Assessment of the iron-folic acid supplement (IFAS) supply chain to improve distribution at community level in Dakar and Fatick regions, Senegal.

Objectives: Ensuring adequate and timely availability of iron folic acid supplements at delivery points is a challenge for success of IFAS interventions. In Dakar and Fatick regions, the supply chain of IFAS was assessed to identify constraints and bottlenecks and to recommend solutions. Methods: Structured interviews with 84 health workers from 36 health facilities were carried out to determine the supply chain constraints in Dakar and Fatick regions. Transcriptions were analyzed using content analysis. Results: Health workers reported IFA stock-outs in 50% of included health districts. Although the needed quantities were reportedly available at regional drugs stores, the limited frequency of overall health commodity orders, applied by health districts to reduce costs, resulted in delayed IFA procurement when stocks were low. These delays were the primary cause of stock-outs reported by health workers. Conclusions: Adequate and consistent supply of IFA supplements could be ensured through allowing larger orders of IFA during regular commodity orders, reducing or subsidizing the cost of IFAS or shipment costs.

Role of Effective Enforcement of Salt Iodization Legislation in Improving the Supply and Distribution of Adequately Iodized Salt.

Objectives: The production and distribution of non iodized salt is banned by the legislation in Senegal and the Ministry of Trade (MoT) supported by the police forces and the Department of Hygiene of the Ministry of Health is mandated to enforce this legislation. However, household use of iodized salt remains <70%. We undertook this survey to compare apparent governmental commitment to enforcing salt iodization legislation and production of iodized salt. Methods: Technical and logistical support were provided to regional offices of MoT covering salt producing regions and Five year data trends were collected from regional MoT offices in two salt producing regions. Analyses included: number and frequency of enforcement activities in productions sites, fines paid by defaulters and total production of adequately iodized salt in comparison to changes in leadership at these offices. Results: Between 2008 and 2012, the level of enforcement/ field controls decreased sharply in region 1 (from 138 to 35) and increased in region2 (from 30 to 140). Fines paid by defaulters between 2008 and 2012 were 600,000FCFA in region1 against 4,075,000FCFA in region2. In region 1, the production and distribution of adequately iodized salt declined from 20,000 to 12,000 MT per year in 2008 and2012, while in region2it steady increased from 6,000 to 25,000 MT per year in2008 and 2012, respectively. Conclusions: Whatever the resources used in training small salt producers, and communicating for their behavior change, Universal Salt Iodization will be difficult to achieve without a commitment of the authorities responsible for enforcing regulations.

Targeted Involvement of Women in Iodized Salt Related Microenterprises Contributes to the Empowerment and Improved Social-economic Status of Participating Women in Senegal.

Objectives: Senegal is the largest producer and trader of salt in West Africa with ~200,000 MT of its 500,000 MT annual yield produced by small salt farmers, mostly comprised of women who face legal, economic and socio-cultural constraints. Micronutrient Initiative is working with the Senegal government's inter-Ministerial Commission to Fight Malnutrition to reinforce the salt iodization program and to achieve universal salt iodization. Program approaches include supporting salt farmers to set-up salt iodization related micro-enterprises to reinforce the capacity of salt farmers to sustainably handle salt iodization. We completed a situation assessment, plan development and implementation whose objective was to systematically review business practices and apply findings through training female salt farmers to sustainably and significantly contribute to increasing the supply of adequately iodized salt through implementation of well articulated and implemented business plans. Methods: Market analyses were conducted in one site among 60 respondents. The resulting business plan formulation and management was disseminated to female salt farmers and community groups, including supportive mentoring and monitoring throughout implementation of business plans for related micro-enterprises. Results: We found that active involvement of female salt farmers in decision making process within salt production area, household and communities increased female salt farmers' incomes, household asset ownership, self confidence and contributions in essential household expenditures such as education and health care, and iodized salt production. Conclusions: Supporting female salt farmers to set-up salt iodization related micro-enterprises contributed to the empowerment of rural women, improvement of quality of family life and the supply of adequately iodized salt.

Effect of Inflammation and Other Potential Confounders on Plasma Zinc Concentration in 12- 59-Months-Old Senegalese Boys and Girls: A National Study.

Objectives: Plasma zinc concentration (PZ) is influenced by many factors leading to over-estimate the real prevalence of zinc deficiency (ZD). This study aimed to assess changes in PZ in 12-59- months-old Senegalese boys and girls after adjusting for the overall known confounding factors. Methods: During a national representative cross sectional survey in Senegal, blood was collected in 583 girls and 568 boys according to procedures recommended by IZiNCG. PZ, CRP and AGP were determined. Published correction factors (Thurnham et al., 2005) were used to adjust PZ to infections. Measured and adjusted values were compared. General Linear Model (GLM) was used to compare PZ changes in girls and boys after adjustment for CRP, AGP, time of blood collection, recent meal and elapsed time from blood draw to centrifugation. Results: Mean PZ were 63.5±14.5 and 63.9±14.3 μg/dL for boys and girls, respectively. PZ was not correlated with CRP, time from last meal to blood draw, but was negatively related to AGP (p <0.0001), time of the sample collection (p <0.001), and was positively related to time between blood draw and centrifugation (P<0.05). After adjusting for infections, PZ increased significantly in boys (66.2±16 μg/dL), and girls (66.5±16 μg/dL), leading to a decreased prevalence of ZD in both sexes without any significant difference. Using GLM, PZ for boys (65.5±3.3) and girls (66.8±3.2) were significantly greater than the measured values (P<0.0001) but were comparable between gender. Conclusions: Blood collection procedures and infection status should be considered during measurement of plasma zinc concentration when assessing zinc status in population.

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.

Household Utilization of Iodized Bouillon Cubes Affects Iodine Intake in Senegal.

Objectives: To prevent iodine deficiency, Senegal mandated the iodization of all salt produced, imported or distributed. There has been a dramatic increase in use of bouillon, which is claimed to contain iodine in Senegal. We undertook this survey to better understand the extend of bouillon cube use in the context of salt iodization. Methods: A nationwide cross-sectional stratified cluster sample household-level survey was conducted to measure urinary iodine concentration in women 15-45 years and children 6-12 years, iodized salt and bouillon consumption, and iodine concentration in salt available in households. In all, 3,768 households were surveyed including 7,980 women and 6,309 children. Results: Only 56% of households surveyed had iodized salt. Average iodine concentration in salt was 22ppm. Average per capita daily household consumption was 4.79 g salt (5.01g urban, 4.60g rural; P<0.001) and 3.98 g bouillon cube (4.29g urban, 3.74g rural; P< 0.05). Median urinary iodine concentration in children was 104.42μg/l (141.25μg/l urban, 82.63μg/l rural) and 92.20μg/l for women (114.73μg/l urban, 72.95μg/l rural). Conclusions: This study shows that household consumption of bouillon cubes is high in Senegal; mean UI seems to be adequate in urban setting but insufficient in rural areas, suggesting a lower intake of iodine from iodized salt/bouillon cube. Adequate iodine concentration in bouillon cube could be an avenue to tackle IDD in Senegal; however, further research is warranted on current content and bioavailability of iodine in bouillon cube as well as feasibility of iodization of bouillon cube as complement to iodized salt in Senegal to guide decisions.

Designing Rigorous Program Evaluations to Assess the Impact on Child Growth of Integrated IYCN Programs in Burkina Faso and Ethiopia.

Objectives: The Micronutrient Initiative and academic partners have designed two program impact evaluations of Infant and Young Child Nutrition (IYCN) interventions in Ethiopia and Burkina Faso. The programs include enhanced behavioral change interventions on IYCN, improved quality of local complementary feeding, provision of Multiple Micronutrient Powders (MNPs) to children 6 to 23 months, and ensuring an integrated preventive and community-based management of moderate acute malnutrition. The objective is to critically review key elements for consideration in the design of future IYCN program evaluations. Methods: Evaluation designs were based on 1) selection of primary and secondary outcome indicators based on the Program Impact Pathways (PIP), 2) Considerations for assignment of intervention and comparison groups; 3) Considerations on designs in the context of integrated programs; 4) Ability to monitor adverse events within a program. Results: Following PIP, both impact and process indicators were identified. In Ethiopia, a matched-control cluster design and in Burkina Faso a cluster randomized matched-control design was used with repeated cross-sectional surveys. Sample size calculations took into account the selection of age-appropriate cohorts for the different impact indicators, and a population based sampling scheme. Following recent discussions around the safety of iron-containing supplements in young children without iron deficiency, the evaluations also included practical methods to assess potential adverse events in program settings. Conclusions: The complexity of measuring impact on child nutrition in an integrated programmatic context is often underestimated, leading to evaluations with inconclusive results or impacts that are difficult to attribute to program. Careful design could help avoid such pitfalls.

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.

Knowledge, Attitudes and Practices of Prenatal Ironfolic Acid Supplementation among Pregnant Women and Health Staff in Rural Niger.

Objectives: We aimed to assess knowledge, attitudes and practices (KAP) of iron and folic acid (IFA) supplementation among pregnant women and health staff in rural Niger. Methods: KAP were assessed in 4 randomly selected villages in the Zinder region of Niger as part of a formative research study conducted to inform the design of a program to improve antenatal care services. Data collection included home interviews of pregnant women (n=72) and a focus group of 8-10 pregnant women in each village. In 5 randomly selected health centers, we observed 33 antenatal care (ANC) consultations, and interviewed pregnant women and health staff following these observations. Results: Among 72 pregnant women interviewed in their homes, 96% had knowledge of IFA supplements and 97% of these stated at least one health benefit of IFA. However, among those who had already attended at least 1 ANC visit (n=52), only 65 % reported having taken IFA supplements on the day prior the interview. Reported side effects were rare. Among 5 health centers visited, 3 had IFA supplement in stock. Health staff did not provide IFA supplements to the pregnant women during 18 of 33 observed ANC consultations of which only 7 cases could be explained by the lack of IFA supplements in stock. Conclusions: IFA supplements are well known by pregnant women. The supply chain of the health centers should be ensured and health staff retrained for an effective IFA supplementation among pregnant women.