Micronutrient powder distribution through Maternal, Neonatal and Child Health Weeks in Nigeria: process evaluation of feasibility and use

Barriers to and Facilitators of the Implementation of a Micronutrient Powder Program for Children: A Systematic Review Based on the Consolidated Framework for Implementation Research

BACKGROUND

As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions.

METHOD

Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process.

RESULTS

A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation.

CONCLUSION

Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.

Caregiver perceptions of nutrition interventions in infants and children under 24 months of age: a systematic review

OBJECTIVE

Efficacy studies show early nutrition interventions improving infant nutrition status, but understanding caregiver acceptability is required for implementation of such interventions. This systematic review examines caregivers' perceptions of nutrition interventions in young children.

DESIGN

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL and PsychINFO from date of online journal inception through December 2020. Interventions included oral (powder/liquid/tablet) and/or intravenous supplementation, food fortification and nutrition counselling. Inclusion criteria included primary research, data presented on caregiver perception and studies published in English. Quality assessment was performed using the Critical Appraisal Skills Programme tool. Studies underwent narrative synthesis using inductive thematic analysis.

SETTING

No restriction.

PARTICIPANTS

Caregivers of children under 24 months of age.

RESULTS

Of 11 798 records identified, thirty-seven publications were included. Interventions included oral supplementation, food fortification and nutrition counselling. Caregivers included mothers (83 %), fathers, grandparents and aunts. Perceptions were gathered through individual interviews, focus group discussions, questionnaires, surveys and ratings. Totally, 89 % of studies noted high acceptability (n 33 most notably increased appetite (n 17). In total, 57 % of studies (n 21) cited low acceptability, commonly from side effects (n 13) such as gastrointestinal issues, appetite loss and stained teeth.

CONCLUSIONS

Positive perceptions and enthusiasm for interventions were frequently reported. Key to implementation was the increased appetite noted by caregivers. A substantial proportion of studies reported negative perceptions, mainly due to side effects. In future interventions, mitigation and education around common side effects are crucial for acceptability. Understanding both positive and negative caregiver perceptions is important for informing future nutrition interventions and strengthening sustainability and implementation.

Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana

BACKGROUND

Eliminating Tuberculosis is one of the targets of Sustainable Development Goal Three. Decentralizing TB care beyond health facilities by leveraging community involvement is crucial for safeguarding effective tuberculosis care. In this study, we explored potential facilitators and inhibitors of the implementation and sustainability of community-based interventions for the prevention and treatment of TB in the Moshupa district, Botswana.

METHODS

This study adopted a qualitative approach using a collective case design. An interpretive paradigm based on relativist ontology and subjectivist epistemology along with abductive research logic was used. The study enrolled treatment supporters of tuberculosis patients diagnosed with drug-susceptible tuberculosis between January 2019 and December 2019 in Moshupa Village for semi-structured interviews, Health care professionals for in-depth interviews, and e community leaders for focus group discussions. Clinic-based observations in Mma-Seetsele clinic were also conducted to corroborate the participants' views. The data collected was analyzed using the NVivo version 12 software package, and statements of the participants were presented as quotes to substantiate the issues discussed.

RESULTS

This study highlighted effective partnerships between health services and external stakeholders, community empowerment, and the availability of policies and standard operating procedures as facilitators of community TB implementation and sustainability. However, Insufficient funding, low service provider training, policies not embracing age and educational eligibility for treatment supporters, shortage of equipment, medicines, and supplies, inadequate transport availability and incentives to meet clients' basic needs, paper-based systems, inadequate supervision, incomplete data reporting, and low service quality affected the Community TB program efficacy and sustainability in Moshupa. We also found that there was low service provider motivation and retention and that clients had low trust in treatment supporters.

CONCLUSION

The findings of this study imply that the operational effectiveness of the community TB care approach to disease elimination is compromised; therefore, initiatives addressing the key components, including the availability of resources, governance arrangements and supportive systems for community health workers, are required for successful community TB implementation and sustainability.

Effect of home visits by community health workers on complementary feeding practices among caregivers of children aged 6-23 months in 10 districts of Bangladesh

Background

Suboptimal complementary feeding contributes to undernutrition in children aged 6-23 months in low- and middle-income countries like Bangladesh. Multifaceted interventions have been taken to improve complementary feeding practices, but there is limited evidence about the effect of home visits by community health workers (CHWs) on complementary feeding practices of the caregivers of children.

Methods

We collated data from the baseline and the corresponding follow-up survey done as part of an evaluation of Bangladesh Maternal, Infant and Young Child Nutrition (MIYCN) programme. We collected data on complementary feeding practices using a 24-h recall questionnaire. Age-appropriate dietary diversity, minimum meal frequency, and minimum acceptable diet were assessed based on recommended food consumption as per child's age. To understand the effect of CHWs' visits on complementary feeding practices, we performed Generalized Estimating Equation (GEE) procedure for dealing with correlated data and adjusted other covariates.

Results

A total of 758 and 745 caregivers of children aged 6-23 months participated in the baseline and follow-up survey, respectively. Complementary feeding practices were improved in 1 year of programme implementation; dietary diversity increased from 46 to 54%, minimum meal frequency from 82 to 91%, and minimum acceptable diet from 41 to 53%. Caregivers of children who had received the visit of CHWs in the last 12 months prior to the day of the follow-up survey were more likely (AOR 1.51; 95% CI 1.10-2.10) to maintain dietary diversity in their children's feeding practices than the caregivers who had not received a CHW visit in the last 12 months. The likelihood of maintaining a minimum acceptable diet in feeding practices was 1.57 times higher (AOR 1.57; 95% CI 1.14-2.17) among the caregivers who were exposed to the visits of the CHWs in the last 12 months compared to the caregivers who were not exposed to the CHW's visits in the last 12 months.

Conclusion

Integration of promotional activities of complementary feeding practices into the mainstream nutrition programme can be instrumental in optimizing complementary feeding practices among the caregivers of the under-five children. However, home visits by CHWs should be prioritized in such an integrated programme.

[Effect of Information Communication on Micronutrient Powders (or Yingyangbao) Feeding Behaviors of Different Generations of Baby Caregivers in Rural Areas]

Objective

To evaluate the status of information communication concerning micronutrient powders (MNP), or yingyangbao in Pinyin, the Chinese Romanization system, in areas covered by the Child Nutrition Improvement Project in a province in southwest China, and to investigate the effect of different communication channels and message communicated on the feeding behaviors of different generations of caregivers.

Methods

In October 2019, 6 counties, including two counties with predominantly Han population, two counties with substantial Tibetan population, and two counties with substantial Yi population, were selected from a province in southwest China through multistage random cluster sampling. A total of 816 pairs of babies and their caregivers from 108 villages in 36 townships were enrolled for the study. The age of the babies ranged between 6 months to 24 months. A structured questionnaire concerning the demographic data of the babies and their caregivers, the communication channel of information on MNP and the message communicated, and the caregivers' MNP feeding behaviors was designed to collect data through face-to-face interviews. Logistic regression was done to analyze the effect of MNP information communication on the feeding behaviors of caregivers from different generations.

Results

Caregivers acquired information on MNP from village and township physicians (85.66%), surrounding populations (15.81%), and brochures and mass media (4.78%). The messages they received included the free availability of MNP (37.50%), feeding methods (49.26%), and the benefits of giving babies MNP (57.84%). Among the caregivers, 89.95% knew about the availability of MNP, 69.73% were aware of the benefits, and 84.07% actually received MNP. The correct feeding rate was 68.26% and the total effective feeding rate was 49.14%. The effective feeding rate of caregivers of the grandparents' generation (59.07%) was higher than that of the caregivers of the parents' generation (45.08%) ( P<0.05). Logistic regression analysis suggested that, for caregivers of the parents' generation, information communication channel of village and township physicians (odds ratio [ OR]=2.20, 95% confidence interval [ CI]: 1.13-4.31) and communication messages on feeding methods ( OR=1.80, 95% CI: 1.19-2.73) and benefits of MNP ( OR=2.40, 95% CI: 1.61-3.57) facilitated their effective feeding behavior, while communication message concerning the free availability of MNP ( OR=0.58, 95% CI: 0.38-0.87) inhibited their effective feeding behavior. For caregivers of the grandparents' generation, information communication channel of village and township physicians ( OR=2.95, 95% CI: 1.12-7.76) and communication messages on the feeding methods ( OR=2.86, 95% CI: 1.34-6.09) were facilitating factors of their effective feeding behaviors.

Conclusion

The main channel of MNP information delivered to caregivers from the areas covered by the study was face-to-face explanation by doctors. The message communicated mainly involved three aspects--the administration method, the benefits and free availability of MNP. The channel and message of MNP information communnication had different effects on the feeding behaviors of caregivers of the parents' and grandparents' generations. Future research should focus on developing targeted information communication strategies according to the characteristics of populations from different generations, so as to improve the caregivers' feeding behavior.

The association between micronutrient powder delivery patterns and caregiver feeding behaviors in rural China

Background

High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China.

Methods

In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence.

Results

The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers’ reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups.

Conclusions

In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13726-4.

Concepções em disputa no uso da suplementação e/ou fortificação de micronutrientes na alimentação escolar para prevenção da anemia

Resumo: A anemia por deficiência de ferro afeta, mundialmente, diferentes populações e, no Brasil, é uma das principais carências nutricionais na infância. Diferentes estratégias são propostas por organismos internacionais e pelo Ministério da Saúde para sua prevenção. O objetivo do estudo foi analisar as ideias em disputa, presentes em documentos oficiais e narrativas dos profissionais da saúde e educação acerca do uso da suplementação e/ou fortificação nutricional como medida de prevenção da anemia no âmbito escolar. Baseou-se na análise de documentos governamentais e entrevistas semiestruturadas com profissionais atuantes em municípios que implementaram a estratégia de fortificação da alimentação escolar (NutriSUS) no Estado do Rio de Janeiro. As ideias disseminadas nos documentos governamentais ressaltam a eficiência da suplementação e da fortificação caseira para prevenção de anemia, com base em pesquisas científicas e se adequa aos objetivos das políticas públicas neles formalizados. As ideias presentes nas narrativas dos profissionais são, por vezes, críticas à necessidade desse tipo de intervenção e, por outras, favoráveis, indicando as controvérsias presentes no próprio processo de operacionalização local das políticas federais. Observaram-se tensões em torno dos conceitos de promoção, prevenção e tratamento por meio do NutriSUS, da dosagem e da forma de administração. As críticas à suplementação ressaltam as práticas alimentares saudáveis como estratégia preferencial. A medicalização em detrimento de ações de promoção da saúde pode tencionar a perspectiva pedagógica no contexto escolar e produzir ideias contraditórias sobre as melhores estratégias de promoção de alimentação saudável.

Process evaluation of an implementation strategy to support uptake of a tuberculosis treatment adherence intervention to improve TB care and outcomes in Malawi

OBJECTIVE

To assess implementation and to identify barriers and facilitators to implementation, sustainability and scalability of an implementation strategy to provide lay health workers (LHWs) with the knowledge, skills and tools needed to implement an intervention to support patient tuberculosis (TB) treatment adherence.

DESIGN

Mixed-methods design including a cluster randomised controlled trial and process evaluation informed by the RE-AIM framework.

SETTING

Forty-five health centres (HCs) in four districts in the south east zone of Malawi, who had an opportunity to receive cascade training.

PARTICIPANTS

Forty-five peer-trainers (PTs), 23 patients and 20 LHWs.

INTERVENTION

Implementation strategy employing peer-led educational outreach, a clinical support tool and peer support network to implement a TB treatment adherence intervention.

OUTCOME MEASURES

Process data were collected from study initiation to the end-of-study PT meeting, and included: LHW and patient interviews, quarterly PT meeting notes, training logs and study team observations and meeting notes. Data sources were first analysed in isolation, followed by method, data source and analyst triangulation. Analyses were conducted independently by two study team members, and themes revised through discussion and involvement of additional study team members as needed.

RESULTS

Forty-one HCs (91%) trained at least one LHW. Of 256 LHWs eligible to participate at study start 152 (59%) completed training, with the proportion trained per HC ranging from 0% to 100% at the end of initial cascade training. Lack of training incentives was the primary barrier to implementation, with intrinsic motivation to improve knowledge and skills, and to improve patient care and outcomes the primary facilitators of participation.

CONCLUSION

We identified important challenges to and potential facilitators of implementation, scalability and sustainability, of the TB treatment adherence intervention. Findings provide guidance to scale-up, and use of the implementation strategies employed, to address LHW training and supervision in other areas.

TRIAL REGISTRATION NUMBER

NCT02533089.

Facility- and community-based delivery of micronutrient powders in Uganda: Opening the black box of implementation using mixed methods

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.

Predictors of micronutrient powder (MNP) knowledge, coverage, and consumption during the scale-up of an integrated infant and young child feeding (IYCF-MNP) programme in Nepal

Large-scale programmes using micronutrient powders (MNPs) may not achieve maximum impact due to limited/inappropriate MNP coverage, consumption, and use. We identify predictors of MNP coverage, maternal knowledge of appropriate use, and child MNP consumption in Nepal. A cross-sectional survey was conducted in 2,578 mother-child pairs representative of children 6-23 months in two districts that were part of the post-pilot, scale-up of an integrated infant and young child feeding-MNP (IYCF-MNP) programme. Children aged 6-23 months were expected to receive 60 MNP sachets every 6 months from a female community health volunteer (FCHV) or health centre. Outcomes of interest were MNP coverage (ever received), maternal knowledge of appropriate use (correct response to seven questions), repeat coverage (receipt ≥ twice; among children 12-23 months who had received MNP at least once, n = 1342), and high intake (child consumed ≥75% of last distribution, excluding those with recent receipt/insufficient time to use 75% at recommended one-sachet-per-day dose, n = 1422). Multivariable log-binomial regression models were used to identify predictors of the four outcomes. Coverage, knowledge of appropriate use, and repeat coverage were 61.3%, 33.5%, and 45.9%, respectively. Among MNP receivers, 97.9% consumed MNP at least once and 38.9% of eligible children consumed ≥75% of last distribution. FCHV IYCF-MNP counselling was positively associated with knowledge, coverage, repeat coverage, and high intake; health worker counselling with knowledge and coverage indicators; and radio messages with coverage indicators only. FCHV counselling had the strongest association with knowledge, coverage, and high intake. Community-based counselling may play a vital role in improving coverage and intake in MNP programmes.

The potential role of micronutrient powders to improve complementary feeding practices

Micronutrient powder (MNP) interventions are often integrated within infant and young child feeding (IYCF) programmes to improve micronutrient intake from complementary foods. This review aims to describe country experiences with MNP interventions and their impact on IYCF practices and develop a framework for how MNP may strengthen complementary feeding practices. A literature review and key informant interviews were used to gather data on complementary feeding practices in MNP programme design, implementation, and evaluation. Findings from 11 MNP programmes in different geographic regions reinforced the potential of MNP interventions to add renewed focus and resources to existing IYCF programmes. MNP plays an important role in ensuring adequate micronutrient intake and reducing anaemia in young children. In some programmes, MNP users had improved IYCF practices, such as breastfeeding to 24 months and children receiving complementary foods with adequate consistency, frequency, and diversity. Our framework highlights how behaviour change communication is an essential component for influencing household actions, not only to generate demand and promote correct and sustained MNP use but also raise awareness of IYCF practices. The actions at MNP policy, delivery, and behaviour change communication levels collectively influence household IYCF practices, and formative research and monitoring and evaluation serve to inform programme design and optimize impact. In conclusion, a limited but growing body of evidence suggests that MNP interventions can contribute to improve complementary feeding practices. However, there is scope for improvement even among integrated MNP and IYCF programmes in order to realize the full potential of MNP interventions for IYCF practices.

Infant and Young Child Feeding (IYCF) Practices Improved in 2 Districts in Nepal during the Scale-Up of an Integrated IYCF and Micronutrient Powder Program

BACKGROUND

Three-quarters of the ≥50 programs that use micronutrient powders (MNPs) integrate MNPs into infant and young child feeding (IYCF) programs, with limited research on impacts on IYCF practices.

OBJECTIVE

This study assessed changes in IYCF practices in 2 districts in Nepal that were part of a post-pilot scale-up of an integrated IYCF-MNP program.

METHODS

This analysis used cross-sectional surveys (n = 2543 and 2578 for baseline and endline) representative of children aged 6-23 mo and their mothers in 2 districts where an IYCF program added MNP distributions through female community health volunteers (FCHVs) and health workers (HWs). Multivariable log-binomial models estimated prevalence ratios comparing reported IYCF at endline with baseline and at endline on the basis of exposure to different sources of IYCF information. Mothers who received FCHV-IYCF counseling with infrequent (≤1 time/mo) and frequent (>1 time/mo) interactions were compared with mothers who never received FCHV-IYCF counseling. The receipt of HW-IYCF counseling and receipt of MNPs from an FCHV (both yes or no) were also compared.

RESULTS

The prevalence of minimum dietary diversity (MDD) and minimum acceptable diet (MAD) was significantly higher at endline than at baseline. In analyses from endline, compared with mothers who never received FCHV counseling, only mothers in the frequent FCHV-IYCF counseling group were more likely to report feeding the minimum meal frequency (MMF) and MAD, with no difference for the infrequent FCHV-IYCF counseling group in these indicators. HW-IYCF counseling was not associated with these indicators. Mothers who received MNPs from their FCHV were more likely to report initiating solid foods at 6 mo and feeding the child the MDD, MMF, and MAD compared with mothers who did not, adjusting for HW- and FCHV-IYCF counseling and demographic covariates.

CONCLUSIONS

Incorporating MNPs into the Nepal IYCF program did not harm IYCF and may have contributed to improvements in select practices. Research that uses experimental designs should verify whether integrated IYCF-MNP programs can improve IYCF practices.

Experiences and lessons learned for programme improvement of micronutrient powders interventions

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.

Experiences and lessons learned for delivery of micronutrient powders interventions

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

Monitoring and evaluating the adherence to a complementary food supplement (Ying Yang Bao) among young children in rural Qinghai, China: a mixed methods evaluation study

BACKGROUND

Large investments are currently made in community-based complementary food supplement (Ying Yang Bao, YYB) programs to improve nutrition of young children in rural areas in China. However, there is a lack of knowledge about the experience and challenges of implementing YYB programs in China. We aimed to: 1) monitor distribution of YYB; 2) assess children's adherence to and acceptability of YYB; and 3) evaluate community-based strategies to improve the program.

METHODS

This mixed methods evaluation study combined data from surveys and focus groups that took place during a controlled interventional evaluation trial. The trial aimed to evaluate the effectiveness of community-based YYB distribution on improving children's health status in rural areas in China. We conducted five cross-sectional surveys with caregivers of children aged 6-23 months (baseline survey (N = 1804) in August 2012 and four follow-up cross-sectional surveys: 1) N = 494 in January 2013; 2) N = 2187 in August 2013; 3) N = 504 in January 2014; and 4) N = 2186 in August 2014) in one rural county in Qinghai Province. We used a two-stage cluster sampling technique to select mothers with eligible children for each survey. Information was collected from caregivers on household characteristics, YYB consumption and acceptability in the surveys. High adherence in each survey was defined as children who consumed at least four YYB sachets during the previous week. A logistic regression model was developed to obtain odds ratios (OR) with 95% confidence intervals of factors associated with high adherence. Also, we conducted 10 focus groups with73 caregivers and health workers involved in the YYB distribution. Content analysis was used to explore qualitative findings, which were used to gain deeper insight into the quantitative results.

RESULTS

Around 90% of caregivers had ever received YYB and more than 80% of children ever took YYB. Caregivers mainly knew about YYB through their village doctors. High adherence to YYB increased from 49.4% in the first follow-up survey (January 2013) to 81.4% in the last follow-up survey (August 2014; P < 0.0001). Repeated training sessions with village doctors could increase adherence. However, due to unplanned YYB stock-out, caregivers did not receive YYB for six months, which may have led to a decrease of high adherence from 64.1% in the second follow-up survey (August 2013) to 53.6% in the third follow-up survey (January 2014; P < 0.0001). Self-reported acceptability increased from 43.2% to 71.8%, partly due to improving the taste of YYB, which was the main reason that children disliked taking YYB. Unfortunately, more than 60% of caregivers did not perceive positive health improvement in their children after taking YYB. Multivariate analysis showed that children with diarrhea (OR = 1.216, 95% CI 1.025-1.442), cough or fever (OR = 1.222, 95% CI 1.072-1.393) during the past two weeks had significantly lower adherence.

CONCLUSIONS

This evaluation study showed that program monitoring in rural West China was critically important for understanding program implementation and adherence trends. This led to strategic changes to the intervention over time: improving the taste of YYB; strengthening health education of village doctors and caregivers; and ensuring continuity of YYB supply. Future programs need to monitor program implementation in other settings in China and elsewhere.

Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results

Background: The Global Alliance for Improved Nutrition is conducting theory-driven process evaluations of micronutrient powder (MNP) programs. Objective: The aim was to generate preliminary theories about factors affecting adherence to recommendations with regard to point-of-use fortification of foods with MNPs. Methods: A literature search was conducted to identify documents with content related to adherence to MNPs as an intervention provided at home to children 6-59 mo of age. Thirty-five studies and 6 program descriptions were identified. We used thematic analyses to generate a comprehensive list of factors that could influence adherence, followed by content analysis to quantify the results. We developed a Program Impact Pathway to concretize the points at which the factors identified affect the process of adherence. Results: In the set of documents reviewed (n = 41), the most influential factors, measured by number of documents reporting the factor having effect, were 1) caregivers' perception of positive changes as a result of MNP use (n = 14), 2) caregivers' perceived child acceptance of food with MNPs (n = 12), and 3) caregivers' forgetfulness (n = 11). Behavior change communication channels (n = 13) and messages (n = 12) were the most frequently reported program design features influencing caregiver knowledge and subsequent adherence. Administration regimen (n = 10), which may be related to caregivers' capacity to remember to give MNPs, was also a frequently cited program design feature affecting adherence. Conclusions: The preponderance of knowledge and perception factors may reflect an underlying theoretical bias among researchers as to what they measure. To achieve programs that support greater adherence, we need to adopt a cultural-ecological perspective to inform program design in order to address a broader set of determinants. Studies that assess progress across the impact pathway, particularly from adherence to biological outcomes, would also provide guidance for evaluation studies, particularly when time or other constraints limit the potential to measure biological outcomes.