The micronutrient powder initiative (MPI)
The ongoing pilot Micronutrient Powder Initiative (MPI) is being implemented in the Tain district (Brong-Ahafo region at the time the program began), Tolon district (Northern region) Talensi district (Upper East region), and Ho West district (Volta region). The Tain district is close to the Ghana border with La Côte d’Ivoire; its capital, Nsawkaw, is about 432 km north-west of Accra, the national capital. The capital of the Tolon district, Tolon, and that of the Talensi district, Tongo, are about 647 km and 800 km, respectively, north of Accra, while the Ho West district shares borders with the Republic of Togo, and its capital, Dzolo-Kpuita, is 175 km north-east of Accra. The total populations of the 4 districts range from about 73,000 in Tolon to 95,000 in Ho West (http://www.ghanadistricts.com/). In 2014, the anemia rates among children < 5 years in the regions in which the districts are located were estimated at 63% for Tain, 82% for Tolon, 74% for Talensi, and 70% for Ho West [3].
The MNP being used in the MPI contains 15 micronutrients per 1 g sachet, including Vitamins A (400 μg RE), D3 (5 μg), E (5 mg TE), B1 (0.5 mg), B2 (0.5 mg), B3 (6 mg), B6 (0.5 mg), folic acid (90 μg), B12 (0.9 μg), C (30 mg), iron (10 mg), zinc (4.1 mg), selenium (17 μg), copper (0.56 mg) and iodine (90 μg) (DSM Nutritional Products Europe Ltd., CH – 4002 Basel). This composition is based on the World Health Organization (WHO) guidelines [7] providing generally one FAO/WHO Recommended Nutrient Intake, RNI (i.e. the daily recommended nutrient intake) for children 1–3 years [23]. Iron is present as encapsulated ferrous fumarate [7, 24]. According to the product details at the UNICEF Supply Catalogue website (https://supply.unicef.org/s0000225.html), the MNP is odorless and off-white or slightly yellow, and has a bland taste so that it has a minimal impact on the taste, smell or color when mixed with food.
As part of each district’s routine medical supplies, the MNPs are typically “picked-up” from the Regional Medical Stores, RMS (serving as the collection point) by the District Nutrition Officer (DNO) and deposited at the District Health Directorate (DHD) store, from where staff dispatched from the various health facilities (polyclinic, clinics, CHPS compound, etc.) collect the MNP. In some cases, the RMSs deliver the MNP to districts and health facilities via “scheduled delivery”, but this happens less often. From each health facility, Community Health Nurses distribute MNP to mothers and caregivers at various contact points, for home (point-of-use) fortification of complementary foods for children 6–23 months of age. The main point for MNP distribution is the CWCs or GMPs held by the health facilities at various permanent (or “static”) and mobile (or “outreach”) locations, which children 0–59 months of age attend monthly. Another contact point for MNP distribution is the out-patient departments of the various health facilities.
The MNP distribution is done alongside the routine provision of complementary feeding counselling to all mothers and caregivers attending the CWC or GMP. As is written as well as illustrated pictorially on the sachet packets, mothers and caregivers receiving the MNPs for their 6–23 mo-old children are advised to give the child 1 sachet per day by mixing “the content of one sachet into a portion of solid or semi-solid food before serving”. There is, however, no description or warning of side effects on the sachet packets, and therefore, it is conceivable that the Community Health Nurses delivering the MNPs would typically not warn mothers/caregivers of any possible side effects. Currently, there are no teaching aids or behavior change materials specifically developed for MNP distribution and consumption. Mothers are introduced to MNPs through infant and young child feeding (IYCF) counselling given using the Ghana Ministry of Health IYCF counseling cards [25]. These counselling cards encourage the commencement of complementary feeding of infants at 6 mo of age; provision of a variety of foods that are easy for infants to eat or swallow; assisting infants to eat complementary foods through coaxing but not forced feeding; and ensuring hygiene [25].
Within the communities, MNP consumption is monitored by Community Health Nurses and Community Health Workers (trained low level cadre of health workers recruited from the communities where they live) [26] through routine home visits for delivering basic preventive and curative services at the household level, under the Community-based Health Planning and Services (CHPS) system [26, 27]. A child may stay in the MPI program for a maximum of 18 months. In the GHS’ approach, each child receives 30 sachets of MNP each month for a period of 3 months, followed by 3 months of not receiving any MNPs, and the cycle is then repeated until the child is 24 months of age. According to available guidelines [28], the target is to give 90 sachets of MNPs generally containing one RNI for each micronutrient over a period of 6 months, but the exact frequency of distribution (eg. all 90 sachets at once every 6 months or 30 sachets every other month, etc.) depends on programmatic feasibility [28].
Through the health facilities, the GHS uses such activities as local radio discussions, meetings with local chiefs and opinion leaders, and community durbars to sensitize communities to the MPI. UNICEF supplies the MNPs to the GHS, as well as provides various logistical and operational support capabilities, such as the training of GHS staff involved in the program implementation, and the supply of registers to track MNP acquisition and distribution.
Lessons learned study design and data collection
This was a qualitative cross-sectional study. During a 2-month period from November to December 2019, data were collected from each of the 4 districts as follows: secondary data on the quantity of MNP sachets received and number of children 6–23 months of age enrolled into the MPI since the beginning of implementation were obtained from the DNO who kept those records as furnished by the health facilities. Next, primary data were collected from 3 sources:
First, interviews were held with at least 5 GHS staff overseeing the MPI implementation, including the DNO (who was responsible for managing the program at the district level) and nurses from the major health facilities distributing the MNPs. Using a semi-structured questionnaire with open-ended questions (Supplementary file 1), information collected included: observations or experiences gained from the program implementation, including challenges or barriers encountered; successful strategies used in the implementation; and lessons learned.
Second, key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with mothers and caregivers who had a previous or current direct experience with feeding MNP to their infants 6–23 months of age. In each of 6 sub-districts within each district, 2 mothers or caregivers serving as key informants were selected to participate in individual KIIs, and up to 10 mothers and caregivers were selected to participate in a FGD. With the help of GHS staff involved with the program implementation in each sub-district, participants were selected for the KIIs or FGDs if they were believed to have considerable knowledge about the MPI and the attitudes of women in the communities towards MNP acceptability and consumption. Semi-structured questionnaires and interview guides prepared for the KIIs (Supplementary file 2) and FGDs (Supplementary file 3) solicited information related to the MPI, including mothers’ and caregivers’ observations or experiences participating in the program and what they had observed about the impact of MNP consumption in their children. It was unknown if any of the KII and FGD participants had purposely stopped feeding MNPs to their children for any reason, given that these participants were from among the list of mothers and caregivers recorded by the CWCs to have previously received, or were currently receiving, MNPs. The GHS staff had no list of those who had refused to try feeding MNPs to their children, and therefore there was none of such participants in the study.
Third, a discussions workshop was conducted in each district, in which at least one frontline staff member from each of 10 health facilities across the district participated. This workshop was used, first, to gather additional information about the MPI not yet captured in the prior interviews with program managers, KIIs and FGDs, and second, to allow the participants to validate, wherever possible, the information already collected through the interviews, KIIs and FGDs. Specific areas discussed at the workshop included those areas covered in the interviews with GHS staff overseeing the program implementation (Supplementary file 1).
In addition to the field notes taken, the interviews and discussions were audio-recorded and later transcribed verbatim. The interviews and workshop discussions with staff of GHS were held in English, whereas the KIIs and FGDs were held in the local languages before being translated into English. Ethics approval for this study was obtained from the Ghana Health Service Ethics Review Committee. Permission to interview the GHS staff was obtained from the Director, Family Health Division, Ghana Health Service.
Data analysis
The secondary data on quantities of MNPs received and the number of children enrolled into the MPI in each district were summarized using appropriate descriptive statistics. Transcripts and filled questionnaires were cleaned and imported into NVivo10 for analysis (QSR International, Melbourne, Australia). These data were analyzed using thematic analysis approach [29]. All transcripts and open-ended questions in the questionnaire were read in order to understand the data and to identify emerging codes and themes. The organizing themes focused on aspects of the MPI including (a) experiences of beneficiaries (mothers and caregivers) enrolled in the program, (b) experiences of program implementers (staff of GHS), including major challenges to program implementation and successful strategies used, and (c) suggested recommendations from beneficiaries and program implementers. The main experiences, challenges to program implementation, and strategies used were summarized, along with quotes from participants, for clarification and support. In all cases, quotes from multiple data sources (key informants, FGD panelists, and/or health workers) were presented showing triangulation of results, to support the conclusions. The facilitators (factors promoting the implementers’ ability and willingness to execute the program successfully, and mothers’ or caregivers’ ability and willingness to accept and utilize the program as promoted) and barriers (factors militating against successful program implementation or uptake) were also summarized.