IPC based on pre-existing models; results were lacking for other types. Conclusions: This overview suggests that interprofessional collaboration can be effective in primary care. Better understanding of the characteristics of IPC processes, their implementation, and the identification of effective elements, merits further attention.

Small-quantity lipid-based nutrient supplements (SQ-LNS) could help prevent malnutrition. Our primary objective was to examine the acceptability and consumption of sweetened and unsweetened versions of SQ-LNS before and after 14-days of repeated exposure. A total of 78 mother-infant dyads recruited from health centers in Morelos, Mexico, were randomized to two groups of SQ-LNS (sweetened, LNS-S, unsweetened, LNS-U). During the study, infants were fed SQ-LNS (20 g) mixed with 30 g of complementary food of the caregiver&rsquo, s choice. The amount of supplement-food mixture consumed was measured before, during and after a 14-day home exposure period. We defined acceptability as consumption of at least 50% of the offered food mixture. At initial exposure, LNS-U consumption was on average 44.0% (95% CI: 31.4, 58.5) and LNS-S 34.8% (25.3, 44.0), at final exposure, LNS-U and LNS-S consumption were 38.5% (27.8, 54.0) and 31.5% (21.6, 43.0). The average change in consumption did not differ between the groups (2.2 p.p. (&minus, 17.2, 24.4)). We conclude that the acceptability of sweetened and unsweetened SQ-LNS was low in this study population. Since consumption did not differ between supplement versions, we encourage the use of the unsweetened version given the potential effects that added sugar may have on weight gain especially in regions facing the double burden of malnutrition.

OBJECTIVES: Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to address malnutrition among infants and toddlers during complementary feeding. There is currently limited research assessing children's acceptability (i.e., behavioral response to the taste) of these supplements, and acceptability may predict long term consumption of these foods. We aimed to adapt a video coding protocol for use in naturalistic settings to determine child food acceptance. METHODS: Infants (ages 7 to 24 months) were fed two versions of an SQ-LNS (sweetened, unsweetened) mixed with a familiar food (e.g., infant oatmeal, banana) by mothers at two different study sites: a laboratory in Denver, Colorado (n = 56; 86% Non-Hispanic White) and family homes in the state of Morelos, Mexico (n = 62). Trained coders used a video coding (VC) scheme to rate child acceptance of each spoon offer using a 4-point scale (0 = refusal, 1 = enforced, 2 = acceptance, 3 = anticipation). The VC scheme was subsequently adapted for use as: 1) a live coding (LC) scheme to be used in participant homes, and 2) a video live coding (VLC) scheme to be used as a reliability check on the LC scheme. The LC scheme was tested with a sample of infants and caregivers (n = 20) selected using stratified sampling [infant age, supplement group (sweetened, unsweetened)] from the Mexico trial. One coder rated the infants’ responses to the SQ-LNS while observing the feeding interaction in the home. A second coder rated the same infants’ responses while later watching a video of the feeding (VLC). To simulate LC, the second coder did not pause the video. Intra-class correlation coefficients (ICC) were calculated to assess inter-rater reliability between sites and coding methods. RESULTS: Reliabilities for VC between Denver and Mexico coders were excellent (ICC > .94), as were reliabilities for coders within study sites (ICCs > .95). Reliabilities calculated between coders utilizing different coding methods were moderate (VLC and LC: ICC = .75), good (LC and VC: ICC = .87), or excellent (VC and VLC: ICC = .93). CONCLUSIONS: Our LC scheme demonstrated good reliability with a VC scheme to assess infant acceptability of an SQ-LNS. Since traditional VC is both resource and time-intensive, our LC scheme may be useful for assessing infant food acceptance in resource-limited settings. FUNDING SOURCES: Global Alliance for Improved Nutrition (GAIN).

OBJECTIVES: Appropriate utilisation of home fortificants such as small-quantity lipid-based nutrition supplements (SQ-LNS) requires providing clear and acceptable instructions of use for the target audience. We conducted formative research to identify locally available foods that could be recommended to mix with unsweetened SQ-LNS in Mexico. METHODS: Thirteen caregivers of 7 to 23 month-old children participated in a SQ-LNS tasting session and guided group discussion at a hospital in a semi-urban area in Morelos, Mexico. After sampling the SQ-LNS, caregivers were asked to select 1 or more of the 9 common complementary foods available to mix with 1 sachet of SQ-LNS (20 g). The common complementary foods available, identified from previous research, were: cooked rice, mashed beans, plain yogurt, strawberry-flavoured yogurt, the sweetened dairy snack Danonino, two types of commercial baby food (carrot and pear), banana, and oatmeal. Caregivers tasted and rated the organoleptic properties of SQ-LNS mixed with each of the foods. Subsequently, we conducted a home feeding session in which caregivers selected 1 of the top 4 foods preferred during the tasting session to mix with SQ-LNS (n = 8). RESULTS: The preferred foods for mixing SQ-LNS in the tasting session were mashed beans (n = 5), cooked rice (n = 2), Danonino (n = 2) and unsweetened yogurt (n = 2). Caregivers preferred these foods because they were considered better in masking the taste of the supplement. During the home feeding session, half of the caregivers selected Danonino to mix with SQ-LNS, and none selected unsweetened yogurt. Some caregivers considered that varying the type of foods used to mix with SQ-LNS could be a useful strategy to improve acceptance and adherence to daily supplementation. CONCLUSIONS: Providing multiple examples of locally available and acceptable complementary foods to mix with SQ-LNS might be necessary to promote daily supplement use in the study context. Formative research is useful for developing recommendations for SQ-LNS use that take into account the customs and preferences of the target population. FUNDING SOURCES: The study was funded by the Government of Canada, as part of the Business Platform for Nutrition Research hosted by the Global Alliance for Improved Nutrition.

Background The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. Objectives We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. Methods We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. Results Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. Conclusions Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Background The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). Objective We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. Methods The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. Results The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. Conclusions The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.

OBJECTIVES: Small quantity lipid-based nutrient supplement (SQ-LNS) are widely used in the treatment for malnutrition among infants and young children during complementary feeding. However, its acceptability by the children is frequently mothers concern. We aimed to identify strategies used by caregivers to encourage consumption of SQ-LNS in 7–24 month-old children in Morelos, Mexico. METHODS: We conducted a 14-day home feeding trial with a convenience sample of 62 caregivers of children aged 7–24 months in semi-urban communities of Morelos, Mexico. Caregivers were instructed to offer children a daily a sachet of 20-g portion of the assigned version SQ-LNS mixed with 30 g of a food commonly fed to the children. After the trial, we conducted 6 focus groups with 24 caregivers to explore their experience with the use of SQ-LNS. The main topics of the focus group guide include general perception of the supplement and the acceptability of the child and the strategies to improve consumption of children that refused the supplement. The focus groups were audio-recorded, transcribed verbatim, and independently coded by two researchers using constant comparison method. We used Nvivo 12 to conduct the analysis. RESULTS: i. Mixing the supplement with foods that masked the taste and/or consistency; ii. Testing new ways of preparing the supplement (alone or mixing it with food to offer variety); iii. Trying various feeding practices (e.g., force feeding, self-feeding, requesting other members of the family to feed the child); iv. Offering the supplement at different points in time (e.g., as a snack, as part of lunch, after nape time, etc.); v. Other strategies (e.g., playing games, distracting children, making threats). The strategies did not vary by type of supplement. CONCLUSIONS: Counseling and communication campaigns that anticipate these strategies to caregivers and include responsive feeding are needed in supplementation programs to contribute to improve acceptability and sustained use of the product. FUNDING SOURCES: Global Alliance for Improved Nutrition (GAIN).

OBJECTIVES: Lipid-based nutrient supplements (LNS) have the potential to improve micronutrient status, growth and development of children. While the sweetened version of the supplement has been found to be acceptable, the acceptability of unsweetened LNS is unknown. The study was conducted to examine the acceptability of unsweetened small-quantity LNS (SQ-LNS) among Mexican children and their caregivers. METHODS: Eligible caregivers of 7 to 24 mo-old children (n = 13) participated in an SQ-LNS tasting session at a hospital in a semi-urban area of the state of Morelos, Mexico. Using a 3-point hedonic scale, they rated the organoleptic characteristics of SQ-LNS (alone and mixed with food) and their willingness to feed it to their child. Subsequently, a focus group discussion was conducted to further explore caregivers’ experiences and perceptions about the supplement. Feeding sessions were carried out in caregivers’ homes, during which children (n = 8) were fed a meal consisting of SQ-LNS (20 g) mixed with a local complementary food (36 g). The amount (g) of meal consumed by the children was measured. RESULTS: Most women (n = 12) liked the smell of the supplement and more than half (n = 8) liked the appearance. However, less than a quarter liked the taste (n = 3) and texture (n = 2) and more than half (n = 8) perceived that their child would dislike it. Irrespective of caregiver's perception regarding the supplement, a majority (n = 9) reported they would be willing to feed it to their children mostly because of its nutritional content and health benefits. Caregivers reported that they would prefer to mix the supplement with food before feeding to child and would try different strategies including mixing the supplement with foods that are commonly eaten at home that the child likes. When caregivers rated LNS mixed with food, results showed that more than half liked the taste (n = 8) and perceived that their child would like it (n = 9). On average, children consumed 23.8 ± 19.2 g of the meal (equivalent to a proportion of 42 ± 34%). CONCLUSIONS: Although the taste of unsweetened SQ-LNS was not largely accepted, caregivers expressed their willingness to feed the supplement to their children using different strategies. The use of unsweetened SQ-LNS in future studies in this population may be acceptable. FUNDING SOURCES: The study was funded by the Government of Canada, as part of the Business Platform for Nutrition Research hosted by the Global Alliance for Improved Nutrition.