Relation between Timing of High-Dose Vitamin A Supplementation and Modified-Relative-Dose-Response Values in Children 12-23 Months in Uganda.

BACKGROUND: High-dose vitamin A (VA) supplements (VAS) can temporarily affect VA status. Hence, micronutrient surveys might need to be timed around VAS campaigns to accurately estimate VA deficiency (VAD) prevalence. Little is known about optimal timing of micronutrient surveys when the modified-relative-dose-response (MRDR) is used as a VA indicator. OBJECTIVES: We evaluated the association between days since the end of a VAS campaign and MRDR values in children aged 12-23 mo in Uganda. METHODS: We pooled data from 2 cross-sectional, population-based surveys in eastern Uganda conducted in 2015-2016 (n = 118 children). We estimated the prevalence of VAD (MRDR ≥0.060). Days since the end of a VAS campaign ("days since VAS") was calculated as the interview date minus the end date of the VAS campaign. The MRDR value was assessed using HPLC. We excluded children whose MRDR values were below the limit of detection (<0.007). We used linear regression to evaluate the association between days since VAS and log-transformed MRDR. In adjusted analyses, we controlled for potential confounders. Statistical analyses accounted for the surveys' complex design. RESULTS: The prevalence of VAD was 5.2% (95% CI: 1.1%, 9.3%). Mean days since VAS was 54.1 d (range 39-68 d). Days since VAS was not associated with log-transformed MRDR in unadjusted analyses ($\hat{\beta } = \ $0.0055; 95% CI: -0.009, 0.020; P = 0.45) or adjusted analyses ($\hat{\beta } = $ -0.0073; 95% CI: -0.024, 0.010; P = 0.39). CONCLUSIONS: MRDR measurement through a nutrition survey began as early as 1.3 mo after the end of a VAS campaign in eastern Uganda. Days since the end of a VAS campaign was not associated with MRDR in Ugandan children aged 12-23 mo. Future studies should consider longitudinal designs and evaluate time since VAS and MRDR in children of different ages and in regions with higher VAD prevalence.

An Integrated Enhanced Infant and Young Child Feeding (IYCF) and Micronutrient Powder Intervention Improved Select IYCF Practices Among Caregivers of Children Aged 12-23 Months in Eastern Uganda.

BACKGROUND: There is little evidence of the impact of integrated programs distributing nutrition supplements with behavior change on infant and young child feeding (IYCF) practices. OBJECTIVE: We evaluated the impact of an integrated IYCF/micronutrient powder intervention on IYCF practices among caregivers of children aged 12-23 mo in eastern Uganda. METHODS: We used pre-post data from 2 population-based, cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts (n = 2816). Caregivers were interviewed in June/July at baseline in 2015 and 12 mo after implementation in 2016. We used generalized linear mixed models with cluster as a random effect to calculate the average intervention effect on receiving IYCF counseling, ever breastfed, current breastfeeding, bottle feeding, introducing complementary feeding at age 6 mo, continued breastfeeding at ages 1 and 2 y, minimum meal frequency (MMF), minimum dietary diversity, minimum acceptable diet (MAD), and consumption of food groups the day preceding the survey. RESULTS: Controlling for child age and sex, household wealth and food security, and caregiver schooling, the intervention was positively associated with having received IYCF counseling by village health team [adjusted prevalence difference-in-difference (APDiD): +51.6%; 95% CI: 44.0%, 59.2%]; timely introduction of complementary feeding (APDiD: +21.7%; 95% CI: 13.4%, 30.1%); having consumed organs or meats (APDiD: +9.0%; 95% CI: 1.4%, 16.6%) or vitamin A-rich fruits or vegetables (APDiD: +17.5%; 95% CI: 4.5%, 30.5%); and MMF (APDiD: +18.6%; 95% CI: 11.2%, 25.9%). The intervention was negatively associated with having consumed grains, roots, or tubers (APDiD: -4.4%; 95% CI: -7.0%, -1.7%) and legumes, nuts, or seeds (APDiD: -15.6%; 95% CI: -26.2%, -5.0%). Prevalences of some IYCF practices were low in Amuria at endline including MAD (19.1%; 95% CI :16.3%, 21.9%). CONCLUSIONS: The intervention had a positive impact on several IYCF practices; however, endline prevalence of some indicators suggests a continued need to improve complementary feeding practices.

Retinol-binding protein, retinol, and modified-relative-dose response in Ugandan children aged 12-23 months and their non-pregnant caregivers.

Retinol-binding protein (RBP), retinol, and modified-relative-dose response (MRDR) are used to assess vitamin A status. We describe vitamin A status in Ugandan children and women using dried blood spot (DBS) RBP, serum RBP, plasma retinol, and MRDR and compare DBS-RBP, serum RBP, and plasma retinol. Blood was collected from 39 children aged 12-23 months and 28 non-pregnant mothers aged 15-49 years as a subsample from a survey in Amuria district, Uganda, in 2016. DBS RBP was assessed using a commercial enzyme immunoassay kit, serum RBP using an in-house sandwich enzyme-linked immunosorbent assay, and plasma retinol/MRDR test using high-performance liquid chromatography. We examined (a) median concentration or value (Q1, Q3); (b) R2 between DBS-RBP, serum RBP, and plasma retinol; and (c) Bland-Altman plots. Median (Q1, Q3) for children and mothers, respectively, were as follows: DBS-RBP 1.15 µmol/L (0.97, 1.42) and 1.73 (1.52, 1.96), serum RBP 0.95 µmol/L (0.78, 1.18) and 1.47 µmol/L (1.30, 1.79), plasma retinol 0.82 µmol/L (0.67, 0.99) and 1.33 µmol/L (1.22, 1.58), and MRDR 0.025 (0.014, 0.042) and 0.014 (0.009, 0.019). DBS RBP-serum RBP R2 was 0.09 for both children and mothers. The mean biases were -0.19 µmol/L (95% limits of agreement [LOA] 0.62, -0.99) for children and -0.01 µmol/L (95% LOA -1.11, -1.31) for mothers. DBS RBP-plasma retinol R2 was 0.11 for children and 0.13 for mothers. Mean biases were 0.33 µmol/L (95% LOA -0.37, 1.03) for children, and 0.29 µmol/L (95% LOA -0.69, 1.27) for mothers. Serum RBP-plasma retinol R2 was 0.75 for children and 0.55 for mothers, with mean biases of 0.13 µmol/L (95% LOA -0.23, 0.49) for children and 0.18 µmol/L (95% LOA -0.61, 0.96) for mothers. Results varied by indicator and matrix. The serum RBP-retinol R2 for children was moderate (0.75), but poor for other comparisons. Understanding the relationships among vitamin A indicators across contexts and population groups is needed.

An Integrated Infant and Young Child Feeding and Micronutrient Powder Intervention Does Not Affect Anemia, Iron Status, or Vitamin A Status among Children Aged 12-23 Months in Eastern Uganda.

BACKGROUND: Micronutrient powders (MNP) can reduce iron deficiency and anemia in children. OBJECTIVE: We evaluated the impact of an integrated infant and young child feeding (IYCF)-MNP intervention on anemia and micronutrient status among children aged 12-23 mo in Eastern Uganda. The intervention focused on MNP distribution, IYCF education, and caregiver behavior change. METHODS: Population-based cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts were collected in June/July 2015 at baseline (n = 1260) and 12 mo after implementation at endline in 2016 (n = 1490). From pooled capillary blood, we assessed hemoglobin, malaria, ferritin, retinol binding protein (RBP), C-reactive protein, and ɑ1-acid glycoprotein. Ferritin and RBP were regression-adjusted to correct for inflammation. Caregivers reported sociodemographic characteristics and MNP knowledge and practices. Linear regression estimated the difference-in-difference (DiD) effect of MNP on hemoglobin, ferritin, and RBP, and logistic regression estimated DiD effect of MNP on anemia (hemoglobin <11.0 g/dL), iron deficiency (ferritin <12.0 µg/L), iron deficiency anemia (hemoglobin <11.0 g/dL and ferritin <12.0 µg/L), and vitamin A deficiency (VAD; RBP equivalent to <0.70 µmol/L retinol: <0.79 µmol/L at baseline and RBP <0.67 µmol/L at endline). RESULTS: In Amuria, 96% of children had ever consumed MNP versus <1% of children in Soroti. Fifty-four percent of caregivers reported organoleptic changes when MNP were added to foods cooked with soda ash. Adjusting for age, sex, malaria, recent morbidity, and household-level factors, the intervention was associated with -0.83 g/dL lower hemoglobin (95% CI, -1.36, -0.30 g/dL; P = 0.003) but not with anemia, ferritin, iron deficiency, iron deficiency anemia, RBP, or VAD. CONCLUSIONS: Despite high program fidelity, the intervention was associated with reduced hemoglobin concentrations but not with change in anemia or micronutrient status among children aged 12-23 mo in Eastern Uganda. Contextual factors, such as cooking with soda ash, might explain the lack of effectiveness.

Facility- and community-based delivery of micronutrient powders in Uganda: Opening the black box of implementation using mixed methods.

Micronutrient powders (MNP) have the potential to increase micronutrient intake, yet documentation of implementation lessons remains a gap. This paper presents results of a pilot in Uganda comparing community- and facility-based delivery of MNP and documenting experiences of caregivers and distributors. The pilot's mixed method evaluation included a cross-sectional endline survey, monthly household visits, and midline and endline interviews. Primary outcomes were ever-covered (received ≥1 MNP packet), repeat-coverage (received ≥2 MNP packets), and adherence (consumed no more than 1 MNP sachet per day, consumed MNP with food, and consumed MNP 3+ days in past week). An adjusted Wald chi-square test compared differences in programme outcomes between arms, and logit regression identified predictors to adherence. Key informant interviews were coded thematically. Most programme outcomes in the endline survey were statistically significantly higher in the community arm, although in both arms, adherence was lower than other outcomes (adherence 31.4% in facility vs. 58.3% in community arm). Counselling, receipt of communication materials, perceived positive effects, MNP knowledge, and child liking MNP were consistent predictors of adherence in both arms. Qualitative findings corroborated survey results, revealing that social encouragement and advocacy facilitated use and that forgetting to give MNP was a barrier. Facility arm caregivers also cited distance, time, and transportation cost as barriers. Distributors had positive experiences with training and supervision but experienced increased workloads in both arms. MNP programme design is context-specific but could benefit from strengthened community sensitization, continued and more effective counselling for caregivers, and increased support for distributors.

Predictors of micronutrient powder sachet coverage and recent intake among children 12-23 months in Eastern Uganda.

We evaluated predictors of micronutrient powder (MNP) sachet coverage and recent intake using data from a cross-sectional survey representative of children aged 12-23 months in Amuria district, Uganda. In June/July 2016, caregivers were interviewed 12 months after implementation of an integrated MNP and infant and young child feeding pilot (N = 761). Logistic regression described predictors of (a) high-MNP sachet coverage (received at least 60 sachets/6 months) and (b) recent intake (consumed MNP during the 2 weeks preceding the survey) among children who had ever received MNP and had complete data (N = 683). Fifty-nine percent (95% Confidence Interval [CI] [53.8, 64.2]) of children had high-MNP sachet coverage, and 65.4% (95% CI [61.0, 69.9]) had recent intake. MNP ration cards (Adjusted Odds Ratio [AOR] 2.67, 95% CI [1.15, 6.23]), organoleptic changes to foods cooked with soda ash (AOR 1.52, 95% CI [1.08, 2.14]), having heard of anaemia (AOR 1.59, 95% CI [1.11, 2.26]), knowledge of correct MNP preparation (AOR 1.89, 95% CI [1.11, 3.19]), and current breastfeeding (AOR 2.04, 95% CI [1.36, 3.08]) were positively associated with MNP coverage whereas older child age (18-23 vs. 12-17 months) was inversely associated with coverage (AOR 0.32, 95% CI [0.23, 0.50]). MNP ration cards (AOR 2.86, 95% CI [1.34, 6.09]), having heard an MNP radio jingle (AOR 1.40, 95% CI [1.01, 1.94]), knowledge of correct MNP preparation (AOR 1.88, 95% CI [1.04, 3.39]), and the child not disliking MNP (AOR 1.90, 95% CI [1.13, 3.22]) were positively associated with recent intake. Interventions that increase caregiver knowledge and skills and focus on older children could improve MNP coverage and recent intake.

Understanding the process of strengthening multi-sectoral efforts for anemia reduction: Qualitative findings from Sierra Leone and Uganda.

Anemia is a significant global health problem, and progress to reduce it has been slow. A multi-sectoral, context-specific, and country-led approach is recommended to effectively address anemia, but there is limited documentation of how this has worked in practice. We present key findings and lessons learned from Sierra Leone and Uganda's experiences establishing national-level anemia coordination platforms. A longitudinal collective case study methodology was used, with in-depth interviews of National Anemia Working Group members in both countries; data was analyzed to distill the salient lessons learned across countries. Similar factors were identified in the 2 countries. Setting the agenda was an important first step, accomplished by using country-specific anemia-related data and obtaining multi-sectoral commitment. Establishment of a cohesive coordination structure provided an effective platform to prioritize and align anemia activities. Strong, committed leadership and representation of diverse stakeholders was essential to maintain the legitimacy of anemia efforts. The main barriers to the policy-making process included misalignment of sectoral mandates, differences in work cultures, as well as competing priorities and increased staff workload. Sierra Leone and Uganda's experiences contribute to the global evidence base for anemia coordination and planning at the national level, particularly around linking health and non-health sectors and developing multi-sectoral platforms. It remains to be seen how and to what extent resulting policies in Sierra Leone and Uganda will translate to implementation.