Discussion
Findings from KI interviews suggest that DRM is not well recognised or addressed through health policy in Canada or globally. Key gaps and barriers to DRM policy development and implementation included multi-level governments, jurisdictional priorities and the need for continued advocacy. Social determinants of health, including food insecurity, also emerged as important considerations. These findings align with other work that suggested factors internal and external to the health system have inhibited incorporation of DRM into health policy.26 Building on advances in the field over the past two decades, there is opportunity to leverage the capacity and momentum of DRM initiatives to generate policy that will positively impact health and decrease associated health systems costs.1 This qualitative analysis of KI interviews contributes to the literature describing DRM policies and the value of incorporating implementation initiatives into policy.
KIs acknowledged coalitions, organisational champions and individuals with lived experiences as key actors for DRM policy development and implementation. Organisational leadership (eg, healthcare administrators), interdisciplinary champions (eg, healthcare providers, policy makers, researchers) and nutrition experts (ie, dietitians) are drivers of change and can embody implementation efforts through support, promotion and leadership.15 These actors can be leaders and advocate for change within their local settings to propel DRM policy development and implementation. The conceptual model of champion impact by Shea suggests that commitment, experience and self-efficacy influence champion performance and ultimately impact.27 These champion characteristics align with those mentioned by KIs and suggest that champions are fundamental leaders of change who can support DRM policy and advocacy.
Globally, coalitions of actors have been advocating for improved DRM management. NutritionDay aims to improve DRM awareness and nutrition care of patients.8 This effort is a worldwide scientific programme that operates on a continuous improvement circle and encourages care institutions (hospitals, intensive care units and nursing homes) to register for the initiative, collect data during a 1-day cross-sectional audit and contribute to the growing body of global DRM literature.8 These large-scale efforts to advance DRM would not be possible without key actors including champions, organisational leaders and individuals with lived experience. The results of the current study indicate that further involvement from organisational leaders and individuals with lived experience are needed. DRM policy development and implementation should occur based on setting-specific needs and contexts but can be informed by cross-country coalitions (eg, ONCA9) that provide overarching goals and objectives.
Despite global and national advancements in DRM, gaps exist between current policy and evidence-informed practice. The economic impact of DRM was viewed as a key context consideration for future policy and a lever to gain attention from senior healthcare administrators. In Canada, it is estimated that DRM costs the healthcare system an additional $2 billion per year (pre-COVID-19).1 Patients with DRM remained in hospital 3 days longer, on average, than patients without DRM and incurred approximately $2900 more in hospital costs compared with well nourished patients.1 A complete economic impact analysis is needed to fully appreciate the gravity of this situation post-COVID-19. Appreciation for the problems and implications of DRM is lacking for many organisational leaders who can implement organisational and system-level change. Absence of widespread DRM diagnosis using ICD-codes relates to policy content and actors, as formal diagnoses would draw attention and awareness to DRM among a broader scope of actors (eg, interdisciplinary care team, hospital leadership, etc). Related to HPT context, specifically cost and capacity, the economic impact of poor screening tool sensitivity is one example of the importance of DRM diagnosis by ICD-codes, especially in settings where DRM is prevalent.28 Strategies to combat DRM exist but are not widely implemented given the lack of policy mandate.
Another key group of actors with ability to influence DRM policy are individuals with lived experience. Patients with DRM have lived experience and play a critical role in shaping strategies, advocacy efforts and DRM policy that will impact patient-oriented outcomes, yet their voice is lacking in these initiatives. Similarly, a study that defined DRM as a health policy issue found that the patient plays a key role in policy development.26 A phenomenological study suggested two key approaches to addressing clinical nutrition policy (eg, DRM) including the need for an interdisciplinary approach and a human rights-based approach.26 Nutrition care as a human right has been recognised by an international declaration29 and underpins our findings whereby access to food as treatment for DRM and implications of social determinants of health came through broadly across themes.
Our findings suggested that DRM policy development processes should centre around cross-sectoral and multi-level governance; mandating and other reinforcement strategies for policy; capitalising on windows of opportunity; and using research and evaluation. Current government health policy is focused on prevention of conditions related to overnutrition and chronic diseases whereas healthcare policy addressing disease states, such as DRM, was often viewed as a local facility or organisation responsibility by KIs, rather than the purview or mandate of government.
The need for research to inform policy development and implementation overlapped with all areas of the HPT framework. It was clear that DRM policy processes evolve relative to the HPT actors, content and contexts within the target setting. It is essential for actors invested in DRM policy to understand their setting, context, purpose and evaluative needs to foster targeted and sustainable policy. KIs identified need for policy processes, contexts and content, but provided few tangible examples of policy implementation or evaluation. Key initiatives to standardise the nutrition care process related to DRM (eg, GLIM) in countries that include screening, assessment and diagnosis of DRM10 11 provide examples for others to build on in their efforts to advance DRM policy development and implementation. KIs discussed GLIM as one step towards DRM care consensus, but the need for tangible policy related to nutrition screening, diagnosis and treatment cannot be understated.
Strengths and limitations
The multi-national first-hand perspectives from experts in policy and/or DRM across settings was a strength of this work. We recognise that this is a large and complex topic, and our broad approach of focusing internationally and across multiple care settings introduced further complexity. The decision to take this broad approach was based on the lack of DRM policy within Canada, and the need to learn from the experiences of other countries and settings. The HPT framework provided structure to the interview questions and analysis. A broad range of perspectives were provided which further strengthens our results and their potential utility. Snowball sampling allowed for inclusion of KIs beyond the researcher’s networks. Finally, use of the HPT framework to inform our approach aligns with health policy analysis and is generalisable across jurisdictional settings (from local-level to global-level policy).18
Purposive sampling is a strength and limitation. KIs were selected based on their ability to provide diverse perspectives from a range of expertise and levels of influence on DRM and health policy implementation, including senior leaders in prominent international organisations. Thus, KIs were selected from countries actively working in DRM policy development and/or implementation.
Potential impact
In line with the CANDReaM commitment to the United Nations Decade of Action on Nutrition,14 our findings inform DRM policy development and implementation and are a key step towards advancing DRM policy efforts in Canada and globally. The opportunity identified is the need for DRM policy that involves interdisciplinary care team members, individuals with lived experience and policy makers. The creation of an alliance with involvement from these groups will facilitate DRM policy development. Guidance documents such as the Integrated Nutrition Pathway for Acute Care30 and the CAN/HSO 5066:2021(E) Malnutrition Prevention, Detection and Treatment standard13 are closely related to DRM policy content and exemplify important key steps towards DRM policy development and implementation in Canada. DRM policy context is system-specific and cost analysis is a facilitator for policy advocacy at the health system level. Direction on setting-specific standardised treatment remains a gap to be further explored. A further understanding of the linkage between food security and DRM may provide one avenue for considering the more systemic issues impacting prevention and treatment of DRM. Finally, DRM policy processes are complex and occur at the jurisdictional level (eg, health system, hospital or facility, other). Strategies to support policy implementation13 30 exist but are not widespread. Research and evaluation throughout the policy development and implementation processes in the clinical setting has begun31 and should be spread to community to better understand setting-specific processes.