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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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Sun C, Ye R, Akhtar M, Dill SE, Yuan P, Zhou H, Rozelle S. Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach. BMC Public Health 2022; 22:2250. [DOI: 10.1186/s12889-022-14731-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/25/2022] [Indexed: 12/04/2022] Open
Abstract
Abstract
Background
The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework.
Methods
Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework.
Results
Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (β = 0.440, P < 0.001), intention (β = 0.374, P < 0.001), knowledge and skills (β = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (β=-0.142, P < 0.001), and caregiver generation (β = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen’s f2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers.
Conclusion
There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence.
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Young MF, Mehta RV, Gosdin L, Kekre P, Verma P, Larson LM, Girard AW, Ramakrishnan U, Chaudhuri I, Srikantiah S, Martorell R. Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial. J Nutr 2021; 151:1983-1992. [PMID: 33880566 PMCID: PMC8245869 DOI: 10.1093/jn/nxab065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/11/2020] [Accepted: 02/22/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking. OBJECTIVES We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization. METHODS We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact. RESULTS At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp). CONCLUSIONS Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Rukshan V Mehta
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Lucas Gosdin
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Priya Kekre
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Leila M Larson
- Arnold School of Public Health, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | - Amy Webb Girard
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | | | | | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
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Dusingizimana T, Weber JL, Ramilan T, Iversen PO, Brough L. A Mixed-Methods Study of Factors Influencing Access to and Use of Micronutrient Powders in Rwanda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:274-285. [PMID: 34048359 PMCID: PMC8324192 DOI: 10.9745/ghsp-d-20-00422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/18/2021] [Indexed: 01/27/2023]
Abstract
Gaps in complementary feeding practices hinder the use of multiple micronutrients powder (MNP) in Rutsiro district in Rwanda. Successful MNP program implementation requires uninterrupted availability and accessibility to the product, as well as greater understanding of health benefits of the MNP. The World Health Organization recommends point-of-use fortification with multiple micronutrients powder (MNP) for foods consumed by children aged 6–23 months in populations where anemia prevalence among children under 2 years or under 5 years of age is 20% or higher. In Rwanda, anemia affects 37% of children under 5 years. The MNP program was implemented to address anemia, but research on factors affecting the implementation of the MNP program is limited. We conducted a mixed-methods study to examine the factors influencing access to and use of MNP among mothers (N=379) in Rutsiro district, northwest Rwanda. Inductive content analysis was used for qualitative data. Logistic regression analysis was used to determine factors associated with the use of MNP. Qualitative results indicated that the unavailability of MNP supplies and distribution issues were major barriers to accessing MNP. Factors influencing the use of MNP included mothers' perceptions of side effects and health benefits of MNP, as well as inappropriate complementary feeding practices. Mothers of older children (aged 12–23 months) were more likely to use MNP than those of younger children (aged 6–11 months) (adjusted odds ratio [aOR]=3.63, P<.001). Mothers whose children participated in the supplementary food program were nearly 3 times more likely to use MNP than those whose children had never participated in the program (aOR=2.84, P=.001). Increasing household hunger score was significantly associated with lower odds of using MNP (aOR=0.80, P=.038). Mechanisms to monitor MNP supply and program implementation need to be strengthened to ensure mothers have access to the product. MNP program implementers should address gaps in complementary feeding practices and ensure mothers have access to adequate complementary foods.
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Affiliation(s)
- Theogene Dusingizimana
- School of Food and Advanced Technology, Massey University, Palmerston North, New Zealand. .,Department of Food Science and Technology, College of Agriculture, Animal Sciences and Veterinary Medicine, University of Rwanda, Musanze, Rwanda
| | - Janet L Weber
- School of Food and Advanced Technology, Massey University, Palmerston North, New Zealand
| | - Thiagarajah Ramilan
- School of Agriculture and Environment, Massey University, Palmerston North, New Zealand
| | - Per Ole Iversen
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Hematology, Oslo University Hospital, Oslo, Norway.,Division of Human Nutrition, Faculty of Medical Health Sciences, Stellebosh University, Tygerberg, South Africa
| | - Louise Brough
- School of Food and Advanced Technology, Massey University, Palmerston North, New Zealand
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Schott W, Richardson B, Baker E, D'Agostino A, Namaste S, Vosti SA. Comparing costs and cost-efficiency of platforms for micronutrient powder (MNP) delivery to children in rural Uganda. Ann N Y Acad Sci 2021; 1502:28-39. [PMID: 34169531 PMCID: PMC8596512 DOI: 10.1111/nyas.14621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
Micronutrient powder (MNP) can reduce iron deficiency in young children, which has been well established in efficacy trials. However, the cost of different delivery platforms has not been determined. We calculated the cost and cost-efficiency of distributed MNP through community-based mechanisms and in health facilities in a primarily rural district in Uganda. An endline survey (n = 1072) identified reach and adherence. During the 9-month pilot, 37,458 (community platform) and 12,390 (facility platform) packets of MNP were distributed. Each packet consisted of 30 MNP sachets. In 2016, total costs were $277,082 (community platform, $0.24/sachet) and $221,568 (facility platform, $0.59/sachet). The cost per child reached was lower in the community platform ($53.24) than the facility platform ($65.97). The cost per child adhering to a protocol was $58.08 (community platform) and $72.69 (facility platform). The estimated cost of scaling up the community platform pilot to the district level over 3 years to cover approximately 17,890 children was $1.23 million (scale-up integrated into a partner agency program) to $1.62 million (government scale-up scenario). Unlike previous estimates, these included opportunity costs. Community-based MNP delivery costs were greater, yet more cost-efficient per child reached and adhering to protocol than facility-based delivery. However, total costs for untargeted MNP delivery under program settings are potentially prohibitive.
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Affiliation(s)
- Whitney Schott
- Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania.,A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Belinda Richardson
- International Agricultural Development, Department of Plant Sciences, University of California, Davis, Davis, California
| | - Emily Baker
- International Agricultural Development, Department of Plant Sciences, University of California, Davis, Davis, California
| | - Alexis D'Agostino
- County of Santa Clara Public Health Department, San Jose, California
| | | | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California-Davis, Davis, California
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Sarma H. Implementation science in nutrition: a summary and synthesis. Public Health Nutr 2021; 24:s1-s6. [PMID: 33634773 PMCID: PMC8042575 DOI: 10.1017/s1368980021000884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled 'Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh'. DESIGN Commentary, summary and synthesis. SETTINGS Low- and middle-income country. RESULTS The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation's effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify 'effective' interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme. CONCLUSIONS Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.
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Affiliation(s)
- Haribondhu Sarma
- Research School of Population Health, Colleague of Health and Medicine, The Australian National University, Canberra, ACT2601, Australia
- Nutrition and Clinical Services Division, icddr,b, Dhaka1212, Bangladesh
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Ford ND, Ruth LJ, Ngalombi S, Lubowa A, Halati S, Ahimbisibwe M, Whitehead RD, Mapango C, Jefferds ME. An Integrated Enhanced Infant and Young Child Feeding (IYCF) and Micronutrient Powder Intervention Improved Select IYCF Practices Among Caregivers of Children Aged 12-23 Months in Eastern Uganda. Curr Dev Nutr 2021; 5:nzab003. [PMID: 33634219 PMCID: PMC7888698 DOI: 10.1093/cdn/nzab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is little evidence of the impact of integrated programs distributing nutrition supplements with behavior change on infant and young child feeding (IYCF) practices. OBJECTIVE We evaluated the impact of an integrated IYCF/micronutrient powder intervention on IYCF practices among caregivers of children aged 12-23 mo in eastern Uganda. METHODS We used pre-post data from 2 population-based, cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts (n = 2816). Caregivers were interviewed in June/July at baseline in 2015 and 12 mo after implementation in 2016. We used generalized linear mixed models with cluster as a random effect to calculate the average intervention effect on receiving IYCF counseling, ever breastfed, current breastfeeding, bottle feeding, introducing complementary feeding at age 6 mo, continued breastfeeding at ages 1 and 2 y, minimum meal frequency (MMF), minimum dietary diversity, minimum acceptable diet (MAD), and consumption of food groups the day preceding the survey. RESULTS Controlling for child age and sex, household wealth and food security, and caregiver schooling, the intervention was positively associated with having received IYCF counseling by village health team [adjusted prevalence difference-in-difference (APDiD): +51.6%; 95% CI: 44.0%, 59.2%]; timely introduction of complementary feeding (APDiD: +21.7%; 95% CI: 13.4%, 30.1%); having consumed organs or meats (APDiD: +9.0%; 95% CI: 1.4%, 16.6%) or vitamin A-rich fruits or vegetables (APDiD: +17.5%; 95% CI: 4.5%, 30.5%); and MMF (APDiD: +18.6%; 95% CI: 11.2%, 25.9%). The intervention was negatively associated with having consumed grains, roots, or tubers (APDiD: -4.4%; 95% CI: -7.0%, -1.7%) and legumes, nuts, or seeds (APDiD: -15.6%; 95% CI: -26.2%, -5.0%). Prevalences of some IYCF practices were low in Amuria at endline including MAD (19.1%; 95% CI :16.3%, 21.9%). CONCLUSIONS The intervention had a positive impact on several IYCF practices; however, endline prevalence of some indicators suggests a continued need to improve complementary feeding practices.
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Affiliation(s)
- Nicole D Ford
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, US Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
- McKing Consulting Corporation, Chamblee, GA 30341, USA
| | - Laird J Ruth
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, US Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
- McKing Consulting Corporation, Chamblee, GA 30341, USA
| | | | - Abdelrahman Lubowa
- School of Food Technology, Nutrition, and Bioengineering, Makerere University, Kampala, Uganda
| | - Siti Halati
- United Nations World Food Program, Kampala, Uganda
| | | | - Ralph D Whitehead
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, US Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Carine Mapango
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, US Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, US Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
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Binns CW, Lee MK, Maycock B, Torheim LE, Nanishi K, Duong DTT. Climate Change, Food Supply, and Dietary Guidelines. Annu Rev Public Health 2021; 42:233-255. [PMID: 33497266 DOI: 10.1146/annurev-publhealth-012420-105044] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Food production is affected by climate change, and, in turn, food production is responsible for 20-30% of greenhouse gases. The food system must increase output as the population increases and must meet nutrition and health needs while simultaneously assisting in achieving the Sustainable Development Goals. Good nutrition is important for combatting infection, reducing child mortality, and controlling obesity and chronic disease throughout the life course. Dietary guidelines provide advice for a healthy diet, and the main principles are now well established and compatible with sustainable development. Climate change will have a significant effect on food supply; however, with political commitment and substantial investment, projected improvements will be sufficient to provide food for the healthy diets needed to achieve the Sustainable Development Goals. Some changes will need to be made to food production, nutrient content will need monitoring, and more equitable distribution is required to meet the dietary guidelines. Increased breastfeeding rates will improve infant and adult health while helping to reduce greenhouse gases.
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Affiliation(s)
- Colin W Binns
- School of Public Health, Curtin University, Perth, Western Australia 6845, Australia;
| | - Mi Kyung Lee
- College of Science, Health, Engineering and Education, Murdoch University, Murdoch, Western Australia 6150, Australia;
| | - Bruce Maycock
- College of Medicine and Health, University of Exeter, Exeter EX1 2LU, United Kingdom.,Asia-Pacific Academic Consortium of Public Health (APACPH), APACPH KL Secretariat Office, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia;
| | - Liv Elin Torheim
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, NO-0130 Oslo, Norway,
| | - Keiko Nanishi
- Office of International Academic Affairs, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo 113-0033, Japan;
| | - Doan Thi Thuy Duong
- Faculty of Social Sciences, Behavior and Health Education, Hanoi University of Public Health, Bac Tu Liem District, Hanoi 100000, Vietnam;
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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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
Abstract
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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10
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Samuel A, Brouwer ID, Pamungkas NP, Terra T, Lelisa A, Kebede A, Osendarp SJM. Determinants of adherence to micronutrient powder use among young children in Ethiopia. MATERNAL AND CHILD NUTRITION 2020; 17:e13111. [PMID: 33169528 PMCID: PMC7988858 DOI: 10.1111/mcn.13111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 10/15/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale‐up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6–11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66–0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54–0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52–0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled‐up, by taking into account factors that positively and negatively determine adherence.
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Affiliation(s)
- Aregash Samuel
- Food Science and Nutrition Research Directorate, Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Inge D Brouwer
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Nindya P Pamungkas
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Tosca Terra
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Azeb Lelisa
- Nutrition International, Ethiopia, C/O Ethiopia-Canada Cooperation Office (CIDA-ECCO), Addis Ababa, Ethiopia
| | - Amha Kebede
- Food Science and Nutrition Research Directorate, Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Saskia J M Osendarp
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
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11
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Gosdin L, Sharma AJ, Tripp K, Amoaful EF, Mahama AB, Selenje L, Jefferds ME, Ramakrishnan U, Martorell R, Addo OY. Barriers to and Facilitators of Iron and Folic Acid Supplementation within a School-Based Integrated Nutrition and Health Promotion Program among Ghanaian Adolescent Girls. Curr Dev Nutr 2020; 4:nzaa135. [PMID: 32914043 PMCID: PMC7467268 DOI: 10.1093/cdn/nzaa135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Anemia is a moderate public health problem among adolescent girls in Ghana. OBJECTIVES We aimed to evaluate the barriers to and facilitators of program fidelity to a school-based anemia reduction program with weekly iron and folic acid (IFA) supplementation. METHODS Authors analyzed directly observed weekly IFA consumption data collected longitudinally and cross-sectional data from a representative survey of 60 secondary schools and 1387 adolescent girls in the Northern and Volta regions of Ghana after 1 school year (2017-2018) of the intervention (30-36 wk). A bottleneck analysis was used to characterize the levels of IFA coverage and used adjusted generalized linear mixed-effects models to quantify the school and student drivers of IFA intake adherence. RESULTS Of girls, 90% had ever consumed the tablet, whereas 56% had consumed ≥15 weekly tablets (mean: 16.4, range: 0-36), indicating average intake adherence was about half of the available tablets. Among ever consumers, 88% of girls liked the tablet, and 27% reported undesirable changes (primarily heavy menstrual flow). School-level factors represented 75% of the variance in IFA consumption over the school year. Total IFA tablets consumed was associated with the ability to make up missed IFA distributions (+1.4 tablets; 95% CI: +0.8, +2.0 tablets), junior compared with senior secondary school (+5.8; 95% CI: +0.1, +11.5), educators' participating in a program-related training (+7.6; 95% CI: +2.9, 12.2), and educator perceptions that implementation was difficult (-6.9; 95% CI: -12.1, -1.7) and was an excessive time burden (-4.4; 95% CI: -8.4, -0.4). CONCLUSIONS Although the program reached Ghanaian schoolgirls, school-level factors were barriers to adherence. Modifications such as expanded training, formalized make-up IFA distributions, sensitization (awareness promotion), and additional support to senior high schools may improve adherence. Spreading the responsibility for IFA distribution to other teachers and streamlining monitoring may reduce the burden at the school level. Strengthening the health education component and improving knowledge of IFA among students may also be beneficial.
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Affiliation(s)
- Lucas Gosdin
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, CDC, Atlanta, GA, USA
| | - Andrea J Sharma
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, CDC, Atlanta, GA, USA
- US Public Health Service Commissioned Corps, Atlanta, GA, USA
| | | | - Esi F Amoaful
- Nutrition Department, Ghana Health Service of Ministry of Health, Accra, Ghana
| | | | | | - Maria E Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, CDC, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Reynaldo Martorell
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - O Yaw Addo
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, CDC, Atlanta, GA, USA
- Emory Global Health Institute, Atlanta, GA, USA
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12
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D'Agostino A, Ssebiryo F, Murphy H, Cristello A, Nakiwala R, Otim K, Sarkar D, Ngalombi S, Schott W, Katuntu D, Griffiths M, Namaste SML. Facility- and community-based delivery of micronutrient powders in Uganda: Opening the black box of implementation using mixed methods. MATERNAL AND CHILD NUTRITION 2020; 15:e12798. [PMID: 31622038 DOI: 10.1111/mcn.12798] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 11/17/2018] [Accepted: 11/20/2018] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Alexis D'Agostino
- Strengthening Partnerships, Results, and Innovation in Nutrition Globally (SPRING) project, JSI Research & Training Institute, Inc., Rosslyn, Virginia, USA
| | - Francis Ssebiryo
- SPRING project, JSI Research & Training Institute, Inc., Kampala, Uganda
| | - Hillary Murphy
- Strengthening Partnerships, Results, and Innovation in Nutrition Globally (SPRING) project, JSI Research & Training Institute, Inc., Rosslyn, Virginia, USA
| | - Angelica Cristello
- Independent Consulant, Strengthening Partnerships, Results, and Innovation in Nutrition Globally (SPRING) project, JSI Research & Training Institute, Inc., Rosslyn, Virginia, USA
| | - Rose Nakiwala
- SPRING project, JSI Research & Training Institute, Inc., Kampala, Uganda
| | - Katherine Otim
- SPRING project, JSI Research & Training Institute, Inc., Kampala, Uganda
| | - Danya Sarkar
- Strengthening Partnerships, Results, and Innovation in Nutrition Globally (SPRING) project, JSI Research & Training Institute, Inc., Rosslyn, Virginia, USA
| | - Sarah Ngalombi
- Nutrition Division, Uganda Ministry of Health, Kampala, Uganda
| | - Whitney Schott
- Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Katuntu
- SPRING project, JSI Research & Training Institute, Inc., Kampala, Uganda
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13
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Tumilowicz A, Vossenaar M, Kjaer K, Vettersand J, Possolo E, Pelto GH, Jefferds ME, Norte A, Dos Santos Dias K, Osman N, Gonzalez W, Poonawala A, Neufeld LM. Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique. MATERNAL AND CHILD NUTRITION 2020; 15:e12718. [PMID: 31622037 PMCID: PMC6856962 DOI: 10.1111/mcn.12718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 11/27/2022]
Abstract
Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.
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Affiliation(s)
| | | | | | | | - Edna Possolo
- Department of Nutrition, Ministry of Health, Maputo, Mozambique
| | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Maria Elena Jefferds
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Augusto Norte
- A-Consultants Statistical Services, Mendoza, Argentina
| | | | - Nadia Osman
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Wendy Gonzalez
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Alia Poonawala
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
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14
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Roschnik N, Diarra H, Dicko Y, Diarra S, Stanley I, Moestue H, McClean J, Verhoef H, Clarke SE. Adherence and acceptability of community-based distribution of micronutrient powders in Southern Mali. MATERNAL AND CHILD NUTRITION 2020; 15:e12831. [PMID: 31622044 PMCID: PMC6856685 DOI: 10.1111/mcn.12831] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/11/2019] [Accepted: 04/02/2019] [Indexed: 11/29/2022]
Abstract
Home fortification with micronutrient powders (MNP) has been shown to reduce anaemia, with high overall acceptability and adherence, but there is limited evidence from West Africa. Around 80% of children younger than 5 years are anaemic in Mali, and new interventions are needed. This paper reports on the adherence and acceptability of a community‐led MNP intervention targeting children aged 6–59 months in Southern Mali. The MNP were delivered by a multidisciplinary group of community volunteers using community‐based preschools, cooking demonstrations, and traditional communication networks to promote MNP, nutrition, hygiene, and child stimulation. The MNP were delivered alongside early childhood development interventions and seasonal malaria chemoprevention. Adherence and acceptability were evaluated through two cross‐sectional surveys in 2014 and 2016 and a qualitative evaluation in 2015. Over 80% of parents reported ever having given MNP to their child, with 65% having given MNP for four or more days in the last week. Likely contributors to uptake include: perceived positive changes in the children following MNP use, the selection of a food vehicle that was already commonly given to children (morning porridge or bouillie) and the community driven, decentralized and integrated delivery approach. These findings support recommendations from recent reviews of MNP implementation to use community‐based delivery approaches and behaviour change components.
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Affiliation(s)
| | - Hawa Diarra
- Sponsorship programmes, Save the Children International, Bamako, Mali
| | - Yahia Dicko
- Sponsorship programmes, Save the Children International, Bamako, Mali
| | - Seybou Diarra
- Sponsorship programmes, Save the Children International, Bamako, Mali
| | - Isobel Stanley
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Moestue
- Department of Education and Child Protection, Save the Children USA, Washington, DC
| | - Judy McClean
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hans Verhoef
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, London, UK.,Cell Biology and Immunology Group, Wageningen University, Wageningen, The Netherlands.,Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Sian E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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15
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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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16
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Use of concurrent evaluation to improve implementation of a home fortification programme in Bangladesh: a methodological innovation. Public Health Nutr 2020; 24:s37-s47. [PMID: 32131925 PMCID: PMC8042578 DOI: 10.1017/s1368980020000439] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Objective: This paper focuses on the use of ‘concurrent evaluation’ to evaluate a nationally scaled-up programme in Bangladesh that was implemented by BRAC (an international development organisation) using Shasthya Shebika (SS) – volunteer community health workers – to promote home fortification with micronutrient powders (MNP) for children under-five. Design: We developed a programme impact pathway to conceptualise the implementation and evaluation strategy and developed a strategic partnership among the key programme stakeholders for better use of evaluation evidence. We developed a multi-method concurrent evaluation strategy to provide insights into the BRAC programme and created provision for course correction to the implementation plan while it was in operation. Setting: One hundred sixty-four sub-districts and six urban slums in Bangladesh. Participants: Caregivers of children 6–59 months, SS and BRAC’s staff members. Results: The evaluation identified low awareness about home fortification among caregivers, inadequate supply and frequent MNP stockouts, and inadequate skills of BRAC’s SS to promote MNP at the community level as hindrances to the achievement of programme goals. The partners regularly discussed evaluation results during and after implementation activities to assess progress in programme coverage and any needs for modification. BRAC initiated a series of corrections to the original implementation plan to address these challenges, which improved the design of the MNP programme; this resulted in enhanced programme outcomes. Conclusions: Concurrent evaluation is an innovative approach to evaluate complex real-world programmes. Here it was utilised in implementing a large-scale nutrition programme to measure implementation process and effectiveness.
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17
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Bonvecchio Arenas A, González W, Théodore FL, Lozada-Tequeanes AL, Garcia-Guerra A, Alvarado R, Fernández-Gaxiola AC, Rawlinson CJ, de la Vega AV, Neufeld LM. Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico. J Nutr 2019; 149:2310S-2322S. [PMID: 31793647 DOI: 10.1093/jn/nxz229] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/24/2019] [Accepted: 08/29/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). OBJECTIVE We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. METHODS The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. RESULTS The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. CONCLUSIONS The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.
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Affiliation(s)
- Anabelle Bonvecchio Arenas
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Wendy González
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Florence L Théodore
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Ana Lilia Lozada-Tequeanes
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Armando Garcia-Guerra
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Rocio Alvarado
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Ana C Fernández-Gaxiola
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Cloe J Rawlinson
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
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18
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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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19
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Tumilowicz A, Habicht J, Mbuya MN, Beal T, Ntozini R, Rohner F, Pelto GH, Fisseha T, Haidar J, Assefa N, Wodajo HY, Wolde TT, Neufeld LM. Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia. MATERNAL & CHILD NUTRITION 2019; 15:e12807. [PMID: 31622042 PMCID: PMC6856804 DOI: 10.1111/mcn.12807] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/28/2019] [Accepted: 02/18/2019] [Indexed: 01/23/2023]
Abstract
A theory-driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross-sectional survey data of caregivers of children 6-23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12-17 months were 32% (P < 0.001) and children 18-23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6-11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.
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Affiliation(s)
| | | | - Mduduzi N.N. Mbuya
- Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
- Global Alliance for Improved NutritionWashingtonDCUSA
| | - Ty Beal
- Global Alliance for Improved NutritionWashingtonDCUSA
- Department of Environmental Science and PolicyUniversity of CaliforniaDavisCaliforniaUSA
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health ResearchHarareZimbabwe
| | | | - Gretel H. Pelto
- Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Tezera Fisseha
- Institute for Education, Health and DevelopmentAddis AbabaEthiopia
| | - Jemal Haidar
- School of Public Health, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Nigussie Assefa
- School of Public Health, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | | | - Telahun Teka Wolde
- Health Services Quality DirectorateFederal Ministry of HealthAddis AbabaEthiopia
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20
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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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21
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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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22
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Randomized control trials demonstrate that nutrition-sensitive social protection interventions increase the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children. Public Health Nutr 2019; 21:1753-1761. [PMID: 29467053 PMCID: PMC5962883 DOI: 10.1017/s1368980017004232] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine the impact of a nutrition-sensitive social protection intervention on mothers' knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and the consumption of MMP and other Fe supplements by their children aged 6-59 months. DESIGN Two randomized controlled trials with treatment arms including cash transfers, food transfers, cash and food transfers, cash and nutrition behaviour change communication (BCC), and food and nutrition BCC were implemented over two years. Both included a control group that received no transfer or BCC. Transfer recipients were mothers living in poor households with at least one child aged less than 2 years at baseline. Probit models were used to analyse endline data. SETTING Rural areas in north-west and south Bangladesh. SUBJECTS Mothers (n 4840) and children 6-59 months (n 4840). RESULTS A transfer accompanied by nutrition BCC increased the share of mothers with knowledge of Fe deficiency (11·9 and 9·2 percentage points for North and South, respectively, P≤0·01), maternal awareness of MMP (29·0 and 22·2 percentage points, P≤0·01), the likelihood that their children 6-59 months had ever consumed MMP (32 and 11·9 percentage points, P≤0·01), consumed MMP in the preceding week (16·9 and 3·9 percentage points, P≤0·01) and consumed either MMP or an Fe supplement in the preceding week (22·3 and 7·1 percentage points, P≤0·01). Improvements were statistically significant relative to groups that received a transfer only. CONCLUSIONS Nutrition-sensitive social protection (transfers with BCC added) may be a promising way to advance progress on micronutrient deficiencies.
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23
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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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24
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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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25
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Mehta R, Martorell R, Chaudhuri I, Girard AW, Ramakrishnan U, Verma P, Kekre P, Srikantiah S, Young MF. Use of monitoring data to improve implementation of a home fortification program in Bihar, India. MATERNAL AND CHILD NUTRITION 2018; 15:e12753. [PMID: 30426653 PMCID: PMC6617994 DOI: 10.1111/mcn.12753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.
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Affiliation(s)
- Rukshan Mehta
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Reynaldo Martorell
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Amy Webb Girard
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Usha Ramakrishnan
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Priya Kekre
- The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Melissa F Young
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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26
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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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27
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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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28
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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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29
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Islam MM, McDonald CM, Krebs NF, Westcott J, Rahman AE, El Arifeen S, Ahmed T, King JC, Black RE. Study Protocol for a Randomized, Double-Blind, Community-Based Efficacy Trial of Various Doses of Zinc in Micronutrient Powders or Tablets in Young Bangladeshi Children. Nutrients 2018; 10:nu10020132. [PMID: 30720778 PMCID: PMC5852708 DOI: 10.3390/nu10020132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/14/2018] [Accepted: 01/16/2018] [Indexed: 01/10/2023] Open
Abstract
Zinc is essential to supporting growth in young children especially for tissues undergoing rapid cellular differentiation and turnover, such as those in the immune system and gastrointestinal tract. Therapeutic zinc supplementation has been initiated in low-income countries as part of diarrhea treatment programs to support these needs for young children, but the effects of preventive supplemental zinc as a tablet or as a multiple micronutrient powder (MNP) on child growth and diarrheal disease are mixed and pose programmatic uncertainties. Thus, a randomized, double-blind community-based efficacy trial of five different doses, forms, and frequencies of preventive zinc supplementation vs. a placebo was designed for a study in children aged 9–11 months in an urban community in Dhaka, Bangladesh. The primary outcomes of this 24-week study are incidence of diarrheal disease and linear growth. Study workers will conduct in-home morbidity checks twice weekly; anthropometry will be measured at baseline, 12 weeks and 24 weeks. Serum zinc and other related biomarkers will be measured in a subsample along with an estimate of the exchangeable zinc pool size using stable isotope techniques in a subgroup. Therapeutic zinc will be provided as part of diarrhea treatment, in accordance with Bangladesh’s national policy. Therefore, the proposed study will determine the additional benefit of a preventive zinc supplementation intervention. The protocol has been approved by the Institutional Review Boards (IRBs) of icddr,b and Children’s Hospital Oakland Research Institute (CHORI). The IRB review process is underway at the University of Colorado Denver as well.
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Affiliation(s)
- M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | | | - Nancy F Krebs
- Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Jamie Westcott
- Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | - Janet C King
- Children's Hospital Oakland Research Institute, Oakland, CA 94609, USA.
| | - Robert E Black
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
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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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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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