High Levels of Iron Deficiency Anaemia (IDA) and Stunting by 6-11 Months of Age in Northern Zambia: Evidence of the Need for Early-Life Intervention Scale-Up.

Objectives: Anaemia and stunting are widespread in Zambia with developmental implications from the individual to the national level. To address these conditions, an integrated Home Fortification with Micronutrient Powders (MNP) and Infant and Young Child Feeding (IYCF) programme has been introduced in Mbala district, Northern Province, Zambia. Here we present key findings from a baseline survey conducted to inform the project and investigate relationships among morbidity, biochemical and anthropometrics in children 6-11 months. Methods: A convenience sample of 631 child-caregiver pairs was recruited from health centres and outposts in Mbala District. We collected demographic, health, biochemical and anthropometric data. Children with severe anaemia or severe acute malnutrition were excluded and referred for treatment. Results: Stunting was 30% and 57% of the children were anaemic (haemoglobin <110 g/L), 42% were iron deficient (serum ferritin <30 μg/L) and 22% had IDA. Children with fever in the previous two weeks had higher rates of anaemia (65% versus 49%, p <0.001) and lower mean haemoglobin (104 g/L versus 107 g/L; p =0.005). 5% were Vitamin A deficient based on retinol binding protein <0.7 μmol/L. Furthermore, 74% of children had signs of inflammation (C-reactive protein >5mg/L and/or alpha-1-glycoprotein >1 g/L). Conclusions: The high rates of anaemia, stunting, and inflammation all indicate a high burden of disease and/or malnutrition among these young children. Children with recent fever were more likely to be anaemic which might have implications for physical and cognitive development. Interventions must target early life to prevent irreversible consequences.

Building Operational Capacity for Successful Implementation of HOME Fortification: Academic Institutional Support for MNP Implementation.

Objectives: Many countries are expressing interest in implementing Home Fortification programmes using Micronutrient Powders (MNP) because of their proven effectiveness and low cost. A gap exists, however, between evidence based guidelines for practical implementation. Therefore our objective was to make technical support globally accessible and build operational capacity for successful implementation of MNP. Methods: As an academic institution and project group we have identified gaps, partners, research needs, and evaluated and streamlined existing guidelines for the implementation of MNP. We developed and field-tested tools for formative research to guide the design of MNP interventions integrated into IYCF and other programmes in Rwanda, Zambia, Cameroon, Laos, Sierra Leone, and Mali. Communication and training strategies and materials were developed, utilized, and continuously improved by our teams in multiple countries followed by comprehensive reporting and recommendations. Results: Broad contextual experience was built and made available to governments in implementing countries, organizational partners, and stakeholders through our team support. We facilitated knowledge exchange through national and global conference presentations and workshops. Research methods, communication and training materials, and monitoring & evaluation tools are constantly improved and adjusted and country specific implementation strategies for MNP are based on our findings. Conclusions: Creating an enabling environment for micronutrient interventions requires collaborative efforts from multiple stakeholders. Our university's multi-disciplinary team has enabled countries to move forward cost-effectively with Home Fortification programmes. Lessons learned are being integrated into practice-oriented technical guidelines and shared with other countries to operationalize and scale-up MNP programmes efficiently and effectively.

Formative Research: A Necessary Step for the Implementation of a Home Fortification Program in Cameroon.

Objectives: To understand caregivers' knowledge on anemia, barriers to optimal infant and young child feeding (IYCF) practices, and the acceptability and appropriate use of micronutrient powders (MNP) in households of children 6-23 months, in order to inform an implementation of MNP in Cameroon. Methods: The study was conducted in health districts of the North and South regions, areas with high prevalence of anaemia among young children. There were two steps: 1) situation analysis including focus group discussions and key informant interviews, 2) 30 day study to assess MNP acceptability and utilization. Caregivers (N=101) were interviewed at baseline, day 10, and day 30. Data were both qualitative and quantitative. Results: The situation analysis demonstrated that knowledge on anaemia and IYCF practices were not appropriate. Potential MNP food vehicles were identified. The 30 day study showed high rates of acceptability (100%). Adherence was challenging for the group on a rigid schedule (30 MNP sachets for 30 days) mainly due to child illness related interruption, which is why a flexible schedule (15 MNP sachets for 30 days) was found more feasible. Opposition to and rumours regarding MNP were observed in some cases. The main motivation factors for giving MNP cited by caregivers were: make child healthy, improve immune system and stimulate appetite. Conclusions: The formative research demonstrated the importance of a strong community sensitisation. A comprehensive communication strategy and community-based capacity building are essential to maximise acceptability, appropriate MNP utilization, adherence, and prevent rumour generation. Further, implementing MNP provides a great opportunity to strengthen IYCF.

Creating an Enabling Environment for Scaling-up MNP in Lao PDR: A Private-public Partnership.

Objectives: The Scaling-Up-Nutrition movement recognizes the importance of multi-stakeholder partnerships to deliver high-impact nutrition interventions. A private-public partnership in Lao PDR - supported by MMG Limited and involving the Ministry of Health (MoH), UNICEF, Population Services International (PSI) and University of British Columbia (UBC) - offers an opportunity to evaluate such a partnership and to develop an operational delivery model for Micronutrient Powders (MNP). Develop an effective, scalable and sustainable operational delivery model for MNP through a multistakeholder approach involving public and private sector partners. Methods: UBC, PSI, UNICEF and the MoH collaborated through telecommunications and in person, and conducted formative research in rural and urban areas to inform communication materials, food vehicles, packaging, and distribution channels for MNP. Input from all partners was provided for interview guides and other evaluation tools. Results: Individually the partners prepared reports on different research components and collectively provided input into findings. Together, a comprehensive communication strategy has been drafted that promotes MNP along with improved complementary feeding. The MoH and UNICEF, with technical input from UBC, is developing a free distribution model using health workers and volunteers to reach children aged 6-23 months. PSI is creating a social marketing model to complement public sector distribution and expand access to MNP for children aged 6-59 months. Conclusions: This private-public partnership has provided an opportunity to create an enabling environment for scaling-up MNP in Lao PDR. Processes to date highlight the value of different partner perspectives in the design and implementation of formative research, communication materials and programme activities.

Formative Research to Guide Successful Scale-up of Micronutrient Powder Programmes: Lessons Learned from a 4 Country Comparison.

Objectives: Micronutrient Powders (MNP) have been shown to reduce anaemia among young children and are reportedly easy-to-use for home fortification of complementary foods. Many countries are considering implementing MNP. However, to facilitate optimal implementation, formative research must be conducted to address country-specific household barriers such as cultural practices, knowledge and beliefs. 1. Compare findings from 4 countries where formative research was conducted to inform MNP protocols and communication materials. 2. Evaluate tools and share lessons learned to inform country-specific MNP programmes. Methods: In Rwanda, Zambia, Cameroon and Lao PDR, focus groups were conducted with caregivers; and individual caregivers, health workers and community leaders were interviewed on IYCF knowledge, attitudes and practices, anaemia and beliefs. Home-based MNP trials then followed children 6-23 months over 14-30 days with caregivers interviewed to evaluate acceptability and adherence at baseline, midpoint and endline. Formative research tools, MNP and IYCF communication and training materials were tested. Results: Practices varied considerably by country and important barriers identified, particularly regarding complementary feeding. Age at introduction, suitable food vehicle availability and consistency were frequently not concordant with recommendations. For example, in Rwanda porridge was too liquid and in Laos sticky rice too dense for delivering MNP. Whereas, home fortification was universally accepted and tools developed were highly usable. Conclusions: Formative research was indispensible as knowledge, attitudes and practices varied widely between countries with implications for usage, training and communication materials. Tailoring global guidelines using our research tools will help ensure optimal development of country-specific protocols and ultimate effectiveness of MNP home fortification scale-up.