Factors that Influence Effective Diarrhea Treatment Programs in Haitian Children.

Objectives: Childhood diarrhea is a major cause of morbidity and mortality in Haiti; a situation exacerbated by the cholera outbreak in 2010. Oral rehydration salts (ORS), when combined with zinc (ORS-zinc), is effective in preventing death and reduces severity of illness—yet their combined use remains low. An intervention to expand delivery of ORS-zinc is underway. To guide the scale up of the intervention, we conducted a qualitative study to identify caregivers’, influencers’ and healthcare providers’ knowledge, attitudes and practices related to diarrhea and its treatment. Methods: Study conducted in two departments in Haiti: North West, where ORS-zinc distribution has already begun, and North, where ORS-zinc will be implemented in 2014. Using rapid ethnographic methods, we conducted 1) semi-structured interviews with both health workers of traditional and modern medicine (n=16), 2) facility observations where child diarrhea is treated (n=4), 3) six focus group discussions (FGD) with caregivers (n= 62) and influencers (n=39). Results: All modern and most traditional health workers recommended ORS in their practice, however, only those already receiving the intervention prescribed zinc while a few modern practitioners in the non-intervention group had heard of it. Facility observations demonstrated a gap in how the use of ORS-zinc is explained to patients. FGD showed that care seeking behaviour is strongly influenced by perceptions of the type of diarrhea and availability of healthcare provider. Conclusions: Knowledge and attitudes affect the prescription and use of ORS-zinc. These findings will affect the design of targeted behavior change interventions for scaling up ORS-zinc in northern Haiti.

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.

Perceptions of Mothers in Nepal on the Roles of Female Community Health Volunteers in Providing Iron Folic Acid and Referral to Antenatal Care.

Objectives: Nepal led a 9 year national scale-up of Iron Intensification Program to address maternal anemia, utilizing an integrated delivery-platform that extended distribution of Iron Folic Acid (IFA) through peer-selected female community health volunteers (FCHVs). The study's purpose, as a segment of a larger-study was to understand the perceptions and acceptability of FCHVs to mothers in Nepal and how this influenced their acceptance and access to health services, antenatal-care (ANC), and access to IFA during pregnancy. Methods: Twelve districts were purposively selected to represent Nepal's diverse ecological-zones (Mountain, Hills and Terai) and exposure to the intervention. One focus group discussion (FGD) with 6-10 mothers was conducted in each district (n=96). Interviews were conducted in Nepali, transcribed verbatim, then translated into English. Coding done in Atlas. ti identified mothers' perspectives of FCHVs, descriptive context, barriers and enablers for accessing ANC and IFA. Results: Mothers suggested that FCHVs are highly valued for their roles in providing IFA during pregnancy, referrals to ANC, and for advice. Remote areas with least access to healthcare expressed greatest appreciation for FCHVs' role in providing treatment and counseling for all conditions, but especially maternal-child health. However, in some peri-urban areas, FCHVs were perceived as having low-literacy and there was a preference for facility-based service and health professionals. Conclusions: Mothers in Nepal perceive FCHVs as integral for providing access and counseling for IFA and referral to ANC; however, with an emerging preference for higher trained professionals in some regions, minimum education standards and trainings for FCHVs may help maintain the relevance of program going forward.

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.

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.

Tools for Strengthening Implementation of Largescale Nutrition Programs: An Evaluation of the Program Assessment Guide (PAG).

Objectives: The Program Assessment Guide (PAG) is a 44 page 9 module workshop facilitation guide developed as "a tool to strengthen the design and implementation of large-scale nutrition programs." It has been used to guide workshops for this purpose in Kyrgyzstan, Bolivia, Tanzania, Nepal and Haiti, among others. There is growing interest in the PAG but experience with its use has not been previously evaluated. We report on an external evaluation to learn from these experiences, as a basis for understanding its performance, factors that influence its performance and potential refinements. Methods: The evaluation was guided by the PAG's underlying theory of change and was based on a review of workshop reports, outputs and evaluations, field visits, assessment of outcomes from selected workshops, programs and locations and an overall synthesis of experience to date. Results: The PAG has been well-accepted by implementers in the workshops, identified bottlenecks not previously recognized and generated concrete action plans for program strengthening. A major challenge has been to ensure implementation of the action plans after the workshop. Conclusions: The PAG shows promise as a tool for strengthening implementation of large-scale nutrition programs but greater efforts and clear expectations of required human and financial resources are needed to secure commitments in order to ensure implementation of the action plan.

Nepal's National Scale-up of The Iron Intensification Program Improved Iron Folic Acid Supplementation Coverage in Pregnancy and Showed Potential for Reducing Anemia.

Objectives: A national scale-up of an integrated facility and community-based delivery of iron and folic acid (IFA) supplements in Nepal spanned almost ten years through the Iron Intensification Program (IIP), over which time national coverage of IFA in pregnant women increased from 23% to 80%. The objective of this research was to estimate the potential effect of duration of district-level exposure to IIP on IFA coverage, and on anemia in mothers in Nepal. Methods: With data of the 2006 and 2011 Demographic Health Surveys (DHS), we used multiple regression modelling and controlled for IIP district exposure, age, pregnancy status, wealth, religion, parity in the last 5 years, weight, education, and ecological region (Terai, Hills & Mountain regions). Results: In 2006, women who had given birth during the intervention implementation period (n=5,110) exposed to the intervention for 1-3 years had a 7% reduced the odds of having anemia (OR: 0.93; 95CI 0.91, 0.95). In 2011, among women who had given birth in the previous 5 years in the Terai (n=864), intervention exposure for 3-5 years suggested a 45% reduction in the odds of having anemia (OR: 0.55; 95CI 0.31, 0.99). Intervention exposure also suggested benefits in likelihoods of mothers receiving IFA (6-11%), and de-worming (12-28%). Conclusions: These results suggest that the IIP had a role in increasing IFA and de-worming coverage and may have protected against anemia. Nepal's example suggests that large scale national programs with long term commitment can successfully impact IFA coverage and potentially impact anemia.

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.

Designing Co-packaging for Zinc & Oral Rehydration Salts (ORS) to Influence Caregiver and Provider Behaviours for Treating Childhood Diarrhea in Guatemala.

Objectives: The Guatemalan Ministry of Public Health and Social Assistance has scaled-up co-adjunctive zinc as a national policy, yet utilization of this newly-available life-saving commodity remains a concern. The purpose of this study was to design effective co-packaging for zinc and ORS, informed by social-marketing, to influence both caregivers' and providers' behaviours in a demonstration project at the health post level in the department of San Marcos, Guatemala. Methods: Local concepts, perceptions and experiences relating to diarrhea and care seeking were explored in 8 focus group discussions (n=82) and 24 key informant interviews with caregivers. Prototype co-packaging and messages were developed and reviewed with 14 mothers and 10 providers in 4 municipalities to pretest the candidate materials. Results: Formative research identified two major challenges to correctly using zinc and ORS to treat childhood diarrhea: 1) the concept of adherence to zinc once symptoms disappeared; and 2) dissolving a tablet in a spoon was a new skill. A campaign of Zinc-10 was created and tested to promote the concept of 10 days of adherence to zinc; additional visual aids focussed on showing dissolving of zinc on a spoon. These candidate concepts and messages were highly accepted by caregivers and providers, yet revisions were needed for images and materials used. Conclusions: Using a social-marketing approach, packaging and promotional messages were developed that were more acceptable to caregivers and providers than the original prototypes. These materials will be tested in a randomized community trial to see the effectiveness of the co-packaging on caregiver adherence and provider behaviour.