Effects of Alternative Spatial Distribution Schemes on Household Access Costs of Lipid-based Nutrient Supplements: Case Study in Rural Burkina Faso.

Objectives: Identifying cost-effective strategies for delivering efficacious nutrient supplements is a policy challenge, especially in rural areas. This paper examines the effects of alternative distribution outlet schemes on transportation costs of 3,146 households in the Dandé health clinic catchment area (1,600 sq. km), Burkina Faso, site of the International Lipid-Based Nutrient Supplements Zinc research project. Methods: Spatially referenced data on households, hospitals, clinics and markets, and on the road networks that link them, are combined with the motorized transportation fare structure to construct a distance-based transportation cost overlay. This overlay is then used to estimate the householdspecific, one-way transportation costs under alternative lipid-based nutrient supplement (LNS) distribution outlet schemes. Results: If the full-service Bobo Dioulasso Hospital is the only outlet, average transportation cost is US$ 1.96 and varies widely across households. Including the local Dandé Hospital in the distribution network reduces the average transportation cost to US$ 1.16; the spatial distribution of household access costs changes. Extending the network to include all health centers reduces average transportation cost to US$ 0.60. Adding markets as distribution outlets does not further reduce average transportation costs. Conclusions: Full-service hospital-based (only) distribution is the most costly LNS distribution scheme to households. Extending the network of outlets to include all hospitals, health centers and clinics reduces average households access costs by nearly 70%; doing so shifts the cost burden from households to other entities charged with managing this larger outlet network. At this site, involving retail outlets offers no household transportation costs savings.

Willingness-to-Pay for LNS Products: Evidence from the iLiNS Studies.

Objectives: Households’ stated willingness-to-pay (WTP) for small-quantity lipid-based nutrient supplements (LNS) influence the economic viability of retail outlets for these products, and will guide public policy action when WTP falls short of LNS production/distribution costs. This presentation provides evidence on WTP for LNS products tested in the context of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Malawi, Ghana and Burkina Faso. Methods: Field-based contingent valuation methods provide estimates of WTP for LNS for pregnant/lactating women (LNS-P&L) and for children 6-24 mo of age (LNS-child), and for their traditional alternatives. Experimental auctions provide incentive-compatible estimates of WTP for LNS-P&L (Ghana) and for LNS-child (Burkina Faso). Results: Average hypothetical WTP at baseline for LNS-child (one 20g sachet) was approximately US$0.39 (Ghana), US$0.23 (Burkina Faso) and US$0.20 (Malawi-DOSE). Average hypothetical WTP at baseline for LNS-P&L (one 20g sachet) was approximately US$0.61 (Ghana) and US$0.17 (Malawi-DYAD). Average experimental WTP for LNS-P&L (20g sachet) was, respectively, approximately US$0.25 (Ghana) and US$0.12 (Burkina Faso). Several household characteristics that could be used for programmatic targeting, e.g., number of children under five years of age, were associated with WTP. Conclusions: Hypothetical WTP is positive for the vast majority of respondents in all study areas and average WTP is above estimated average national production costs for all LNS products; hence, LNS products may be commercially viable. However, large proportions of respondents reported WTP below average production costs (e.g., approximately 6% of respondents reported zero WTP in the Ghana baseline) signalling the need to consider publically assisted mechanisms for reaching resource-poor households.

The Cost of Home Delivery Schemes for Lipid-based Nutrient Supplement Products: A Policy Experiment from Rural Malawi.

Objectives: Public policy makers may play a role in promoting products demonstrated to be efficacious. Home delivery reduces households’ out-of-pocket costs of accessing these products; however, home delivery may be expensive, especially in rural areas. This paper provides evidence based on a home-delivery scheme undertaken by the International Lipid-Based Nutrient Supplements (iLiNS-DOSE) Project in rural Malawi. Methods: Estimates of home delivery costs for lipid-based nutrient supplements (LNS), including product procurement, transportation, staffing and storage costs, are based on those faced by the iLiNS-DOSE Project. A cost model was developed and used to run a hypothetical five-year policy experiment to provide LNS to 60% of the approximately 12,000 young children aged 6-24 months. LNS is delivered bi-weekly to all children in the targeted age bracket; older early-enrollees and young late-enrollees would not receive the full 18-month intervention. Results: Total cost of the hypothetical five-year intervention would be approximately US$3.3m. Cost per treated-child is US$69; cost per fully-treated-child is US$89. 63% and 21% of the total cost is attributable to product purchases and personnel costs, respectively. Conclusions: Home delivery of LNS products brings the private costs of procuring them to zero. However, the cost of procurement, storage and weekly home delivery of these products, shouldered by the public sector in our example, can be large relative to other product delivery mechanisms. Changes to intervention protocol (target population, frequency of delivery, etc.) will affect costs. The expected health and other benefits associated with each proposed intervention strategy should be compared to these costs to set priorities.

Urinary Excretion of 8-isoprostane-F2α, a Biomarker of In vivo Lipid Peroxidation and Oxidative Stress, is Increased in Pregnant Ghanaian Women Taking 60 mg Iron Compared to 20 mg Iron and Multiple Micronutrients.

Objectives: To compare the effects of 3 different iron-containing supplements on 8-isoprostane- F2α, a subclinical indicator of oxidative stress, in pregnant women in Ghana. Methods: Pregnant women were randomly assigned to receive one of the following 3 interventions: Fe/FA: 60 mg iron and 400 μg folic acid capsule, MMN: 20 mg iron and 18 micronutrients capsule, or LNS: 20 mg iron and multiple micronutrients in a lipid-based nutrient supplement as part of the International Lipid-based Nutrient Supplement trial. We measured urinary 8-isoprostane-F2α and creatinine, to calculate 8-isoprostane-F2α: creatinine ratio in a subsample of 217 women at <20 wk and 36 wk gestation. Results: The overall effect of intervention group on mean (± SE) 8-isoprostane-F2α: creatinine at 36 wk was significant (p=0.04). The significant pairwise comparison was between the Fe/FA group (1.87±0.12 ng/mg creatinine) and the MMN group (1.48±0.09, p=0.02). The LNS group (1.64±0.10) was not significantly different from either of the other two groups. Conclusions: Our findings suggest that an increase in oxidative stress may occur with daily 60 mg iron compared to 20 mg iron with multiple micronutrients among pregnant women in Ghana.

Adherence to Intake Recommendations of Lipidbased Nutrient Supplements (LNS) and Iron/Folic Acid (IFA) among Pregnant and Lactating Women (PLW) in a Community Health Program Setting.

Objectives: Limited knowledge exists on sustained adherence to small quantity LNS for PLW and how this compares to other prenatal supplements, particularly in programmatic settings. We aimed to address these gaps. Methods: A random subsample of women (n=360) from an ongoing LNS effectiveness trial were selected for home interviews about use and preferences of LNS or IFA. Purposively selected women (n=16) and key informants (n=18) participated in in-depth interviews about perceptions and acceptability of LNS. Results: Prevalence of high-adherers (≥70%) based on self-reported supplement consumption was 67%, 68%, 81%, 87% and 71% among LNS recipients during pregnancy, early and late lactation and IFA recipients during pregnancy and early lactation, respectively (P=0.044). Programmatic factors (e.g. distribution and visits by program staff) were significantly associated with reported high adherence in all groups. Among LNS recipients, overall supplement acceptability score was positively associated (odds ratio (OR): 2.94; P<0.0010) and reports of previous stillbirths were negatively associated (OR: 0.12; P=0.0054) with reported high-adherence. In in-depth interviews, women reported benefits of taking LNS to both themselves and their infants, but some faced barriers to consumption such as aversion to LNS odor and taste during pregnancy, forgetfulness, and disruptions in supply. Conclusions: Adherence to LNS was sustained throughout the physiological periods at levels comparable to other supplementation programs. To achieve high adherence, these results suggest that maternal supplementation programs should focus on programmatic barriers and consider counseling on reminder techniques. Odor and taste acceptability of LNS, particularly during pregnancy, may also need to be addressed.

Impact of Small-quantity Lipid-based Nutrient Supplements on Infant and Young Child Feeding Practices.

Objectives: Lipid-based nutrient supplements (LNS) are energy-dense and could change infant and young child feeding (IYCF) practices by changing caregiver perceptions of needs and/or child appetite and demand for breast milk and local complementary foods. We hypothesized that LNS (10-40g/day) would not have significant impacts on IYCF practices. Methods: Infants in three randomized controlled trials were assigned to receive either LNS from 9- 18 mo (Burkina Faso) or 6-18 mo (Ghana and Malawi) or a delayed intervention (DI). All caregivers were given brief didactic messages promoting continued breastfeeding and diverse diets at first distribution of LNS; messages were repeated periodically in Ghana and Malawi (all groups) and not repeated systematically in Burkina Faso. IYCF practices were assessed at 18 mo by caregiver recall of the preceding day and week. Results: The reported prevalence of continued breastfeeding did not vary by intervention group in any site, and was 97%, 74%, and 89% in Burkina Faso, Ghana, and Malawi. Reported frequency of breastfeeding yesterday also did not vary. The proportion of infants meeting the WHO recommendation for minimum dietary diversity (4+ food groups) did not differ by intervention group and was 37%, 75%, and 68% in Burkina Faso, Ghana and Malawi. In Burkina Faso, infants in the LNS group were more likely to meet the WHO recommendation for number of meals/snacks yesterday (79%, vs. 66% in DI group). Conclusions: Provision of LNS did not change most IYCF practices but increased frequency of feeding in one site.

Infant feeding practices among low-income Mexican urban women: a four month follow-up

We studied the infant feeding practices of 61 healthy women who delivered vaginally and without complications in two public hospitals in the city of Hermosillo, Sonora, Mexico. During the hospital stay, 51% of the women were planning full breastfeeding (full-BF), 43% partial breastfeeding (partial-BF) and 6% exclusive formula feeding (FF). At 2 weeks and 4 months post-partum (pp) the predominant feeding modes were partial-BF (59%) and FF (61%) respectively. The parameters that were positively associated with any breastfeeding at 4 months pp were: social support, previous breastfeeding experience and neonatal feeding mode. The infant feeding policies in both hospitals were not conducive for breastfeeding. The majority of infants were already receiving solid foods and juices by 3 months pp