Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia.

Objectives: Bolivia is among few countries to have scaled-up Micronutrient Powders (MNPs) for children to the national level. Here we explore Bolivia’s experience as an early-adopter and in doing so, identify enabling conditions and stakeholders that led to scale-up, and barriers to increasing coverage and adherence. Methods: We reviewed a wide variety of documents spanning several years of program implementation (2006-2012) and communicated with those involved with the program. We defined scale-up as the process of increasing coverage to benefit more children and used a health system model to identify programmatic components. Results: Bolivia replaced iron syrup for children 6-23 months of age with MNPs in 2006. In 2012, MNP coverage reached 65% of Bolivia's approximately 536,000 children in this age group. Adherence rates in 2010 for children consuming all 60 sachets were 45% and 52% in urban and rural areas, respectively. Enabling political factors included integrating MNPs into the existing public health system. Politicians and policy makers helped accelerate scale-up by including MNPs within the national development plan and prioritizing effective coordination, including private sector engagement. Training of healthcare providers, support for supply chain management, communications, and program monitoring remain critical components of MNP scale-up. Behaviour change and demand creation strategies targeting the healthcare provider and caregiver were identified as key factors to sustain and increase coverage and adherence rates. Conclusions: Countries considering replacing iron syrup and transitioning to MNP implementation can benefit from Bolivia’s experience, particularly in creating an enabling environment whereby MNPs can be integrated within existing health and nutrition programs.

Role of National Legislation in the Interpretation and Practice of Salt Iodization Standards.

Objectives: The ICCIDD/GN Iodine Task Force was established in response to changing environment and program maturity of salt iodization programs worldwide. It aims to improve the evidence and thus the quality and effectiveness of iodine nutrition programs to help update program guidelines. To assess the role of national legislation in the interpretation and practice of salt iodization standards to achieve optimal iodine intake. Methods: A review of scientific literature, reports and data, including the development of a database to review current legislation and policies regarding universal salt iodization (USI) in national programs for eliminating iodine deficiency disorders, was conducted and analyzed to provide information on the interpretation of iodization standards. Results: Review of legislation governing iodization indicates variation in the interpretation of normative guidance (20-40 ppm) on standards. True USI (iodize all salt for human and animal consumption) is not always mandated or implemented. There are examples of changes in legislation in response to dynamic national contexts such as consumption of processed foods. Varied standards and legislation between countries complicate regional approaches to standards setting and can create trade barriers. When iodization is voluntary, information gaps often exist regarding application of the standard and the extent to which iodized salt is used in processed foods. Conclusions: Adherence to normative guidance for iodization standards is not a prerequisite for achieving optimal iodine intake. Legislation governing iodization should preferably be mandatory and support the use of iodized salt for ALL human consumption, to facilitate an evidence based approach to setting standard in a dynamic context.

Socially Marketing Micronutrients: The Development of a Multi-channel Communications Campaign in Bolivia.

Objectives: To describe the process for developing a national multi-channel communications campaign, emphasizing mass media, to increase demand and utilization of micronutrient supplements for women and children in Bolivia as part of the national Programa Multisectorial Desnutrición Cero. Methods: The design of campaign materials and messages was informed by a baseline knowledge, attitude, and practice (KAP) assessment (n=452), conducted in four departments. Findings were used, along with channel analysis, to develop a dissemination plan. Draft materials were field-tested using focus groups (n=12) with target audiences (n=120) and modified based on feedback. All activities were carried-out in collaboration with the Ministry of Health and Sports. Results: The baseline KAP survey showed variation across different micronutrient supplements and departments, for example any knowledge of vitamin A ranged from 55-100% and any knowledge of therapeutic zinc for diarrhoea or stunting ranged from 10-30%. Television and radio were the preferred channels for receiving health and nutrition information, including on services available. Field-testing of draft materials found generally high acceptance and valuing of the materials; feedback led to modifications which increased emphasis on enablers for how to conduct the recommended practices. Final materials included television and radio advertisements, roadside billboards, health center banners, and calendars for caregivers. Conclusions: A national multi-channel communications campaign to promote micronutrient supplementation was developed. After seven months of implementation, an endline survey will be conducted to assess the association between campaign exposure and KAP, which will allow us to understand the potential influence of each communication channel on coverage and utilization of micronutrient supplements.

Consumption of Higher Frequency and Duration of Micronutrient Powders Does not Increase Diarrhea Morbidity among Peruvian Children 6-11 Months of Age.

Objectives: There have been concerns around the safety of daily iron-containing multiple micronutrient powders (MNP) in young children in malaria-endemic and malaria-free environments. We analysed the effects of different MNP delivery regimens on diarrhea-related morbidity in children in a malaria-free area of Peru. Methods: A total of 400 children 6 to 11 months of age, were randomized to one of four groups: every-other day for 6 months (A), daily for 6 months (B), every-other-day for 12 months (C), and daily for 12 months (D). All children were followed for 12 months. All MNP had the same formulation, including 12.5 mg iron, and zinc, vitamin A, vitamin C and folic acid. MNP were provided to caregivers every month and data on consumption and diarrhea morbidity were assessed twice a month. Point prevalence of diarrhea morbidity was calculated as number of days ill per total days of observation. Results: Data of 399 (99.8%) children were analyzed by intention-to-treat. Group A was the control with 2.07% diarrhea days. No differences in diarrhea morbidity were observed among groups (group B: 1.85% days with diarrhea (OR:0.89; 95%CI0.79,1.01); group C:2.06% (OR:0.96.95%CI:0.88,1.12); group D:2.14% (OR:1.03;95%CI: 0.92,1.16). There were also no differences among regimens, stratified by age at baseline (6-8 mo vs 9-11 mo) but overall young children were ill more frequently than older children. Conclusions: Daily consumption of MNPs for longer periods of time, does not lead to increased diarrhea compared to every-other-day supplementation for 6 months. The reasons for the lower OR of daily consumption for 6 months are being explored.

Review of Iodine and Salt Sources for Establishing Iodization Standards.

Objectives: The ICCIDD/GN Iodine Task Force was established in response to changing environment and program maturity of salt iodization programs worldwide. It aims to improve the evidence and thus the quality and effectiveness of iodine nutrition programs to help update program guidelines. To review dietary sources of iodine intake, including salt from different sources and other natural iodine sources to inform the development of iodization standards. Methods: A review of published literature and reports, data and/or information from national programs for eliminating iodine deficiency disorders was conducted to gather both knowledge and program experience. Results: Globally salt intake through processed foods is increasing; however, in many countries such salt is not iodized. Except for marine food, most natural food sources are low in iodine. In Western countries without mandatory Universal salt iodization, the most significant food groups contributing to iodine intake are dairy and cereal products, however, there is a large disparity in iodine content within and between foods due to natural variations. Little information exists regarding the additional dietary iodine via iodized livestock salt. Generally, iodine content in drinking water is low and contributes relatively little towards iodine intake of large populations. Conclusions: Natural sources of iodine in the diet as well as the iodine contribution via livestock salt as less informative for establishing national standards however, a key consideration is the source of dietary salt. Since most of the salt intake proceeds from industrial salt, iodine standards should be applicable to the total dietary salt supply.

Poor Pregnancy and Birth Outcomes are Associated with the Indicators of Inadequate Dietary Intakes of Micronutrients in Rural Women of the Amhara Region of Ethiopia.

Objectives: High prevalence of poor pregnancy (miscarriage) and birth (stillbirth) outcomes has been reported among poor women in Ethiopia. This study evaluated the underlining associated factors. Methods: The study used a cross-sectional design to interview 5192 mothers of children under 5 years of age, who were living in 60 villages, across 60 sub-districts in 6 zones of the Amhara Region of Ethiopia. Socio-demographic, obstetric, and birth information were collected using standardised questionnaires and household salts were tested with rapid test kits. The study protocol received ethical approval from McGill University, Ethiopian Health and Nutrition Research Institute, and the Ethiopian National Research Ethics Review Committee. Results: Households were mainly individual dwellings (83.4%) with agricultural land (90.9%) and rearing livestock (94.1%). Majority of household heads and mothers were illiterate (63.7% and 81.2%, respectively). Sanitation (61.0% scored ≤ 1 out of 3), assets (84.1% scored ≤5 out of 10) and use of iodised salt (6.4%) were very poor and goiter presence in the family was high (41.7%). Prevalence of miscarriage was 95.4 per 1000 pregnancies and stillbirth was 22.7 per 1000 live births. The use of non-iodised salt was associated with miscarriage (r=0.06; p<0.05). Self-reported anaemia, vomiting, and urinary tract infection during pregnancy were common (37.2%, 26.08%, and 19.47% respectively) and were associated with prevalence of miscarriage and stillbirth(r=0.04 to 0.06; p<0.05). Conclusions: Poor pregnancy and birth outcomes occur frequently in rural Ethiopia and are associated with indicators of inadequate dietary intakes of micronutrients.