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This paper uses programme theory to assess, in the context of an effectiveness evaluation, the feasibility and acceptability of distributing micronutrient Sprinkles through a food-assisted maternal and child health and nutrition programme in rural Haiti. We laid out the steps related to programme delivery and household utilization of Sprinkles and...
Citations
... A number of studies and programs that distributed LNS and micronutrient powders have compared methods to assess adherence, often combined with studying acceptance in formative research [43][44][45]. In Malawi, comparison between maternal self-report and lab analysis of fortified oil added to porridge found consistent results between methods, although the authors note the bias of mothers reporting the amount that they were taught to use rather than actual usage [20]. ...
Background:
Levels of adherence to recommended protocols in an intervention trial can affect outcomes and confound the results. To broaden the evidence about the selection and utility of adherence measures in varying contexts, we describe the level of adherence to the Mycotoxin Mitigation Trial (MMT) randomized intervention using caregiver-reported survey questions and compare inferences of adherence between multi-module surveys and interactive 24 h dietary recalls based on our program theory.
Methods:
The MMT was a two-arm cluster-randomized trial conducted in 52 health facilities (clusters) in central Tanzania. Surveys were conducted with all trial participants at three time points and dietary recalls were conducted in a cohort at 12 mo.
Results:
The 12 mo survey was conducted with 2112 caregivers and the 18 mo survey was conducted with 2527 caregivers. A cohort of participants (n = 282, 20 clusters) was selected for dietary recalls, balanced by arm. Reported feeding of blended porridge flours, whether MMT-provided or own-sourced, was high at 12 and 18 mo, between 73 and 95%, with only slight differences between the surveys and recalls. Inferences were similar for continuation of breastfeeding, feeding frequency, and dietary diversity. Only the amount of porridge fed the previous day differed statistically by method, with higher amounts reported in the recalls compared to the survey.
Conclusions:
Detailed analysis of reported behaviors, based on the MMT program theory, supports high adherence to the recommended trial behaviors. Survey data and 24 h dietary recalls were convergent for almost all indicators, strengthening the trial's conclusions and allowing for either method to be selected for similar research.
... Twenty-four studies acknowledged barriers in knowledge and beliefs about the intervention of caregivers, among which ten studies positively reported facilitators in this construct. Specifically, caregivers' perception of children's nutritional improvement highly improved the intervention adherence [11,24,28,32,36,41,44,46,54,56]. However, the lack of awareness and inadequate knowledge of the product in caregivers prevailed [21,30,31,37,43,45,46]. ...
... We explored the interrelationship between several constructs that impact MNP program implementation, as shown in Figure 2. For instance, the training for health providers (inner setting) has facilitated the process of SBCC among users (process), which improved caregivers' knowledge and belief towards MNP (individual characteristics) [19,20,56]. Additionally, community health workers (inner setting) played core roles in the processes of delivering the information, reflecting, and monitoring (process) [32,61]. ...
Background:
As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions.
Method:
Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process.
Results:
A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation.
Conclusion:
Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.
... The most noted perceived infant benefits (N = 25) were increased appetite (N = 17), improved overall health and diet (N = 16), and prevention of disease, illness, or malnutrition (N = 11). When noting improved overall diet and health, specifics of perceived increased blood health and digestion were highlighted (17,18,19,20,21). In the context of prevention of disease, illness, or malnutrition, the interventions were compared to a medicine in a beneficial sense (22,23,24,25). ...
... Additionally, caregivers noted perceptions of improved https://doi.org/10.1017/S1368980023001246 Published online by Cambridge University Press Accepted manuscript growth (height, weight) and improved strength (N = 10), as well as improved energy (N = 10) and neurodevelopmental improvements (N = 7) (17,18,19,20,21,24,25,26,27,28,29,30,31,32). ...
... Ease in packing and storage, accessibility, and affordability were keys factors in caregiver use of intervention (N = 10) (20,24,25,26,29,31,35,38,39,40). Education around purpose and administration of the intervention were key to ensuring acceptability and continuation of use as caregivers wanted to follow nutrition guidance when it was given (N = 7) (18,19,22,25,28,33,41). It was noted that giving the intervention to their infant gave caregivers a feeling of empowerment (33). ...
Objective:
Efficacy studies show early nutrition interventions improving infant nutrition status, but understanding caregiver acceptability is required for implementation of such interventions. This systematic review examines caregivers' perceptions of nutrition interventions in young children.
Design:
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL and PsychINFO from date of online journal inception through December 2020. Interventions included oral (powder/liquid/tablet) and/or intravenous supplementation, food fortification, and nutrition counselling. Inclusion criteria included primary research, data presented on caregiver perception, and studies published in English. Quality assessment was performed using the Critical Appraisal Skills Programme tool. Studies underwent narrative synthesis using inductive thematic analysis.
Setting:
No restriction.
Participants:
Caregivers of children under 24 months of age.
Results:
Of 11,798 records identified, 37 publications were included. Interventions included oral supplementation, food fortification, and nutrition counselling. Caregivers included mothers (83%), fathers, grandparents, and aunts. Perceptions were gathered through individual interviews, focus group discussions, questionnaires, surveys, and ratings. 89% of studies noted high acceptability (N=33 most notably increased appetite (N=17). 57% of studies (N=21) cited low acceptability, commonly from side effects (N=13) such as gastrointestinal issues, appetite loss and stained teeth.
Conclusions:
Positive perceptions and enthusiasm for interventions were frequently reported. Key to implementation was the increased appetite noted by caregivers. A substantial proportion of studies reported negative perceptions, mainly due to side effects. In future interventions mitigation and education around common side effects is crucial for acceptability. Understanding both positive and negative caregiver perceptions is important for informing future nutrition interventions and strengthening sustainability and implementation.
... Consistent with our results, caregivers reporting these types of side effects was a risk factor for the high adherence to MNPs; conversely, caregivers not reporting side effects, thus perceiving these side effects as positive, would increase adherence (Jefferds et al., 2015). Previous studies demonstrated that if caregivers were informed in detail about side effects before administering MNPs to their children, the caregivers better understand that these side effects are normal and may consider them positive signs that MNPs have observable effects on their child (Loechl et al., 2009 ...
Adherence to home fortification of foods with multiple micronutrient powders (MNPs) is an essential indicator of effective implementation of MNP programmes. A meta-analysis was conducted to evaluate the high adherence rate (HAR) to MNPs and further investigate the factors that influence HAR. We searched PubMed, Web of Science, Embase, CAB Abstracts, MEDLINE (OVID), Cochrane Library, China National Knowledge Infrastructure, Wanfang and VP, from the date of database inception to 9 November 2020. We included peer-reviewed observational studies that investigated adherence to MNPs. Data on the HAR to MNPs and influencing factors on HAR were extracted and then pooled together. A total of 10 studies were included. The pooled HAR to MNPs was 63.28% (51.12%–74.64%). Among HARs, rates were higher in middle-income countries (65.21%) than low-income countries (55.23%). Parental age over 30 years (maternal age OR = 1.25, 95% CI: 1.08–1.44; paternal age OR = 1.17, 95% CI: 1.04–1.32), children aged 18–36 months (OR = 1.45, 95% CI: 1.12–1.88), maternal educational attainment of college or above (OR = 1.38, 95% CI:1.10–1.73), caregiver with the perception that other mothers use MNPs (OR = 1.52, 95% CI:1.19–1.95), caregiver being aware of the importance of iron (OR = 1.42, 95% CI: 1.18–1.71), caregiver having correct knowledge of MNPs (OR = 1.36, 95% CI:1.19–1.57) and caregiver reporting children have no side effects from MNPs (OR = 2.77, 95% CI: 2.46–3.11) were contributing factors to high adherence to MNPs. The overall HAR to MNPs was relatively low; hence, effective and trusted communication channels need to be established, along with more thorough dissemination of the knowledge of MNPs to caregivers, to improve MNPs adherence rates, especially in low-income countries.
... However, our results suggest that there were differences in attitudes, perceptions, motivations and self-efficacy levels in FPS owners and ASHAs, which argue for a segmented training approach with these two groups of frontline workers to ensure that the needs and motivations of each are addressed. (Robert et al., 2006) and tasting sessions (Loechl et al., 2009) or provide supportive supervision (Kim et al., 2015;Sarma et al., 2020) and refresher training sessions. ...
Double fortified salt (DFS) has proven efficacy in addressing iron deficiency and anaemia, thus improving maternal and child nutrition outcomes. However, DFS delivery in large-scale settings is less understood, with limited documentation of its fidelity of implementation (FOI). We assessed the FOI of the DFS intervention in Uttar Pradesh, India, to improve the design and implementation of such programmes that aim to reduce the anaemia burden, especially in women of reproductive age (WRA). We conducted in-depth interviews with DFS programme staff (n = 25) and end-user WRAs (23), guided by a programme impact pathway. We transcribed and thematically analysed the interviews and used an adapted analytic framework to document FOI across four domains—objects of intervention, implementation staff, implementation context and target of implementation. DFS utilisation remained low due to a combination of factors including poor product quality, distribution challenges, ineffective promotion and low awareness amongst end-user WRAs. Motivation levels were higher amongst district-level staff compared to frontline staff, who lacked supervisory support and effective incentives to promote DFS. Three typologies of DFS users emerged—‘believers’, ‘thrifters’ and ‘naysayers’—who indicated differing reasons for DFS purchase and its use or nonuse. The implementation of the DFS programme varied significantly from its theorised programme impact pathway. The adapted analytic framework helped document FOI and assess the programme's readiness for impact assessments and subsequent scale-up. The programme needs product quality improvements, incentivised distribution and stronger promotion to effectively deliver and improve the realisation of its potential as an anaemia prevention strategy.
... Home visits led to enhanced understanding and use of MNP, which greatly facilitated its acceptance and use among mothers and caregivers. This activity has also been reported as a helpful component in nutrition programs in Haiti, 17 Nigeria, 14 and Peru. 16 Thus, results of the study suggest that preparation and use of MNP and BigMo blend by mothers at home is optimized when regularly monitored by CHWs. ...
... For example, India has demonstrated a successful use of routine program data by service providers for Polio and HIV/AIDS programs, which led to program improvements that effectively translated into services reaching targeted groups (15). While there has been growing recognition and utilization of a data-driven approach to inform the implementation of nutrition interventions and programs (16)(17)(18)(19), this has not been universal and further guidance is needed on best practices for embracing a data-driven approach. There remain critical questions on key factors that could inhibit or facilitate data-collection and utilization efforts within the context of ongoing nutrition interventions. ...
Background
In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (clinicaltrials.gov NCT03378141). However, we have a limited understanding of providers’ experiences and challenges of collecting and using data for decision making.
Objective
To identify barriers and facilitators to the 1) collection of data and 2) use of data for decision-making.
Methods
In-depth interviews (N = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors and A&T staff in two districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (N = 103) were surveyed to assess data use experiences.
Results
Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision-making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW education level, political structure and lack of cooperation between FLWs and supervisors.
Conclusions
Use of data for decision-making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data collection efforts, the use of data to inform decision-making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.
... Although improving product quality is paramount, an interim strategy could be to proactively inform users to anticipate sensory changes in food due to DFS, and create awareness about the reasons for these changes, such that they consider discoloration in food as a signal of nutritional value. Similar programs that distributed micronutrient powders in multiple contexts have successfully adopted such a communication strategy, in which users readily accepted the intervention once they were aware of what to expect and convinced about product safety and benefit (39)(40)(41). ...
Background
Double fortified salt (DFS) is efficacious in addressing iron deficiency, but evidence of its effectiveness is limited. The few published evaluations do not include details on program implementation, limiting their utility for programmatic decisions.
Objectives
We sought to characterize the coverage of a DFS program implemented through the Public Distribution System (PDS) in Uttar Pradesh, India, and understand the drivers of DFS adherence.
Methods
After 8 mo of implementation, we surveyed 1202 households in 5 districts and collected data on sociodemographic characteristics, asset ownership, food security, and regular PDS utilization. We defined DFS program coverage as the proportion of PDS beneficiaries who had heard of and purchased DFS, and we defined DFS adherence as DFS use reported by households. We used principal component analysis to create an asset-based index of relative wealth, and we categorized households into higher/lower relative wealth quintiles. We conducted path analyses to examine the drivers of DFS adherence, particularly the mediated influence of household wealth on DFS adherence. The evaluation is registered with 3ie's Registry for International Development Impact Evaluations (RIDIE‐STUDY‐ID‐58f6eeb45c050).
Results
The DFS program had good coverage: 83% of respondents had heard of DFS and 74% had purchased it at least once. However, only 23% exclusively used DFS. Respondents had low awareness about DFS benefits and considered DFS quality as poor. Being in a lower household wealth quintile and being food insecure were significant drivers of DFS adherence, and regular PDS utilization acted as a mediator. Adherence was lower in urban areas.
Conclusions
We observed significant heterogeneity in DFS implementation as reflected by high coverage and low adherence. Findings from this process evaluation informed the design of an adaptive impact evaluation and provided generalizable insights for ensuring that the potential for impact is realized. Efforts are needed to increase awareness, improve product quality, as well as mitigate against the sensory challenges identified.
... As explained in Avula et al.'s (20) study, the PIP analysis has many advantages, which include, but are not limited to, helping evaluators interpret impact results and identifying corrective actions for implementers. Yet there are few published examples of such analyses related to nutrition programs (20)(21)(22)(23)(24)(25)(26)(27), and even fewer when it comes to examples related to CT programs (28). Because the focus is generally on documenting what impact interventions have, and be-cause PIP analysis can be time-and staff-consuming, researchers have not necessarily prioritized this approach. ...
Background:
Evaluations are often limited to affirming what impact health and nutrition interventions have, without providing enough insights into "how/why" impacts are achieved.
Objectives:
This article describes how a Program Impact Pathway (PIP) analysis was used to tailor theory-driven impact and process evaluation of a "Cash-Plus" program combining unconditional cash transfers with behavior change communication (BCC) activities, which was implemented to improve children's growth in Togo.
Methods:
A theoretical PIP diagram was developed using existing literature, program documentation, and interviews with the program's stakeholders at the central level. Next, the PIP diagram was refined through 2 regional participatory workshops, 6 mo after the program began. Workshop participants were multilevel field implementers and were asked to 1) discuss their vision of the program's objectives; 2) describe the "inputs-process-outputs-outcomes-impacts" flow; 3) reflect on modifiers that may arise along the PIP; and 4) report bottlenecks in the program's conception or implementation and suggest corrective actions. The PIP was used to determine research questions that should be investigated during impact or process evaluation and guided the choice of data collection methods and tools.
Results:
The PIP analysis identified 3 impact pathways, all based on the synergy between cash and raised women's knowledge. Along these pathways, the motivation and workload of frontline workers, along with issues in cash flow, were identified as factors that may affect the delivery of activities, whereas women's control over resources, time availability, support from relatives, and the presence of markets and health and school services were recognized as factors that may influence the uptake of activities. Improved communication between stakeholders and increased involvement of husbands were suggested for better impact achievement.
Conclusions:
The participatory PIP analysis helped implementers and evaluators to share a common vision of the program's objective and logic, encouraged communication across sectors, and facilitated course-adjustments of the program.
... These include barriers at both the service delivery level and beneficiary level. The involvement of frontline workers (health workers, community health workers (CHWs), vendors and pharmacists) can improve access and acceptance (9)(10)(11)(12) . Caregivers' awareness, motivation and skill in applying MNP to children's food may improve uptake and sustained use (12) . ...
... They do this by interacting with caregivers and discussing their problems with the programme team (10) . There are some barriers to a successful implementation of MNP interventions, such as misconceptions around MNP, side-effects of MNP and inconsistent supply of MNP product (12) , and regular home visits (expected at least one visit per month) by CHWs might help overcome these (11,29,30) . ...
Objective
We assessed the role of home visits by Shasthya Shebika (SS) – female volunteer community health workers (CHWs) – in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver–provider interaction on coverage variables.
Design
We used data from three cross-sectional surveys undertaken at baseline ( n 1927), midline ( n 1924) and endline ( n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver’s household in the 12 months preceding the survey considering three outcome variables – message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an ‘interaction term’ and calculated an odds ratio (OR) to assess the modifying effect of SS’s home visits on coverage.
Settings
Sixty-eight sub-districts from ten districts of Bangladesh.
Participants
Children aged 6–59 months and their caregivers.
Results
A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS’s home visit on effective coverage.
Conclusions
The households visited by BRAC’s volunteer CHWs have better message and contact coverage among the children aged 6–59 months.
