Market-based approach to promoting home fortification of diets with micronutrient powder through volunteer frontline health workers: A qualitative study.

BACKGROUND: The potential of market-based approach in distributing micronutrient powder (MNP) through volunteer frontline health workers has been recognized. BRAC, the largest non-government organization (NGO) in Bangladesh, uses Shasthya Shebikas as volunteer frontline health workers to sell MNP for promotion of home fortification (HF) of diets for under-5 children. We aimed to understand the opportunities and challenges of BRAC's market-based approach in promoting HF with MNP. METHODS: We conducted a descriptive qualitative study in the four selected districts of Bangladesh: Faridpur, Gaibandha, Rangpur, and Rajbari. In-depth interviews, key informant interviews, and focus group discussions were deployed to collect data from purposively-selected Shasthya Shebikas and their immediate supervisors at the field level-Shasthya Kormis, Field Organizers, Managers, and mothers or caregivers of under-5 children. We performed thematic analysis to analyze data. RESULTS: We have found that the Shasthya Shebikas play a critical role in promoting access of MNP by the mother/caregivers of children aged 6-59 months at the community level. They counsel the caregivers to seek primary advice about the product and also informally identify undernourished children so that they can receive special attention regarding the use of MNP. However, low profit margins, over-due payments for the sold sachets, poor collaboration with and free distribution of MNP by other NGOs, and inadequate training of Shasthya Shebikas on marketing of MNP have posed major challenges for them to perform as effective sales agents of the product. CONCLUSION: The market-based approach in promoting HF with MNP through frontline volunteer health workers shows much potential, with ample opportunities and few possible challenges. Considering the dynamics, the intervention should fine-tune the factors crucial to maximizing the potentials of Shasthya Shebikas for marketing MNP and promoting HF in order to improve nutrition status of the infants and young children.

Caregiver perceived barriers to the use of micronutrient powder for children aged 6-59 months in Bangladesh.

BACKGROUND: The effectiveness of micronutrient powder (MNP) on the health outcome of children is yet to be proved. Although studies identified the barriers to the use of MNP the underlying factors related to the barriers to the use of MNP are still unexplored. We examined the underlying factors associated with the barriers reported by the caregivers of the children aged 6-59 months in Bangladesh. METHODS: We analyzed pooled data of 3, 634 caregiver-child dyads extracted from eight cross-sectional surveys. The surveys were conducted as part of an evaluation of the Maternal, Infant and Young Children Nutrition programme (phase 2) in Bangladesh. We performed univariate analysis to find the barriers reported by the caregivers of the children. We identified the underlying factors related to the reported barriers by performing multiple logistic regression analysis. RESULTS: The mostly reported barrier was perceived lack of need for MNP among the caregivers of the children (39.9%), followed by lack of awareness of the product (21.7%) and cost of the product (18.1%). Caregivers of older children (adjusted odds ratio (aOR): 1.69; 95% CI: 1.43, 2.00) and caregivers who maintained good infant and young child feeding practices (aOR: 1.32; 95% CI: 1.12, 1.57) perceived more lack of need for MNP. Caregivers of the female children (aOR: 0.79; 95% CI: 0.63, 0.98) were less likely to report that their children disliked MNP compared to the caregivers of the male children. CONCLUSION: Programmes intended to effectively promote MNP among the caregivers of children aged 6-59 months should carefully consider the factors that could underlie the barriers to the use of MNP.

Implementation science in nutrition: a summary and synthesis.

OBJECTIVE: This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled 'Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh'. DESIGN: Commentary, summary and synthesis. SETTINGS: Low- and middle-income country. RESULTS: The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation's effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify 'effective' interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme. CONCLUSIONS: Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.

The Effects of Deworming and Multiple Micronutrients on Anaemia in Preschool Children in Bangladesh: Analysis of Five Cross-Sectional Surveys.

Anaemia is a major public health problem among children < 5 years of age in Bangladesh due to recurrent intestinal parasite infections. The aim of this study was to understand the association between combining deworming and MNP home fortification (MNP + Deworming) and the prevalence of anaemia among children < 5 years of age in Bangladesh. We used pooled data from five cross-sectional surveys and performed multivariable logistic regression and calculated crude and adjusted odds ratios (AORs) to quantify the association of anaemia with the exposure variables. A total of 9948 households were considered for this paper. In the unadjusted logistic regression, no significant association was detected between the effective MNP coverage and anaemia prevalence, but the associations were significant (p < 0.001) between the deworming and anaemia prevalence and between the MNP + Deworming condition and anaemia prevalence. In the adjusted model, children who were exposed to both deworming and effective MNP coverage were 30% (AOR 0.70; 95% CI 0.52, 0.94; p = 0.018) less likely to be anaemic compared with children who were unexposed to combined MNP + Deworming. The combined effects of deworming and MNP supplementation on the reduction in anaemia prevalence highlighted the importance of using integrated and multidisciplinary intervention strategies.

Unintended consequences of programmatic changes to infant and young child feeding practices in Bangladesh.

BRAC, an international development organization, implemented a home-fortification programme from 2014 to 2018 in Bangladesh. This study aimed to understand the unintended consequences of programmatic changes that occurred during the implementation of the programme on the prevalence of good infant and young child feeding (IYCF) practices and other associated factors. We used pooled data from eight cross-sectional surveys and data from a series of qualitative investigations carried out as part of a mixed-methods evaluation approach. A total of 6,479 caregivers of children aged 6 to 23 months participated in the surveys. The prevalence of good IYCF practices increased from baseline (42.1%) to midline (45.3%), but it decreased at the endline survey (31.9%). Qualitative investigations identified several reasons for low IYCF practices at the programme level, such as the withdrawal of community health worker (CHW) incentives for promoting IYCF, providing incentives for the home-fortification of micronutrient powder (MNP) and changing the focus from IYCF promotion to MNP promotion. A multivariable generalized estimating equation model for pooled data revealed that caregivers were 28% (adjusted risk ratio [ARR]: 0.72, 95% CI [0.67, 0.78]) less likely to maintain good IYCF practices during the period when CHWs were not incentivized to promote IYCF compared to the period when CHWs were incentivized to promote it. The prevalence of good IYCF practices decreased from both baseline and midline to the endline survey due to the unintended consequences of the programmatic changes. An integrated intervention strategy to promote the home-fortification of MNP and IYCF could be helpful to avoid unintended negative consequences of programmatic changes.

Factors Influencing Child Feeding Practices Related to Home Fortification With Micronutrient Powder Among Caregivers of Under-5 Children in Bangladesh.

BACKGROUND: Anemia is a major public health concern in Bangladesh, affecting about 51% of under-5 children. There are a number of strategies to overcome this micronutrient-deficiency burden, and home fortification (HF) with micronutrient powder (MNP) is one of them. OBJECTIVE: As part of an evaluation of an HF with MNP intervention program, we conducted a qualitative study to understand the factors influencing demand, purchase, and utilization of MNP by caregivers of under-5 children. METHODS: We purposively selected study participants from 5 subdistricts and 1 urban slum in Bangladesh where HF with Pushtikona (a brand name of MNP) program is available. Data were collected through household observations and conducting in-depth interviews and focus group discussions with caregivers, grandmothers, and fathers of under-5 children. RESULTS: Our study showed that caregivers were initially cautious, using Pushtikona on a trial basis, and afterward they employed various strategies to get their children to eat food fortified with Pushtikona. Barriers to acceptance and use of Pushtikona included inappropriate initiation of complementary feeding, discouragement from influential family members as well as miscommunication, conflicting information, and irregular visits by the health workers who sell Pushtikona to caregivers. Based on these findings, we characterized the users of Pushtikona as regular, ever, irregular, and never. CONCLUSION: The evidence suggests that focusing on counseling caregivers and other family members on the importance of MNP and on age-appropriate feeding practices will be critical to the success of this intervention program as will regular visits by health workers and improved service delivery.