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Nguyen GT, Gauvreau C, Mansuri N, Wight L, Wong B, Neposlan J, Petricca K, Denburg A. Implementation factors of non-communicable disease policies and programmes for children and youth in low-income and middle-income countries: a systematic review. BMJ Paediatr Open 2024; 8:e002556. [PMID: 38830723 PMCID: PMC11149138 DOI: 10.1136/bmjpo-2024-002556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Despite declared life-course principles in non-communicable disease (NCD) prevention and management, worldwide focus has been on older rather than younger populations. However, the burden from childhood NCDs has mounted; particularly in low-income and middle-income countries (LMICs). There is limited knowledge regarding the implementation of paediatric NCD policies and programmes in LMICs, despite their disproportionate burden of morbidity and mortality. We aimed to understand the barriers to and facilitators of paediatric NCD policy and programme implementation in LMICs. METHODS We systematically searched medical databases, Web of Science and WHOLIS for studies on paediatric NCD policy and programme implementation in LMICs. Screening and quality assessment were performed independently by researchers, using consensus to resolve differences. Data extraction was conducted within the WHO health system building-blocks framework. Narrative thematic synthesis was conducted. RESULTS 93 studies (1992-2020) were included, spanning 86 LMICs. Most were of moderate or high quality. 78% reported on paediatric NCDs outside the four major NCD categories contributing to the adult burden. Across the framework, more barriers than facilitators were identified. The most prevalently reported factors were related to health service delivery, with system fragmentation impeding the continuity of age-specific NCD care. A significant facilitator was intersectoral collaborations between health and education actors to deliver care in trusted community settings. Non-health factors were also important to paediatric NCD policies and programmes, such as community stakeholders, sociocultural support to caregivers and school disruptions. CONCLUSIONS Multiple barriers prevent the optimal implementation of paediatric NCD policies and programmes in LMIC health systems. The low sociopolitical visibility of paediatric NCDs limits their prioritisation, resulting in fragmented service delivery and constraining the integration of programmes across key sectors impacting children, including health, education and social services. Implementation research is needed to understand specific contextual solutions to improve access to paediatric NCD services in diverse LMIC settings.
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Affiliation(s)
- Gina T Nguyen
- University College Dublin School of Medicine, Dublin, Ireland
| | - Cindy Gauvreau
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Lisa Wight
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | - Bryan Wong
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Josh Neposlan
- University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kadia Petricca
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Avram Denburg
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Sun Y, Ma J, Wei X, Dong J, Wu S, Huang Y. 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. Nutrients 2023; 15:5073. [PMID: 38140331 PMCID: PMC10745920 DOI: 10.3390/nu15245073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
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.
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Affiliation(s)
- Yinuo Sun
- School of Public Health, Peking University, Xueyuan Rd, No. 38, Beijing 100181, China; (Y.S.); (J.M.); (J.D.)
| | - Jiyan Ma
- School of Public Health, Peking University, Xueyuan Rd, No. 38, Beijing 100181, China; (Y.S.); (J.M.); (J.D.)
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (X.W.); (S.W.)
| | - Jingya Dong
- School of Public Health, Peking University, Xueyuan Rd, No. 38, Beijing 100181, China; (Y.S.); (J.M.); (J.D.)
| | - Shishi Wu
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (X.W.); (S.W.)
| | - Yangmu Huang
- School of Public Health, Peking University, Xueyuan Rd, No. 38, Beijing 100181, China; (Y.S.); (J.M.); (J.D.)
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Mildon A, Lopez de Romaña D, Jefferds MED, Rogers LM, Golan JM, Arabi M. Integrating and coordinating programs for the management of anemia across the life course. Ann N Y Acad Sci 2023; 1525:160-172. [PMID: 37194608 PMCID: PMC10918752 DOI: 10.1111/nyas.15002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Anemia is a major global public health concern with a complex etiology. The main determinants are nutritional factors, infection and inflammation, inherited blood disorders, and women's reproductive biology, but the relative role of each varies between settings. Effective anemia programming, therefore, requires evidence-based, data-driven, contextualized multisectoral strategies, with coordinated implementation. Priority population groups are preschool children, adolescent girls, and pregnant and nonpregnant women of reproductive age. Opportunities for comprehensive anemia programming include: (i) bundling interventions through shared delivery platforms, including antenatal care, community-based platforms, schools, and workplaces; (ii) integrating delivery platforms to extend reach; (iii) integrating anemia and malaria programs in endemic areas; and (iv) integrating anemia programming across the life course. Major barriers to effective anemia programming include weak delivery systems, lack of data or poor use of data, lack of financial and human resources, and poor coordination. Systems strengthening and implementation research approaches are needed to address critical gaps, explore promising platforms, and identify solutions to persistent barriers to high intervention coverage. Immediate priorities are to close the gap between access to service delivery platforms and coverage of anemia interventions, reduce subnational coverage disparities, and improve the collection and use of data to inform anemia strategies and programming.
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Affiliation(s)
| | | | | | - Lisa M. Rogers
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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Hodgins S, Klemm R. Micronutrient Powders for Infants and Young Children. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:216-219. [PMID: 34048361 PMCID: PMC8324200 DOI: 10.9745/ghsp-d-21-00263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/02/2022]
Abstract
Providing standalone micronutrient products for household use is not an easy strategy, but under the right conditions, it can work. To be effective, micronutrient powder programs require robust commodity logistics and support of uptake and adherence.
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Affiliation(s)
- Stephen Hodgins
- Editor-in-Chief, Global Health: Science and Practice Journal, and Associate Professor, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
| | - Rolf Klemm
- Helen Keller International, New York, NY, USA
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Brewer JD, Shinnick J, Román K, Santos MP, Paz-Soldan VA, Buttenheim AM. Behavioral Insights Into Micronutrient Powder Use for Childhood Anemia in Arequipa, Peru. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:721-731. [PMID: 33361238 PMCID: PMC7784068 DOI: 10.9745/ghsp-d-20-00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
Abstract
Health care provider-caregiver interactions and caregivers’ shifting emotional states between intention formation and use affected their adherence to a government-provided micronutrient powder intervention to prevent childhood anemia. In counseling directed to caregivers, we suggest providers offer clear messaging on MNP impact and planning for challenges during MNP use. Childhood anemia remains a significant driver of morbidity in low- and middle-income countries, including Peru. To identify behavioral challenges to using micronutrient powder (MNP) that is given to supplement children’s diets and prevent anemia, we applied a behavioral design approach to interviews and focus groups with 129 caregivers in Arequipa, Peru. We examined 3 key points in the decision-making process: accessing MNP through the health system; forming intentions to use MNP; and MNP use at the time of child feeding. Using the NUDGE (Narrow, Understand, Discover, Generate, Evaluate) approach, we identified the following behavioral barriers and facilitators: (1) caregivers’ experiences with health care providers shaped their motivation to access MNP; (2) caregivers felt accessing MNP at clinics was inconvenient and created hassle factors; (3) caregivers’ mental models about anemia prevention shaped MNP intentions and use; (4) caregivers’ salient negative experiences could have caused them to stop giving MNP; (5) caregivers forgot to give MNP if they did not have cues to remind them but could be prompted with salient cues; and (6) caregivers were affected by emotional, cognitive, and attentional factors during feeding that were difficult to anticipate. Our results, based on a behavioral design approach, suggest opportunities to adapt current messaging, counseling, and education around MNP use. Adaptations include providing culturally relevant messages, leveraging caregivers’ emotional and cognitive states, and encouraging small but impactful changes to feeding routines to address barriers to MNP use.
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Affiliation(s)
- Jessica D Brewer
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Julianna Shinnick
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Karina Román
- Department of Health Management, Universidad Peruana Cayetano Heredia Facultad de Salud Pública y Administración Carlos Vidal Layseca, Lima, Peru.,Asociación Benéfica PRISMA, Lima, Peru
| | - Maria P Santos
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.,Asociación Benéfica PRISMA, Lima, Peru.,Zoonotic Disease Research Lab, Universidad Peruana Cayetano Heredia Facultad de Salud Pública y Administración Carlos Vidal Layseca, Arequipa, Peru
| | - Alison M Buttenheim
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
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Bassey C, Crooks H, Paterson K, Ball R, Howell K, Humphries-Cuff I, Gaffigan K, Rao N, Whitty JA, Hooper L. Impact of home food production on nutritional blindness, stunting, wasting, underweight and mortality in children: a systematic review and meta-analysis of controlled trials. Crit Rev Food Sci Nutr 2020; 62:1856-1869. [PMID: 33272038 DOI: 10.1080/10408398.2020.1848786] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Vitamin A deficiency is highly prevalent and remains the major cause of nutritional blindness in children in low-and middle-income countries, despite supplementation programmes. Xeropthalmia (severe drying and thickening of the conjunctiva) is caused by vitamin A deficiency and leads to irreversible blindness. Vitamin A supplementation programmes effectively reduce vitamin A deficiency but many rural children are not reached. Home food production may help prevent rural children's vitamin A deficiency. We aimed to systematically review trials assessing effects of home food production (also called homestead food production and agricultural interventions) on xeropthalmia, nightblindness, stunting, wasting, underweight and mortality (primary outcomes). We searched Medline, Embase, Scopus, Cochrane CENTRAL and trials registers to February 2019. Inclusion of studies, data extraction and risk of bias were assessed independently in duplicate. Random-effects meta-analysis, sensitivity analyses, subgrouping and GRADE were used. We included 16 trials randomizing 2498 children, none reported xerophthalmia, night-blindness or mortality. Home food production may slightly reduce stunting (mean difference (MD) 0.13 (z-score), 95% CI 0.01 to 0.24), wasting (MD 0.05 (z-score), 95% CI -0.04 to 0.14) and underweight (MD 0.07 (z-score), 95% CI -0.01 to 0.15) in young children (all GRADE low-consistency evidence), and increase dietary diversity (standardized mean difference (SMD) 0.24, 95% CI 0.15 to 0.34). Home food production may usefully complement vitamin A supplementation for rural children. Large, long-duration trials with good randomization, allocation concealment and correct adjustment for clustering are needed to assess effectiveness of home food production on nutritional blindness in young children.
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Affiliation(s)
- Chizoba Bassey
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Harriet Crooks
- Student Services, University of East Anglia, Norwich, UK
| | - Katherine Paterson
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rachel Ball
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Kristoffer Howell
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Iona Humphries-Cuff
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Kirsty Gaffigan
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Nitya Rao
- School of Developmental Studies, University of East Anglia, Norwich, UK
| | - Jennifer A Whitty
- Norwich Medical School, University of East Anglia, Norwich, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) East of England, UK
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
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Leonard D, Buettner P, Thompson F, Makrides M, McDermott R. Early childhood anaemia more than doubles the risk of developmental vulnerability at school-age among Aboriginal and Torres Strait Islander children of remote Far North Queensland: Findings of a retrospective cohort study. Nutr Diet 2020; 77:298-309. [PMID: 31914484 PMCID: PMC7317940 DOI: 10.1111/1747-0080.12602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/15/2019] [Accepted: 11/25/2019] [Indexed: 11/28/2022]
Abstract
AIMS Early childhood anaemia, usually attributed to iron deficiency, is associated with persistent detrimental effects on child development. This study investigates the association of anaemia between age six and 23 months with indicators of childhood development at school-age among children of remote Aboriginal and Torres Strait Islander communities of Far North Queensland. METHODS The triennial Australian Early Development Census (AEDC) encompasses five domains of early childhood development-physical health and wellbeing, social competence, emotional maturity, language and cognitive skills (school-based), communication skills and general knowledge. AEDC 2012 and 2015 assessments were linked with health information for children and their mothers from remote Aboriginal and Torres Strait Islander communities of Far North Queensland. RESULTS AEDC assessments were available for 250 children who had measurements of haemoglobin recorded at age 6 to 23 months. More children who had had early childhood anaemia (n = 66/143, 46.2%, [37.9%, 54.4%]) were developmentally vulnerable on two or more domains compared to those who had not been anaemic (n = 25/107, 23.4% [15.2%, 31.5%], P < .001). Multivariable analysis confirmed that early childhood anaemia more than doubled the risk of developmental vulnerability (OR 2.2 [1.1, 4.3] P = .020) at school age. CONCLUSIONS Early childhood anaemia is a risk factor for developmental vulnerability at school-age in this setting. Interventions combining nutrition promotion and multi-micronutrient food fortification, are effective in prevention of early childhood anaemia. Such interventions could also improve early childhood development and subsequent educational achievement.
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Affiliation(s)
- Dympna Leonard
- Australian Institute of Tropical Health and MedicineJames Cook UniversityCairnsQueenslandAustralia
| | - Petra Buettner
- Australian Institute of Tropical Health and MedicineJames Cook UniversityCairnsQueenslandAustralia
- Tropical Health Solutions Pty LtdTownsvilleQueenslandAustralia
| | - Fintan Thompson
- Australian Institute of Tropical Health and MedicineJames Cook UniversityCairnsQueenslandAustralia
| | - Maria Makrides
- Healthy Mothers, Babies and ChildrenSouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
- Discipline of Paediatrics, School of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Robyn McDermott
- Australian Institute of Tropical Health and MedicineJames Cook UniversityCairnsQueenslandAustralia
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Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME. 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. MATERNAL AND CHILD NUTRITION 2020; 15:e12712. [PMID: 31622040 PMCID: PMC6856851 DOI: 10.1111/mcn.12712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lindsey M Locks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Nutrition Section, United Nations Children's Fund (UNICEF) Headquarters, New York, New York, USA
| | - Pradiumna Dahal
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Rajkumar Pokharel
- Nutrition Section, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | | | - Naveen Paudyal
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Ralph D Whitehead
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stanley Chitekwe
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Zuguo Mei
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
| | - Bikash Lamichhane
- Child Health Division, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | - Aashima Garg
- Nutrition Section, United Nations Children's Fund (UNICEF) Headquarters, New York, New York, USA
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
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Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh. Public Health Nutr 2020; 24:s48-s58. [PMID: 32131922 PMCID: PMC8042577 DOI: 10.1017/s1368980020000038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables. DESIGN We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage. SETTINGS Sixty-eight sub-districts from ten districts of Bangladesh. PARTICIPANTS Children aged 6-59 months and their caregivers. RESULTS A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage. CONCLUSIONS The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.
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Schnefke CH, Tumilowicz A, Pelto GH, Gebreyesus SH, Gonzalez W, Hrabar M, Mahmood S, Pedro C, Picolo M, Possolo E, Scarlatescu OA, Tarlton D, Vettersand J. Designing an ethnographic interview for evaluation of micronutrient powder trial: Challenges and opportunities for implementation science. MATERNAL AND CHILD NUTRITION 2019; 15:e12804. [PMID: 31622039 PMCID: PMC6856841 DOI: 10.1111/mcn.12804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 02/03/2019] [Accepted: 02/21/2019] [Indexed: 11/29/2022]
Abstract
The evidence base for micronutrient powder (MNP) interventions predominantly consists of quantitative studies focused on measuring coverage, utilization, and/or biological outcomes. We need other types of studies to broaden the scope of our knowledge about determinants of MNP programme effectiveness. Addressing this knowledge gap, this paper focuses on the process of designing an ethnographic research protocol to obtain caregivers' perspectives on the factors that influenced their use of intervention delivery services and their adherence to MNP recommendations. The research was undertaken within the context of formative evaluations conducted in Mozambique and Ethiopia. Ethnography provides a means for acquiring and interpreting this knowledge and is an approach particularly well suited for formative evaluation to understand the response of a population to new interventions and programme delivery processes. We describe decisions made and challenges encountered in developing the protocol, and their implications for advancing methodology in implementation research science. In addition to a core team of three investigators, we added an “advisory group” of 10 experts to advise us as we developed the protocol. The advisory group reviewed multiple drafts of the interview protocol and participated in mock interviews. In the protocol development process, we faced the issues and made decisions about concerned gaps in content, cultural adaptations and comprehension, and interview guide structure and format. Differences between the core team and the advisory group in methodological approaches to the structure and content of questions call attention to the importance of establishing greater communication among implementation scientists working in nutrition interventions.
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Affiliation(s)
- Courtney H Schnefke
- Public Health Research Division, RTI International, Research Triangle Park, North Carolina
| | | | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Seifu Hagos Gebreyesus
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wendy Gonzalez
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | | | - Shanzeh Mahmood
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Catia Pedro
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Melanie Picolo
- Maternal and Child Survival Program/PATH, Maputo, Mozambique
| | - Edna Possolo
- Department of Nutrition, Ministry of Health, Maputo, Mozambique
| | | | - Dessie Tarlton
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
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Ford ND, Ruth LJ, Ngalombi S, Lubowa A, Halati S, Ahimbisibwe M, Mapango C, Whitehead Jr RD, Jefferds ME. Predictors of micronutrient powder sachet coverage and recent intake among children 12-23 months in Eastern Uganda. MATERNAL & CHILD NUTRITION 2019; 15:e12792. [PMID: 31622041 PMCID: PMC7199021 DOI: 10.1111/mcn.12792] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/21/2018] [Accepted: 01/18/2019] [Indexed: 11/29/2022]
Abstract
We evaluated predictors of micronutrient powder (MNP) sachet coverage and recent intake using data from a cross-sectional survey representative of children aged 12-23 months in Amuria district, Uganda. In June/July 2016, caregivers were interviewed 12 months after implementation of an integrated MNP and infant and young child feeding pilot (N = 761). Logistic regression described predictors of (a) high-MNP sachet coverage (received at least 60 sachets/6 months) and (b) recent intake (consumed MNP during the 2 weeks preceding the survey) among children who had ever received MNP and had complete data (N = 683). Fifty-nine percent (95% Confidence Interval [CI] [53.8, 64.2]) of children had high-MNP sachet coverage, and 65.4% (95% CI [61.0, 69.9]) had recent intake. MNP ration cards (Adjusted Odds Ratio [AOR] 2.67, 95% CI [1.15, 6.23]), organoleptic changes to foods cooked with soda ash (AOR 1.52, 95% CI [1.08, 2.14]), having heard of anaemia (AOR 1.59, 95% CI [1.11, 2.26]), knowledge of correct MNP preparation (AOR 1.89, 95% CI [1.11, 3.19]), and current breastfeeding (AOR 2.04, 95% CI [1.36, 3.08]) were positively associated with MNP coverage whereas older child age (18-23 vs. 12-17 months) was inversely associated with coverage (AOR 0.32, 95% CI [0.23, 0.50]). MNP ration cards (AOR 2.86, 95% CI [1.34, 6.09]), having heard an MNP radio jingle (AOR 1.40, 95% CI [1.01, 1.94]), knowledge of correct MNP preparation (AOR 1.88, 95% CI [1.04, 3.39]), and the child not disliking MNP (AOR 1.90, 95% CI [1.13, 3.22]) were positively associated with recent intake. Interventions that increase caregiver knowledge and skills and focus on older children could improve MNP coverage and recent intake.
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Affiliation(s)
- Nicole D. Ford
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgiaUSA
- McKing Consulting Corp.FairfaxVirginiaUSA
| | - Laird J. Ruth
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgiaUSA
- McKing Consulting Corp.FairfaxVirginiaUSA
| | - Sarah Ngalombi
- Nutrition DivisionUganda Ministry of HealthKampalaUganda
| | - Abdelrahman Lubowa
- School of Food Technology, Nutrition and BioengineeringMakerere UniversityKampalaUganda
| | - Siti Halati
- Nutrition SectionUnited Nations World Food ProgrammeKampalaUganda
| | | | - Carine Mapango
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgiaUSA
| | - Ralph D. Whitehead Jr
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgiaUSA
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgiaUSA
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12
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Pelletier D, DePee S. Micronutrient powder programs: New findings and future directions for implementation science. MATERNAL & CHILD NUTRITION 2019; 15:e12802. [PMID: 30828965 PMCID: PMC6857038 DOI: 10.1111/mcn.12802] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/24/2023]
Affiliation(s)
- David Pelletier
- Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Saskia DePee
- Nutrition DivisionWorld Food ProgrammeRomeItaly
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
- Human NutritionWageningen UniversityWageningenthe Netherlands
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13
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Pérez-Escamilla R, Engmann C. Integrating nutrition services into health care systems platforms: Where are we and where do we go from here. MATERNAL AND CHILD NUTRITION 2019; 15 Suppl 1:e12743. [PMID: 30748115 DOI: 10.1111/mcn.12743] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Abstract
Integrating maternal-child nutrition into health care services is a desirable but complex task that requires implementation research studies. This special supplement, entitled "How to Strengthen Nutrition into the Health Platform: Programmatic Evidence and Experience from Low- and Middle-Income Countries" presents a collection of mixed-methods research and case studies mostly conducted in sub-Saharan Africa that help us gain a better understanding of the barriers and facilitators for this integration to happen. Collectively, the evidence confirms that integrating nutrition services as part of health care systems and other platforms is feasible, but for that to be successful, there is a need to address strong barriers related to all six key health care systems building blocks identified by the World Health Organization. These include financing, health information systems, health workforce, supplies and technology, governance, and service delivery. Moving forward, it is crucial that more robust implementation science research is conducted within the rough and tumble of real-world programming to better understand how to best integrate and scale up nutrition services across health care systems and other platforms based on dynamic complex adaptive systems frameworks. This research can help better understand how the key health care systems building blocks need to interlock and communicate with each other to improve the policymakers' ability to integrate and scale up nutrition services in a more timely and cost-effective way.
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Affiliation(s)
- Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Cyril Engmann
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Global Health, University of Washington School of Public Health, Seattle, Washington, USA.,Maternal, Newborn, Child Health & Nutrition, PATH, Seattle, Washington, USA
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14
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Picolo M, Barros I, Joyeux M, Gottwalt A, Possolo E, Sigauque B, Kavle JA. Rethinking integrated nutrition-health strategies to address micronutrient deficiencies in children under five in Mozambique. MATERNAL AND CHILD NUTRITION 2019; 15 Suppl 1:e12721. [PMID: 30748114 PMCID: PMC6593804 DOI: 10.1111/mcn.12721] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 11/30/2022]
Abstract
In Mozambique, about two thirds of children 6–59 months of age are affected by vitamin A deficiency and anaemia. The objective of this case study is to provide programme considerations for planning, implementing, monitoring, and evaluating vitamin A and iron deficiency interventions within the context of lessons learned to date for vitamin A supplementation, micronutrient powders (MNPs), and food‐based strategies. For 15 years, the Mozambique Ministry of Health implemented twice‐yearly vitamin A supplementation through both campaigns and routine health services. Yet coverage in 2017 (55%) was not much higher than in 2003 (44%). Reaching every district/reaching every child, a strategy adapted from the field of immunization, was used to achieve equitable coverage of vitamin A and for microplanning of outreach services in health facilities, with support from the Maternal and Child Survival Program. In Mozambique, a free or subsidized distribution model for MNPs has been rolled out, yet integration of MNPs into infant and young child feeding programming (i.e., cooking demonstrations) is needed to reinforce “the who, what, and why” of MNPs through culturally sensitive behaviour change communication. Food‐based strategies to promote dietary diversity, such as through complementary feeding recipes, are also critical. To harmonize efforts, the Mozambique government should consider the development of a national strategy for the prevention and control of micronutrient malnutrition, with clear monitoring and evaluation targets. Ongoing monitoring of the prevalence of micronutrient deficiencies and coverage of implemented micronutrient interventions is needed to make evidence‐based decisions to drive nutrition–health programming.
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Affiliation(s)
- Melanie Picolo
- USAID's Maternal and Child Survival Program (MCSP)/PATH Mozambique, Maputo, Mozambique
| | - Iracema Barros
- USAID's Maternal and Child Survival Program (MCSP)/PATH Mozambique, Maputo, Mozambique
| | | | - Allison Gottwalt
- USAID's Maternal and Child Survival Program (MCSP)/PATH, Washington, District of Columbia, USA
| | - Edna Possolo
- Ministry of Health, Mozambique, Maputo, Mozambique
| | - Betuel Sigauque
- USAID's Maternal and Child Survival Program (MCSP)/John Snow Inc. (JSI) Mozambique, Maputo, Mozambique
| | - Justine A Kavle
- USAID's Maternal and Child Survival Program (MCSP)/PATH, Washington, District of Columbia, USA
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15
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Leonard D, Buttner P, Thompson F, Makrides M, McDermott R. Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study. Aust N Z J Public Health 2019; 43:319-327. [PMID: 31180619 DOI: 10.1111/1753-6405.12911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/01/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland. METHODS This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data. RESULTS Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher incidence of anaemia was seen among children of mothers with parity three or more (CC/MI p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early growth (CC/MI p<0.001). CONCLUSION Early childhood anaemia is common among Aboriginal and Torres Strait Islander children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent infections are likely causes. Implications for public health: Prevention of early childhood anaemia in 'Close the Gap' initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North Queensland - and elsewhere in northern Australia.
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Affiliation(s)
- Dympna Leonard
- Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland
| | - Petra Buttner
- Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland
| | - Fintan Thompson
- Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland
| | - Maria Makrides
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, South Australia
| | - Robyn McDermott
- Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland
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16
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Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME. Changes in growth, anaemia, and iron deficiency among children aged 6-23 months in two districts in Nepal that were part of the post-pilot scale-up of an integrated infant and young child feeding and micronutrient powder intervention. MATERNAL & CHILD NUTRITION 2019; 15:e12693. [PMID: 30226293 PMCID: PMC6585661 DOI: 10.1111/mcn.12693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/16/2018] [Accepted: 08/31/2018] [Indexed: 11/27/2022]
Abstract
There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross-sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6-23 months in two districts in Nepal that were part of a post-pilot scale-up of a IYCF-MNP programme. Multivariable log-binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length-for-age z-score <-2), wasting (weight-for-length z-score <-2), underweight (weight-for-age z-score <-2), anaemia (altitude-adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude-adjusted haemoglobin <100 g/L), iron deficiency (inflammation-adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12-23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable-adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal-FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF-MNP programmes to improve children's nutritional status.
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Affiliation(s)
- Lindsey M. Locks
- Department of NutritionHarvard TH Chan School of Public HealthBostonMassachusetts
- Nutrition SectionUnited Nations Children's Fund (UNICEF) HeadquartersNew YorkNew York
| | - Pradiumna Dahal
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | | | | | - Naveen Paudyal
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | - Ralph D. Whitehead
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
| | - Stanley Chitekwe
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | - Zuguo Mei
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
| | | | - Aashima Garg
- Nutrition SectionUnited Nations Children's Fund (UNICEF) HeadquartersNew YorkNew York
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
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17
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McLean J, Northrup-Lyons M, Reid RJ, Smith L, Ho K, Mucumbitsi A, Kayumba J, Omwega A, McDonald C, Schauer C, Zlotkin S. From evidence to national scale: An implementation framework for micronutrient powders in Rwanda. MATERNAL AND CHILD NUTRITION 2018; 15:e12752. [PMID: 30426670 DOI: 10.1111/mcn.12752] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 09/07/2018] [Accepted: 11/01/2018] [Indexed: 11/30/2022]
Abstract
Micronutrient powders (MNP) are an efficacious intervention in terms of reducing anaemia among young children, yet challenges remain regarding implementation at scale. Research that can guide effective implementation of nutrition interventions and facilitate integration into existing health care platforms is needed. This paper seeks to advance the implementation science knowledge base by presenting our multiphased strategy and findings for scaling-up MNP in Rwanda. The multiphased implementation strategy, spanning a 5-year period (2011-2016), included (a) a feasibility study involving formative research, (b) a 30-day trial of improved practices (n = 60 households), (c) a 12-month pilot that included an effectiveness study (n = 1,066 caregiver/child pairs), and (d) a staggered approach to national scale-up. At the end of Phase 4, the programme had been implemented in 19 of Rwanda's 30 districts with the scale-up in the final 11 districts completed in the following year. The caregivers of over 270,000 eligible children 6-23 months of age received a box of 30 MNP sachets in the final 3-month assessment period, representing a coverage rate of 87%. Initial problems with the supply chain and distribution and ongoing challenges to monitoring and reporting have been the largest obstacles. Continued success will be dependent on adequate resources for capacity development, refresher training, and responsive monitoring. Rwanda is one of the first countries to successfully scale-up home fortification subnationally with MNP. Lessons learned have implications for other countries.
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Affiliation(s)
- Judy McLean
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martina Northrup-Lyons
- School of Population & Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert J Reid
- Munk School of Global Affairs & Public Policy, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Smith
- School of Population & Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathy Ho
- School of Population & Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexis Mucumbitsi
- Nutrition and Hygiene Department in National Early Childhood Care and Development Program, Ministry of Health, Kigali, Rwanda
| | | | | | | | - Claudia Schauer
- Centre for Global Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- Centre for Global Health, Hospital for Sick Children, Toronto, Ontario, Canada
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18
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Abstract
Nutritionally, the first 1,000 days of an infant's life - from conception to two years - has been identified as a highly influential period, during which lasting health can be achieved. Significant evidence links patterns of infant feeding to both short and long-term health outcomes, many of which can be prevented through nutritional modifications. Recommended globally, breastfeeding is recognised as the gold standard of infant nutrition; providing key nutrients to achieve optimal health, growth and development, and conferring immunologic protective effects against disease. Nevertheless, infant formulas are often the sole source of nutrition for many infants during the first stage of life. Producers of infant formula strive to supply high quality, healthy, safe alternatives to breast milk with a comparable balance of nutrients to human milk imitating its composition and functional performance measures. The concept of 'nutritional programming', and the theory that exposure to specific conditions, can predispose an individual's health status in later life has become an accepted dictum, and has sparked important nutritional research prospects. This review explores the impact of early life nutrition, specifically, how different feeding methods affect health outcomes.
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Affiliation(s)
- Susan Finn
- Nutrition and Health Science from Cork Institute of Technology
| | | | | | - Roy D. Sleator
- University College Cork and National University of Ireland
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19
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Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME. 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. Curr Dev Nutr 2018; 2:nzy019. [PMID: 29984348 PMCID: PMC6022604 DOI: 10.1093/cdn/nzy019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/16/2018] [Accepted: 04/12/2018] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Lindsey M Locks
- Harvard TH Chan School of Public Health, Boston, MA
- UNICEF Headquarters, New York, NY
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20
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Vossenaar M, Tumilowicz A, D'Agostino A, Bonvecchio A, Grajeda R, Imanalieva C, Irizarry L, Mulokozi G, Sudardjo MN, Tsevegsuren N, Neufeld LM. Experiences and lessons learned for programme improvement of micronutrient powders interventions. MATERNAL AND CHILD NUTRITION 2018; 13 Suppl 1. [PMID: 28960877 PMCID: PMC5656835 DOI: 10.1111/mcn.12496] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/25/2017] [Accepted: 07/06/2017] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
| | | | - Alexis D'Agostino
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, Virginia, USA.,John Snow Inc., Arlington, Virginia, USA
| | | | - Ruben Grajeda
- Pan-American Health Organization, Washington, District of Columbia, USA
| | | | | | - Generose Mulokozi
- Tanzania Food and Nutrition Center, Dar es Salaam, Tanzania.,IMA World Health, Dar es Salaam, Tanzania
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21
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Reerink I, Namaste SM, Poonawala A, Nyhus Dhillon C, Aburto N, Chaudhery D, Kroeun H, Griffiths M, Haque MR, Bonvecchio A, Jefferds ME, Rawat R. Experiences and lessons learned for delivery of micronutrient powders interventions. MATERNAL AND CHILD NUTRITION 2018; 13 Suppl 1. [PMID: 28960878 PMCID: PMC5656897 DOI: 10.1111/mcn.12495] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/25/2017] [Accepted: 06/16/2017] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
| | - Sorrel Ml Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, Virginia, USA.,Helen Keller International, Washington, District of Columbia, USA
| | - Alia Poonawala
- Global Alliance for Improved Nutrition, Geneva, Switzerland
| | | | | | | | - Hou Kroeun
- Helen Keller International, Phnom Penh, Cambodia
| | | | | | | | - Maria Elena Jefferds
- Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rahul Rawat
- International Food Policy Research Institute, Dakar, Senegal.,Bill and Melinda Gates Foundation, Seattle, Washington, USA
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22
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Nyhus Dhillon C, Sarkar D, Klemm RDW, Neufeld LM, Rawat R, Tumilowicz A, Namaste SML. Executive summary for the Micronutrient Powders Consultation: Lessons Learned for Operational Guidance. MATERNAL & CHILD NUTRITION 2017; 13 Suppl 1:e12493. [PMID: 28960876 PMCID: PMC5656884 DOI: 10.1111/mcn.12493] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/16/2017] [Accepted: 07/05/2017] [Indexed: 01/23/2023]
Abstract
Iron deficiency anaemia is estimated to be the leading cause of years lived with disability among children. Young children's diets are often inadequate in iron and other micronutrients, and provision of essential vitamin and minerals has long been recommended. With the limited programmatic success of iron drop/syrup interventions, interest in micronutrient powders (MNP) has increased. MNP are a mixture of vitamins and minerals, enclosed in single-dose sachets, which are stirred into a child's portion of food immediately before consumption. MNP are an efficacious intervention for reducing iron deficiency anaemia and filling important nutrient gaps in children 6-23 months of age. As of 2014, 50 countries have implemented MNP programmes including 9 at a national level. This paper provides an overview of a 3-paper series, based on findings from the "Micronutrient Powders Consultation: Lessons Learned for Operational Guidance" held by the USAID-funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project. The objectives of the Consultation were to identify and summarize the most recent MNP programme experiences and lessons learned for operationalizing MNP for young children and prioritize an implementation research agenda. The Consultation was composed of 3 working groups that used the following methods: deliberations among 49 MNP programme implementers and experts, a review of published and grey literature, questionnaires, and key informant interviews, described in this overview. The following articles summarize findings in 3 broad programme areas: planning, implementation, and continual programme improvement. The papers also outline priorities for implementation research to inform improved operationalization of MNP.
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Affiliation(s)
| | - Danya Sarkar
- Strengthening Partnerships, Results, and Innovations in Nutrition GloballyArlingtonVirginiaUSA
- John Snow, Inc.ArlingtonVAUSA
| | - Rolf DW Klemm
- Helen Keller InternationalWashingtonDistrict of ColumbiaUSA
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Rahul Rawat
- International Food Policy Research InstituteDakarSenegal
- Bill and Melinda Gates FoundationSeattleWashingtonUSA
| | | | - Sorrel ML Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition GloballyArlingtonVirginiaUSA
- Helen Keller InternationalWashingtonDistrict of ColumbiaUSA
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23
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Schauer C, Sunley N, Hubbell Melgarejo C, Nyhus Dhillon C, Roca C, Tapia G, Mathema P, Walton S, Situma R, Zlotkin S, DW Klemm R. Experiences and lessons learned for planning and supply of micronutrient powders interventions. MATERNAL & CHILD NUTRITION 2017; 13 Suppl 1:e12494. [PMID: 28960875 PMCID: PMC5656916 DOI: 10.1111/mcn.12494] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 01/23/2023]
Abstract
Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. 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 powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale-up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale-up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.
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Affiliation(s)
- Claudia Schauer
- Centre for Global Child Health and Home Fortification Technical Advisory Group (HF‐TAG)TorontoOntarioCanada
| | | | - Carrie Hubbell Melgarejo
- Strengthening Partnerships, Results, and Innovations in Nutrition GloballyArlingtonVirginiaUSA
- The Manoff GroupWashington, District of ColumbiaUSA
| | | | | | | | | | - Shelley Walton
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | | | - Stanley Zlotkin
- Center for Global Child HealthHospital for Sick ChildrenTorontoOntarioCanada
- Departments of Pediatrics & Nutritional SciencesUniversity of TorontoTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Rolf DW Klemm
- Helen Keller InternationalWashingtonDistrict of ColumbiaUSA
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24
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Tumilowicz A, Schnefke CH, Neufeld LM, Pelto GH. Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results. Curr Dev Nutr 2017; 1:e001123. [PMID: 29955708 PMCID: PMC5998355 DOI: 10.3945/cdn.117.001123] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 06/05/2017] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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