Promotion of Zinc Tablets with ORS through Child Health Weeks Improves Caregiver Knowledge, Attitudes, and Practice on Treatment of Diarrhoea in Nigeria.

We examined whether the Maternal, Newborn and Child Health Weeks (MNCHW) in Nigeria would present an opportunity to raise awareness of and demand for the use of zinc and ORS in the treatment for diarrhoea, guided by a conceptual framework designed to assess three theoretical underpinnings (characteristics and performance standard of the health workers, potential reach, and intensity of the intervention), along the impact pathway. Zinc and ORS with education for their appropriate use during the next diarrhoeal episode were delivered as part of the November 2010 and May 2011 MNCHW. On the day of but before participating in MNCHW activities, semi-structured interviews were used for collecting information on knowledge, attitudes, and practice (KAP) relating to diarrhoea from 602 caregivers with children aged less than five years. Forty-eight health workers were also interviewed. Nearly all health workers (98%) correctly mentioned the dosage of zinc while only 58% correctly stated the preparation of ORS. The proportion of caregivers with knowledge on the treatment for diarrhoea increased from 46.4% in November 2010 pre-MNCHW to 71.3% in May 2011 pre-MNCHW interviews (p<0.001). More caregivers correctly mentioned the dosage of zinc (80.9%) and stated the preparation of ORS (88.8%) in the November 2010 exit interview immediately after the MNCHW encounter compared to the levels a few months later in the home follow-up visit (53.1% and 37.4% respectively). After attending both rounds of November 2010 and May 2011 MNCHW, caregivers’ knowledge on the treatment of diarrhoea increased seven times compared to the caregivers who attended the May 2011 MNCHW only (OR=7.0, p<0.001). Additionally, caregivers were 40% less likely to seek advice outside the home in the treatment for diarrhoea if they had attended both the MNCHWs than if they had attended the May 2011 MNCHW only (OR=0.6, p<0.029). We conclude that providing opportunities for caregivers to receive a sample of zinc and ORS and to learn about its use in the treatment for diarrhoea, from trained health workers during MNCHW, has the potential to increase KAP relating to the use of zinc and ORS in the treatment for diarrhoea and for future diarrhoeal episodes.

Distribution of Iron, Vitamin A and Zinc Deficiencies in Children and Women in Senegal.

Objectives: Reliable data on the micronutrient status of women and children was needed in Senegal to guide evidence-based decision making on interventions to reduce micronutrient deficiencies (MND). This study presents the findings of the first ever national MND survey carried out in Senegal in 2010. Methods: A cross sectional household survey sampled 1,810 households stratified by two urban and two rural zones. Data were collected on biochemical indicators of iron, vitamin A and zinc deficiency from 1,316 women 15-49 y and 1,887 children 12-59 mo. The analysis adjusted for subclinical inflammation. Results: Subclinical inflammation affected 27.7% of women and 49.5% of children. 44.7% women and 61.5% children had serum ferritin below 15 or 12 μg/l, respectively. 2.1% women and 18.2% children had serum retinol <0.70μmol/l; 66.7% women and 39.6% children had serum zinc below cutoff. Only 12.8% of women and 11.6% of children had no MND; 18.4% of women and 15.4% of children had at least 3 coexisting MND. The risk of a child having iron (OR 2.70; [1.49, 4.88]) or vitamin A (OR 13.66; [4.07, 45.84]) deficiency was higher in households where a woman had iron or vitamin A deficiency. Child anemia (66%) and zinc deficiency were not related to the status of women in the household. Women and children in rural areas were more affected by iron and vitamin A deficiencies compared to urban areas. Conclusions: MND affect a large proportion of women and children in Senegal. Further study of factors contributing to Intra-household clustering and rural/urban differences of MND is warranted.

Revitalizing Iron Folic Acid (IFA) Supplementation for Pregnant Women: Current Trends and Opportunities Based on Multi-country Formative Assessments.

Objectives: To identify existing barriers and potential enabling opportunities for the revitalization of iron and folic acid (IFA) supplementation to reduce anemia in pregnant women. Methods: A synthesis of formative research results from eight countries (Afghanistan, Bangladesh, Ethiopia, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand current antenatal care-seeking practices and identify relevant barriers and enablers associated with improved coverage and adherence to prenatal IFA supplementation. Results: Anemia in pregnancy is a well-known health concern by women, family decision-makers and health care providers in all countries studied. Widely varying views on when to start IFA supplementation, the dosage and the duration were expressed by women, family members and health care providers. Broad awareness of and modest attendance at facility-based ANC by pregnant women support this delivery channel for IFA, yet timely access is hindered by conflicting beliefs about the value of early initiation of ANC and the importance of prenatal IFA without anemia symptoms. Variable access and poor quality ANC services, specifically inadequate counseling on managing side effects and insufficient number of tablets given, are barriers to improving IFA coverage and ensuring adherence (≥90 tablets). In some cases, community-based delivery of ANC and IFA provided greater accessibility and follow-up for pregnant women. Conclusions: Improved ANC access and quality is needed to facilitate IFA supplementation. There is potential for community-based delivery and counseling to address concerns with IFA supplement supply and adherence. Renewed investment in IFA programs with strong behaviour change designs is urgently needed to achieve reductions in anemia.

Caregiver’s Knowledge, Attitudes and Practices on the Utilization of Zinc and lo-ORS for Diarrhea Treatment in Northern Nigeria.

Objectives: The caregiver’s knowledge, attitudes and practices on the utilization of Zinc and ORS for diarrhea treatment in Northern Nigeria call for concerns. We conducted a baseline in Northern Nigeria to determine the coverage, adherence, barriers and facilitating factors that affect utilization of Zinc and lo-ORS supplementation from service delivery and recipient perspectives. Methods: Qualitative and quantitative methods were used to collect data from eligible caregivers of under-five children between March-July 2013. Results: We found that awareness on use of zinc and lo-ORS in treating diarrhea is low among caregivers across surveyed states, awareness in Jigawa (44.5%) and Katsina (14.9%) states were higher than in Benue state (2.7%) while it was lower in Yobe (0.3%) and Zamfara states (0%). The percentage of caregivers of under-5 children with diarrhea using recommended dose of Zinc and Lo-ORS at home was also low (2.1% for Jigawa, while katsina, Yobe and Zamfara recorded 0%). In contradiction, the percentage of caregivers who seek any form of treatment for diarrhea ranges from 66.7% in Jigawa to 97.2 in Zamfara. Barriers to utilization of zinc and lo-ORS were similar across the surveyed states. They included non-availability, lack of adequate knowledge of the benefits and efficacy of zinc and lo-ORS and preference for herbal (traditional) medicine. Conclusions: The findings formed the basis for development of SBCC strategies, for each segment of the population with special focus on caregivers of children under-fives to address the gaps in knowledge, attitudes and practices on the utilization of zinc and ORS for diarrhea treatment.

Trends and Opportunities in Zinc and Oral Rehydration Salts (ORS) for Diarrhea Treatment across Multi-country Formative Assessments.

Objectives: Treatment of diarrhea with zinc and ORS has both life-saving potential and diarrhea prevention benefits, yet here we explore the barriers as to why coverage and adherence remain low. Methods: A synthesis of formative research results from nine countries (Afghanistan, Bangladesh, Ethiopia, India, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand child diarrhea treatment practices and identify the barriers and enablers associated with ORS and zinc use. Results: In all countries, caregivers felt that diarrhea can be adequately cared for at home with local foods and drinks, traditional remedies and herbal medicine, tailored to the type of diarrhea. Perceived causes of diarrhea and advice from senior family members directly influenced treatment seeking. ORS was widely known for preventing dehydration in children with diarrhea, but was perceived as ineffective in stopping diarrhea. Caregivers and some health workers preferred antibiotics and anti-diarrheal medicines to “stop” diarrhea promptly. Outreach activities and free treatment for child diarrhea motivated caregivers to seek facility-based treatment. Barriers to ORS and zinc use include low awareness of zinc at multiple levels, frequent supply stock-outs and poor prescribing practices of health workers. Barriers to adherence to the full course of zinc include the common practice of stopping treatment when diarrhea stops and a lack of caregiver awareness of the benefits of zinc for prevention of diarrhea. Conclusions: Addressing context-specific beliefs about diarrhea causes and the effectiveness of home-remedies is essential to improve care-seeking behaviours. Maintaining adequate supplies and promoting the benefits of zinc will help to improve coverage and adherence.

Knowledge, Attitude and Practices (KAP) that Contribute to Low Vitamin A Coverage among Caregivers of Children 6-59 Months: Results from the KAP Survey done in Kenya.

Objectives: The uptake of VAS for children 6-59 months in Kenya is low with only 30% receiving the recommended two doses of VAS yearly. The KAP survey was done to determine socio-cultural enablers and barriers of coverage and uptake of two dose VAS and thus inform the design of responsive behavior change and communication (BCC) strategies. Methods: KAP involved 3842 caregiver interviews,48 In-depth Interviews (IDIs),69 key informant interviews (KIIs) and 48 focus group discussions (FGDs) in 12 counties. Results: The KAP identified facility health workers (FHWs), community health workers (CHWs), and Early childhood and development centers (ECD) teachers as the key influencers to VAS uptake and coverage. Barriers to uptake and coverage include: 1) Restrictive policy that only allows trained health workers to deliver VAS 2) Low knowledge on correct and benefits of VAS 3) Inadequate reporting tools and poor recording and reporting 4) Low demand/uptake of VAS by caregivers post immunization 5) Frequent stock-outs especially for 100,000 IUs capsules. Enablers to uptake and coverage include: 1) Integration of VAS into other child survival services2)Delivery of VAS through ECD centers3) Consistent stocks availability. Conclusions: The KAP results will be used to identify key barriers for the target population and their potential for influencing VAS uptake and coverage. The KAP results will be used to inform the VAS strategy and also the development of a BCC strategy that responds to the socio-cultural beliefs and roles of the targeted population thereby creating an enabling environment for VAS uptake and coverage among children 6-59 months.

A Health Systems Strengthening Approach to Improve Nutrition of Pregnant Women and Newborns in Ethiopia, Kenya and Senegal.

Objectives: Coverage of nutrition interventions for pregnant women is poor, but potential for improvement is limited where health systems are weak. The Community-based Maternal and Newborn Health and Nutrition (CBMNH) program aims to increase utilization and quality of health and nutrition services for pregnant women and newborns by strengthening health systems. With the program's focus on increasing demand for prenatal and birth services, we implemented Knowledge, Attitudes and Practices (KAP) surveys to identify key individuals/factors influencing demand and use. Methods: As part of the baseline surveys, we randomly selected women with children 0-11 months. Using mixed methods, we assessed current KAP surrounding nutrition in antenatal care. Results: We identified gaps in the provision and utilization of services, particularly antenatal care (ANC), iron-folic acid supplements (IFA), among others. The proportion of women who had attended 4 ANC visits during pregnancy was 4.8% in Ethiopia, 43% in Kenya, and 50% in Senegal; about a fifth in Ethiopia and Kenya and 60.7% in Senegal attended ANC in the first trimester. Only 3.4% of women in Ethiopia, 36.7% in Kenya and 93.6% in Senegal had taken ≥90 IFA tablets during pregnancy. Qualitative data found that knowledge and attitudes of women regarding care seeking for ANC and benefits of IFA during pregnancy period was low. Conclusions: In all 3 countries, but particularly Ethiopia, health and nutrition services for pregnant women and newborns are under-provided and under-utilized. This evaluation revealed both demand and supply side barriers that are now being addressed as part of the on-going program.

Adequacy of Diets for Kenyan Women and Children under Five Years Using 24 hr Recall Data.

Objectives: The Ministry of Health in conjunction with several stakeholders conducted a nationally representative 24-hour dietary recall component of the Kenya National Micronutrient Survey (KNMS) to characterize the average intake and dietary pattern of women of reproductive age and children 7-59 months. Methods: 296 clusters were randomly selected for the KNMS survey. Within each cluster, we randomly selected 2 households that met the inclusion criteria of having either a women of reproductive age, a child under five years of age or both, who are usual residents of the household. An interactive 24-hr recall multiple pass approach was used to collect one day dietary intake data on all households and repeated on a sub-set of 20% households on non-consecutive days. Using PC-SIDE software (version 1.0, June 2013) for data analysis, we determined the usual intake of each nutrient. We report here the dietary data of 399 women (15-49 years) 55 children (7-12 months) and 214 children (13-59 months). Results: Average energy, iron, vitamin A and zinc intakes in women were 1944 kcal, 12.6 mg, 778 μg and 8.1 mg respectively while these nutrient intakes in children 7-12 months and 13-59 months were 473 Kcal, 2.5 mg, 126 μg, 2.1mg and 1036 kcal, 6.3 mg, 366 μg, 4.3 mg respectively. Prevalence of inadequacy among women, children 7-12 months and children 13-59 months using EAR cutoffs and adjusting for intra individual variability was 17%, 94% and 9% for iron; 43%, 99% and 41% for vitamin A; 49%, 62% and 23% for zinc respectively. Conclusions: These data point towards a number of programmatic interventions to improve the adequacy of diets for Kenyan women and children.

Myths and Perceptions on Diarrhea and Use of ORS/Zinc among Mothers and Caregivers of under Five Years Old Children among a Nomadic Community in Kenya.

Objectives: Diarrheal disease is the second leading cause of death in children aged below five years in Kenya. Community and individual myths, perceptions and attitudes toward diarrhea does influence caregiver decisions and practices in the diarrhea prevention and management. This paper explores these myths and perceptions among mothers and caregivers the under five year old children in a nomadic Maasai community in Kenya. Methods: Qualitative data was collected from 42 Key informants including chiefs, laibons, village elders, religious leaders and 12 focus group discussions, comprising of 86 caregivers of children under 5 years. Transcriptions were entered into MAXQDA version 11 qualitative analysis programme to retrieve segments under each thematic area including myths and perceptions related to causation, prevention and treatment of diarrhea among under five years. Results: The reported myths and perceptions related to causation of diarrhea include: when child is teething, breast feeding while mother is pregnant, and having too much sex while child is still breast feeding. The use of special herbs and deworming tablets were reported to protect children from diarrhea. In addition, it was widely believed that herbs mixed with either blood or alcohol work better than modern drugs used in diarrhea management. The laibons and traditional birth attendants were the main sources of the herbal medicines in the community. Some respondents showed a strong lack of faith in the use of ORS for diarrhea management. Conclusions: There are serious myths and perceptions that can compromise prevention and management of diarrhoea in this community which need to be addressed.

Understanding Barriers and Facilitating Factors for Uptake of Zinc and ORS in Kenya; a case of Kitui County.

Objectives: Diarrhea is a key public health challenge in Kenya with a prevalence of 17% and contributes to 21% of underfive child deaths. Whereas effective treatment is available, its uptake is very low with 39% and less than 1% receiving ORS and Zinc respectively. Current diarrhea prevention and treatment approaches are generalized thus missing out on regional variability, challenges and uniqueness. The objective of this paper is to explore factors that facilitate or hinder diarrhea management in one region in Kenya. Methods: Cross sectional study employing both quantitative and qualitative approaches involving 764 household interviews, 15 key informant interviews and 10 focus group discussions targeting caregivers of children below five years, key influencers, and community health workers in the two districts and 8 health facilities. Results: Key facilitating factors: Availability of diarrhea policy, zinc/ORS at public health facilities for free, good knowledge by caregivers on ORS for diarrhea treatment (85%), need for child with diarrhea to drink more fluids (90%) and that diarrhea is life threatening (93%). Key barriers include poor health seeking behavior for diarrhea, limited access to diarrhea messages, misconception that only children with 5 or more loose stools need treatment, cultural practices like gum massage during teething which lead to contamination hence diarrhea, inappropriate treatment practices (use of herbs and body piercing), low uptake of zinc and ORS, non-participation by men and challenges with water and sanitation. Conclusions: Kitui experiences unique challenges related to knowledge, cultural practices which hinder appropriate diarrhea management and must be overcome through region-specific program adaptations.

Bacterial populations in complementary foods and drinking-water in households with children aged 10-15 months in Zanzibar, Tanzania.

Bacteria were quantified in samples of drinking-water and in two porridges prepared for infant-feeding [fortified instant soy-rice porridge (SRP) and cooked porridge (Lishe bora, LB)] in 54 households. Bacterial numbers were measured again after the porridges had been held at room temperature for four hours (T4). Findings were benchmarked against bacterial numbers in traditional complementary foods sampled from 120 households. Total bacteria, coliform, and Enterobacteriaceae counts were enumerated using Petrifilm. The mean log bacterial numbers were the lowest for LB at TO (2.24 +/- 0.84 cfu/g aerobic counts) and the highest for SRP at T4 (4.63 +/- 0.56 cfu/g aerobic counts). The total bacteria, coliform and Enterobacteriaceae counts were higher at T4 than at T0 for LB (p < or = 0.001); however, only the coliform and Enterobacteriaceae counts were higher at T4 than at T0 for SRP (p<0.001). Drinking-water, SRP0, traditional foods, and SRP4 all had the mean aerobic counts higher than the acceptable cut-off but the total bacterial count in SRP0 was not significantly (p=0.543) different from drinking-water. However, coliform and Enterobacteriaceae counts in SRPO were higher than in drinking-water (p<0.001). Also, although the aerobic counts of SRP4 were not significantly (p>0.999) different from traditional foods, the coliform and Enterobacteriaceae counts were significantly higher in SRP4 than in traditional foods (p<0.001). It is, therefore, recommended that food safety concerns be addressed when improving complementary foods.