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The lancet series nutritional interventions in Ghana: a determinants analysis approach to inform nutrition strategic planning
BMC Nutritionvolume 3, Article number: 27 (2017)
Malnutrition is a leading cause of mortality and morbidity among children in low- and middle-income countries. Ghana is one of 36 countries with the highest burden of stunting, globally. The aim of this work is to use data driven planning methods to conduct in-depth analysis on the Lancet series nutrition interventions in Ghana to inform nutritional strategic planning.
A mixed methods approach was employed for this national nutritional assessment conducted in May 2016. Quantitative data on nutritional interventions were generated by application of the Determinants Analysis Tool and phenomenological approach was employed to explain the causes of barriers identified. Outputs from the tool were analyzed by simple descriptive statistics and data from group discussions were assessed by thematic content analysis. The base line years for this assessment were 2014 and 2015.
Overall in Ghana, 21.0% of frontline health workers are trained on lactation management and breastfeeding counselling and support, 56.6% of mothers of children 0–2 years initiated breastfeeding within one hour of birth, and 59.4% of mothers with children 0–5 months took iron folate supplementation for 90 or more days during pregnancy. In addition, only 19.9% of children 12–59 months received two doses of vitamin A supplementation in a calendar year, and 32.5% of children 6–59 months with severe acute malnutrition were admitted for treatment at health facilities. In all, among infants 6–8 months old, 6.9% were fed with minimum dietary diversity, 50.6% received age appropriate meal frequency and 21.6% received iron rich diet. Inadequate pre-service and in-service training for staff, low prioritization and coordination (at higher levels) and weak integration of services (at lower levels) were key barriers to nutrition coverage in Ghana.
Data driven analysis and planning based on proven nutritional interventions in Ghana demonstrated gaps and barriers and garnered workable strategies to improve nutrition services.
Malnutrition is a leading cause of mortality and morbidity among children in low- and middle-income countries [1, 2]. In Sub-Saharan Africa, under nutrition constitutes a leading cause of death in children under five years old [3, 4]. Multiple interventions and multi-sectoral approach are needed to prevent different aspects of nutritional depletion and deprivation such as severe malnutrition, anaemia, wasting and stunting [2, 5, 6].
The implications and consequences of these nutritional deprivation in later adult life make it imperative for national nutritional programmes to focus on sufficient feeding for individuals, families and communities as well as a responsive health care delivery system [3, 7, 8]. Child malnutrition within a household is greatly influenced by issues at national and regional levels .
Ghana is beset with under nutrition among children, and is one of 36 countries with the highest burden of stunting, globally . In Ghana 19% of children are stunted, 5% of children are wasted and 11% of children are underweight . Anaemia as a result of under nutrition among children is another key national challenge, 66% of children aged 6–59 months have some level of anaemia, 37% have moderate levels of anaemia and 2% have severe anaemia [10, 11]. National coverage on interventions is relatively low with inadequate engagement of the health sector and other sectors to address food security, food safety and hygiene for sustained improvement .
Current national efforts to reduce nutritional deprivations in Ghana include building capacity of service providers and volunteers in nutritional counselling, and improving knowledge and skill of service providers in the management of severe acute malnutrition [12, 13]. In addition, national scale up of infant and young child feeding activities include strengthening health care practices through the Baby-Friendly Hospital Initiative and creating demand for services through participation of local leaders and communities on sociocultural practices around malnutrition [12, 13].
Progress has been made over the past decade, as demonstrated in the 2014 Demographic and Health Survey (GDHS) . Infant mortality declined from 77 deaths per 1,000 live births in 1988 to 41 in 2014 and under-5 mortality declined substantially from 155 to 60 death per 1,000 live births over the same period. These improvements at the national level notwithstanding, inequities exist in status of children by regional and geographical location in the country [10, 11]. Under-5 mortality in 2014 ranged from 47 deaths per 1,000 live births in Greater Accra (the capital region) to 111 deaths per 1,000 live births in Northern region (a predominantly rural region), while stunting ranged from 10.4% in Greater Accra to 33.1% in the Northern Region. The improvements in anaemia, stunting and wasting among children in Ghana have generally been uneven, with wide geographical disparities and among different wealth quintiles .
Interestingly, the burden of nutrition in Ghana is not limited to children because adult men and women are affected as well. In adults under- and over nutrition are both demonstrated through national surveys to be a health challenge. Overall, among men and women aged 15–49 years, 6% of women and 10% of men are underweight (Body Mass Index, BMI <18.5), while 40% of women and 16% of men are overweight (BMI > =25.0) .
Major causes and determinants of malnutrition in Ghana include, inadequate diet diversity (insufficient food/nutrient intake and inadequate consumption of foods rich in micronutrients and protein including eggs and legumes); poor environmental, household and individual hygiene including hand hygiene practices; as well as generally poor infant and young child feeding practices .
This assessment of national nutrition interventions based on The Lancet Series-Maternal and Child Nutrition [14, 15] was thus intended to determine the status of these proven nutritional interventions in Ghana, identify barriers to service provision and develop workable strategies. It used data driven planning methods to conduct in-depth analysis needed to guide programme scale up and targeting, to improve coverage and scope of proven nutritional interventions.
Mixed methods approach were employed for this national nutritional assessment conducted in May 2016. Quantitative data on nutritional interventions was generated by application of the Determinants Analysis Tool and phenomenological approach was employed to explain the causes of barriers identified. Four participants (Regional Deputy Director of Public Health, Regional Public Health Nurse, Regional Nutrition Officer and Regional Health Information Officer) were purposively selected from each of the ten administrative regions in the Ghana due to their background and role in nutrition services. In addition local facilitators (Nutrition Unit of the Ghana Health Service) and representatives from some development partners (including UNICEF, WHO and World Food Programme (WFP) participated. Ghana has ten administrative regions, and officers from all ten regions were included to provide a nationwide representation. The national assessment was undertaken in the Ashanti Region of Ghana for three days to assess barriers to coverage of nutrition services and included desk review, group discussions and key informants interviews. Facilitators assisted in the desk reviews, conduct of interviews and provided mentoring and coaching on capturing major issues and recording of key points from the group discussion.
Main causes of identified bottlenecks to the nutritional interventions were thematically analysed through a phenomenological approach under service delivery factors and enabling environment factors through group discussions. Phenomenological approach was used to allow a deeper understanding of an event or phenomenon by looking at the story of the group who experienced a shared lived experience or phenomenon . Six teams made up of regional, national and international personnel were formed in line with the key interventions to provide qualitative explanation and assessment of the outputs from the tool.
The determinants analysis framework
The Determinants Analysis framework is premised on the notion that effective coverage of services is influenced by four main factors or determinants namely: supply, demand, quality and environment. The Ten Determinant Model Tool produces a graphical output (Fig. 1) that facilitates identification of the key bottlenecks.
Overall, the Ten Determinant Model used for this nutrition assessment in Ghana had FOUR Domains with TEN Determinants: Enabling Environment (Social Norms, Management/Coordination, Legislation/Policy and Budget/Expenditures); Supply (Commodities, Human Resource and Access); Demand (Initial Utilisation, Continuous Utilisation/Knowledge) and Effective Coverage/Behaviour [17, 18].
Identification of the low bars on the supply-determinant side of the graph as well as a sharp drop from one bar to the next on the demand and quality-determinant side of the graph enables managers to identify and prioritize bottlenecks to the effective health service coverage.
The Ten Determinant Model is based on Microsoft Excel sheets linked together with sections for data inputs linked to outputs. Input data produce simple bar graphs that display the determinants of health service coverage and thus facilitate identification of key bottlenecks that influence effective coverage (illustrated in Fig. 1). The section for data input is fully linked with the section that displays the outputs. The tool directly utilised data from District Health Information Management System (DHIMS), Multi-Indicator Cluster Survey (MICS) Reports , Demographic and Health Surveys (DHS)  and other sources of data including programme monitoring and review reports. The DHIMS is a tool for collection, validation, analysis, and presentation of aggregate statistical data, tailored to integrated health information management activities in the Ghana Health Service.
Outcome measures and data analysis
Six key nutrition tracer interventions based on The Lancet Series-Maternal and Child Nutrition , were selected as, Community Management of Acute Malnutrition (CMAM), Complementary Feeding, Early Initiation to Breastfeeding, Exclusive Breastfeeding, Vitamin A Supplementation, and Iron-Folic Acid Supplementation. Each intervention was assessed based on a particular delivery platform (as individualized facility based services or schedulable and outreach services or as family oriented practices and community based services) to enable accurate identification of barriers and bottlenecks. In this analysis, minimum acceptable diet for complementary feeding was assessed using two sub components-minimum dietary diversity and age appropriate meal frequency as specified in the Ministry of Health National Nutrition Policy of Ghana . Each of the six thematic groups had a moderator and a recorder. Data from group discussions were organized and described using manual thematic content analysis for qualitative data. Each group worked on a different theme to eliminated the issue of duplication and repetition of information among the groups. Quantitative data were analyzed with simple descriptive statistics (i.e. proportions and percentages) by Microsoft Excel 2013.
The base line years for this assessment were 2014 and 2015 and national coverage targets were used as the benchmark to assess these coverage indicators. Outputs from the tool were analyzed by simple descriptive statistics such as frequency, proportions and ratios. The determinants analysis principles were applied to identify bottlenecks. Causality analysis were conducted to identify barriers resulting in these bottleneck. This formed the basis in determining strategies to remove the bottlenecks on nutritional deprivation in Ghana.
All data used was aggregated data at national level and had no link to individuals. In all cases, documentations and computerized records were kept secure and accessible to persons directly involved in developing the operational plans. The Ghana Health Service Ethics Review Committee and office of the Policy, Planning, Monitoring and Evaluation Division of the Ghana Health Service gave approval for documentation and dissemination of the Determinant Analysis process in Ghana.
The assessment provided quantitative values on the performance of each indicator from outputs of the tool, while qualitative explanation and assessment of identified bottlenecks was through causality analysis and group discussions. Details of the analysis are indicated in a comprehensive descriptive Table (Table 1).
Maternal and child undernutrition, consisting of stunting, wasting, and deficiencies of essential vitamins and minerals, was the subject of a Series of papers in The Lancet in 2008 [4, 7, 14]. It was suggested then that, long-term consequences of undernutrition could be reduced through high and equitable coverage of proven nutrition interventions. Included in these were the nutrition specific interventions [4, 7, 14]. Lancet series have been in existence close to eight years and have provided guidance to countries in their quest to improve health and nutrition of children under five years of age and Ghana is no exception. Six of the key nutrition specific interventions were selected for assessment at the national level in Ghana.
The analysis readily highlighted gaps in service coverage quantitatively (from service and survey data) and provided a platform for qualitatively analyzing barriers and bottlenecks in the continuum of care for the newborn. These discussions included key service providers and policy makers with sufficient knowledge of the context of nutritional service delivery in Ghana.
The current national efforts to reduce nutritional deprivations in Ghana outlined in the National Nutrition Policy of 2013 include building capacity of service providers and volunteers in nutritional counselling, improving knowledge and skill of service providers in the management of severe acute malnutrition and a national scale up of infant and young child feeding activities by strengthening health care practices through the Baby-Friendly Hospital Initiative [12, 13]. In addition, a number of initiatives and frameworks have been developed and implemented by the national Ministry of Health to address the problem of high under five mortality including the Child Health policy, Millennium Accelerated Framework, Accelerated immunization with introduction of new and additional vaccines, as well as the Global Funded programmes for Malaria, Tuberculosis and HIV .
The challenge has been major gaps in access and utilization of these interventions and the reality however is that, most of these interventions and frameworks have been centrally developed with little attention paid to data driven approaches and causal analysis of barriers at the service delivery level.
To overcome these challenges, the current analysis based the national nutritional strategies on the framework developed by Bezanson and Isenman in 2010  to provide guidance as Ghana implements the national nutrition policy. The ‘Framework for Action for Scaling Up Nutrition’ in 2010 was based on a broad collaborative effort of the World Bank, United Nations Children Fund (UNICEF), World Health Organization (WHO), World Food Programme (WFP) and a wide range of other international partners from developing countries, with the objective to catalyse actions to move undernutrition toward the centre stage of international discourse .
The action oriented framework from a national discourse (key service providers, policy managers and health managers) is aimed to garner local and governmental support to improving stunting, wasting and anaemia, and reduce inequities- in a setting situated among the lowest 32 countries with such health indices .
A summary of the key elements of the framework is provided as a template and shown in Table 2.
Key lessons learned
Good quality data are essential for effective planning and analysis, and data validation to improve data quality and accuracy is a core activity that should be undertaken by all levels of the health system. The Determinant Analysis process enables health managers and frontline health workers to readily identify gaps, undertake a causal analysis of the barriers and identify solutions. It garners a data driven approach to implementation even at the lowest level.
The purpose of the study was to assess nutrition services and therefore role of service providers at the basic level (street level bureaucrats) is essential and should have been involved in the assessment. However, critical issues from the basic level were captured by regional officers who work directly with these street level bureaucrats. In addition, the Ten Determinant Model used for the assessment did not explicitly capture indicators on policy, legal, social norms and budget-related factors that shape the determinants of health service coverage. However, these cross-cutting factors were systematically considered as part of analyzing each identified bottleneck during the causal analysis.
Overall in Ghana, there were gaps and insufficient coverage for the six Lancet nutrition specific interventions assessed. Inadequate pre-service and in-service training for staff, low prioritization and coordination (at higher levels) and weak integration of services (at lower levels) were key barriers to nutrition coverage in Ghana. Data driven analysis and planning based on proven nutritional interventions demonstrated gaps and barriers and garnered workable strategies (framework to guide implementation) to improve nutrition services.
Specific recommendations for improving nutrition services include, districts, sub-districts and community level systems being supported with basic commodities to provide the full complement of services. Involvement of all health care workers at districts, sub-districts and community levels and community based volunteers, as well as involvement of health facility managers, stakeholders and partners will be key. Dissemination of all existing and new policies and field guides to the lower levels will be essential. National and sub-national levels should improve data validation activities through regular monitoring and coordination.
Community based volunteers
Community Health Workers
Community-based Health Planning Services
District Health Information Management System
Exclusive breast feeding
Iron and Folate Supplementation
Infant and young child feeding
Severe acute malnutrition
United Nations Children Fund
Vitamin A Supplementation
World Food Programme
World Health Organization
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A special gratitude is extended to all who contributed towards this process. Acknowledgement is specifically made of the support from UNICEF, and officers and staff of Family Health Division of the Ghana Health Service. We acknowledge the contribution of all the regional directors of health and national and international facilitators, for the effort expended in making the assessment successful.
No source of funding was available for the research.
Availability of data and materials
Available Data used for the analysis and assessment have been included and presented as a supplementary material during submission.
AEY, LKS and AOY developed the concept, AEY, and LKS are members of the National Determinant Analysis Facilitation Team for Ghana Health Service and UNICEF and were involved in the analysis in Ghana. AEY, AOY, PKA, EOA, LKS, ABM, LS and VN contributed to the writing and reviewing of various sections of the manuscript. All the authors reviewed the final version of the manuscript before submission. All authors read and approved the final manuscript.
The authors declare no competing interest. The views expressed in this paper are those of the authors. No official endorsement by the Ministry of Health of Ghana/Ghana Health Service is intended or should be inferred.
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Ethics approval and consent to participate
All data used were aggregated data at regional and national and had no link to individuals. In all cases, documentations and computerized records were kept secure and accessible to persons directly involved in the analysis. The Ghana Health Service Ethics Review Committee and office of the Policy, Planning, Monitoring and Evaluation Division of the Ghana Health Service gave approval for documentation and dissemination of the Determinant Analysis process in Ghana.
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