Exploring Gaps, Opportunities, Barriers and Enablers in Malnutrition Management

Malnutrition: A Pressing Global Health Challenge

Disease-related malnutrition (DRM) is a critical public health issue that significantly impacts patient outcomes and healthcare systems worldwide. It is estimated that up to half of adults and one-third of children admitted to Canadian hospitals present with DRM, which is associated with poor prognosis, increased complications, and higher healthcare costs.

Despite the availability of strategies to screen, diagnose and treat DRM, policy-level changes to facilitate implementation and sustainability have been lacking. To address this gap, the Canadian Nutrition Society and Canadian Malnutrition Task Force initiated the CANDReaM (Creating Alliances Nationally for policy to address Disease Related Malnutrition) commitment, aimed at developing policy approaches to combat DRM.

Insights from Key Informant Interviews

As part of the CANDReaM initiative, the research team conducted qualitative interviews with 22 key informants (KIs) from seven countries across four regions. These KIs represented diverse roles and disciplines, including academia, healthcare systems, governments, non-profit organizations, industry, and patient groups. The interviews explored the gaps, opportunities, barriers and enablers to DRM policy development and implementation.

Actors Driving DRM Policy

The Health Policy Triangle (HPT) framework, which considers actors, content, context and processes, guided the analysis of the interview findings. The KIs identified three key groups of actors essential for DRM policy:

1. Champions in Healthcare: These were healthcare professionals, researchers and academics who championed DRM practice change, leveraging their relationships to raise awareness and support policy action.

2. Senior Leaders in Healthcare Administration: While often unaware of the relevance of DRM, these leaders were recognized as vital for driving organizational-level DRM policies.

3. Individuals with Lived Experience: Patients and their advocacy groups were deemed crucial, yet often missing, voices in shaping DRM policy.

KIs emphasized the need to engage these diverse actors, as their involvement could accelerate the development and implementation of effective DRM policies.

DRM Policy Content

The KIs described three essential components of DRM policy content:

1. Screening: Establishing consensus on standardized DRM screening tools and processes.

2. Diagnosis: Ensuring formal DRM diagnoses are recognized by health systems, often through the use of International Classification of Diseases (ICD) codes.

3. Treatment: Addressing access to and ability to prescribe appropriate nutritional treatments, such as oral nutritional supplements and enteral nutrition.

Aligning these policy content elements with the unique contexts of different healthcare settings (e.g., hospital, long-term care, community) was viewed as crucial for successful implementation.

DRM Policy Context

The KIs highlighted several contextual factors that influence DRM policy development and implementation:

1. Setting-Specific Factors: Characteristics of the healthcare organization, such as capacity for research, geographical reach, and workflow, were seen as critical considerations.

2. Cost and Capacity: Demonstrating the healthcare cost savings associated with proper DRM diagnosis and treatment was identified as a key driver for policy action.

3. Social Determinants of Health: Issues like food insecurity and affordability were recognized as important contextual factors to address alongside DRM.

Understanding the nuances of each setting’s context was deemed essential, as enablers in one setting may present as barriers in another.

DRM Policy Processes

The KIs discussed four key elements of the policy development and implementation process:

1. Cross-Sectoral and Multi-Level Governance: Engaging stakeholders across disciplines, departments and levels of government was viewed as crucial for policy success.

2. Mandating and Other Reinforcement Strategies: While policy mandates were seen as important, KIs emphasized the need for complementary implementation strategies, such as accreditation and performance metrics.

3. Windows of Opportunity: Aligning policy efforts with organizational changes, new guidelines, or the involvement of individuals with lived experience was identified as a facilitator.

4. Research and Evaluation: Generating and disseminating evidence on the impact of DRM interventions and policies was deemed essential for advocacy and policy implementation.

Opportunities and Recommendations

The insights from the KI interviews highlight several opportunities to advance DRM policy development and implementation:

1. Leverage Existing Momentum: Build upon the progress made through global initiatives, such as the Global Leadership Initiative on Malnutrition (GLIM) and the United Nations Decade of Action on Nutrition, to drive DRM policy efforts.

2. Engage Diverse Actors: Empower healthcare champions, senior leaders, and individuals with lived experience to actively participate in the policy development process.

3. Align Policy Content with Context: Ensure DRM policy content is tailored to the specific needs and characteristics of different healthcare settings.

4. Demonstrate the Economic Impact: Conduct comprehensive cost-benefit analyses to highlight the potential healthcare savings associated with effective DRM management.

5. Incorporate Social Determinants: Address the broader systemic issues, such as food insecurity, that contribute to the development and perpetuation of DRM.

6. Foster Multi-Stakeholder Collaboration: Facilitate cross-sectoral and multi-level governance to align policy development and implementation efforts.

7. Leverage Research and Evaluation: Strengthen the evidence base on the impact of DRM interventions and policies to inform advocacy and policy implementation.

By addressing these opportunities, policymakers, healthcare professionals, and advocates can work together to develop and implement effective DRM policies that improve patient outcomes and support sustainable healthcare systems.

Conclusion

The findings from the KI interviews underscore the critical need for policy-level changes to address the pervasive issue of DRM. By understanding the gaps, opportunities, barriers and enablers identified, stakeholders can tailor their efforts to drive meaningful progress in malnutrition management. Ultimately, the implementation of comprehensive DRM policies has the potential to transform healthcare systems and positively impact the lives of millions of individuals affected by this preventable and treatable condition.