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Table 1 Nutritional interventions, key bottlenecks and major causes of nutritional deprivations in ghana based on determinant analysis

From: The lancet series nutritional interventions in Ghana: a determinants analysis approach to inform nutrition strategic planning

Determinant Identified Bottleneck (quantitative assessment) Main Causes of Bottleneck (qualitative assessment)
Early Initiation of Breastfeeding i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support
ii. Effective coverage: Only 56.6% of mothers of children 0–2 years who gave birth in a health facility breastfed their infants within 1 hour of birth
Human Resource:
Service Delivery Level-Inadequate integration of nutrition and breastfeeding component into Maternal and newborn care training
Enabling Environment- Inadequate pre-service training on breastfeeding for frontline workers
Effective coverage
Service Delivery Level- Lack of support to mothers to breastfeed in first hour of birth, Poor staff attitude, Inhibitory Social Norms on Feeding after delivery (example prohibition of giving colostrum to the baby, inclusion of water in diet of newborn and keeping babies indoors for the first seven days), as well as preference for early introduction of formula by mother
Enabling Environment-Poor enforcement of baby friendly policy in health facilities
Exclusive Breastfeeding i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support
ii. Effective coverage: Only 52.3% of children 0–5 months were exclusively breast-fed
Human resource
Service Delivery Level- Unstructured orientation on exclusive breastfeeding counselling of frontline worker e.g. community health workers (CHW) not prioritized by sub-national health management teams
Enabling Environment – Inadequate pre-service training on breastfeeding, and too many competing priorities at the higher levels of health delivery (Ministry of Health level and health training institutions)
Effective coverage
Service Delivery Level- inadequate engagement of family members by frontline workers during counselling at antenatal, postnatal, child welfare clinics and home visits.
Enabling Environment- ineffective planning and conduct of home visits (mismatch between time of home visits and availability of service recipients) as well as financial and logistic constraints for effective transportation
Iron and Folate Supplementation (IFA) i. Data availability- was a major bottleneck for the iron folate supplementation Determinant
ii. Effective coverage: Only 59.4% of mothers with children 0–5 months took IFA for 90 or more days during pregnancy
Effective coverage
Service Delivery Level- Frontline staff at the Antenatal clinic staff do not prioritize counselling on iron and folate supplementation during service provision, as well as non-compliance of pregnant women on iron folate supplementation (due to fear of side effects)
Enabling Environment- National level health managers have not prioritized inclusion of iron folate supplementation data in health information management systems nationally. In addition weak supervision of frontline staff affects delivery of this service
Vitamin A Supplementation
(VAS)
i. Initial Utilisation- Only 22.0% of children 12–59 months received Vitamin A supplementation (VAS) in semester 1
ii. Initial Utilisation- Only 19.9% of children 12–59 months received VAS in semester 2
iii. Effective coverage: Only 19.9% of children 12–59 months received two doses of VAS in a calendar year
Initial Utilisation and Effective Coverage
Service Delivery Level- Limited counseling on the importance of vitamin A from frontline workers to caregivers, inefficient planned preventive & maintenance schedule for vehicles/motorbikes for outreach services and general inadequate coordination of training plans for frontline staff by health managers
Enabling Environment – Absence of a national comprehensive Vitamin A supplementation strategy to reach children 12–59 months in routine services, limited data capture on children 0–59 months provided vitamin A in health information management systems and limited supervision and appraisal of frontline health workers using Vitamin A supplementation indicators
Treatment and Management- Community based management of acute malnutrition (CMAM) Initial Utilisation- Only 32.5% of children 6–59 months with severe acute malnutrition (SAM) admitted for treatment at health facilities Initial Utilisation:
Service Delivery Level- Limited active surveillance on severe acute malnutrition within the communities (due to complaints of high workload by health workers), and inimical sociocultural beliefs among caregivers (that the cause and treatment of severe acute malnutrition is spiritual). In addition, there is limited frequency and intensity as well as targeting of cases of severe acute malnutrition with social mobilization as well as limited service access for treatment
Enabling Environment – Gap between policy and implementation of the policy on free treatment for Children less than 5 years with severe acute malnutrition, Ineffective service integration, coordination and management of community based management of acute malnutrition
Complementary Feeding (CF) i. Human resource: Only 21% of community health workers trained on complementary feeding counselling, support and communication
ii. Effective coverage * : (This was assessed for all the 3 components of minimum acceptable diet)
a. Only 6.9% of children 6–8 months were fed with minimum dietary diversity (with ≥ 4 food groups)
b. In all 50.6% of children 6–8 months received age appropriate meal frequency in the past 24 hours
c.  Only 21.6% of children 6–8 months received iron rich diet in the past 24 hours
Human resource
Service Delivery Level- Ineffective planning and management of pre-service and in-service training, high attrition of frontline staff due to transfers and movement for further education as well as poor targeting and selection of health workers for training.
Enabling Environment – Limited priority and coordination at higher levels of the health care system on comprehensive infant and young child feeding and the content of curriculum of health training institutions do not adequately cater for the practical skill required by frontline workers to provide optimum services.
Effective coverage
Service Delivery Level- Unavailability of diverse foods sources and inequitable intra-household food distribution, as well as a generally low intake of high bioavailable iron-rich foods at the family level
Enabling Environment – Limited resources for service provision, limited availability of affordable home fortified iron-rich products on the market in the country and inadequate inter-sectoral collaboration.