Toward a better understanding of adherence to micronutrient powders

Caregivers all over the world want to give their children the best start in life, especially in the first 1,000 days, from conception to two years of age, when children need high intake of vitamins and minerals for healthy development. Several interventions, for example, breastfeeding, supplementation, and food fortification of complementary foods, are available to support a child’s healthy growth. However, a combination of cultural, environmental, and programmatic factors can sometimes hinder the successful implementation of these integrated nutrition interventions.

This is where micronutrient powders (MNPs) come in. Introduced by Dr. Stanley Zlotkin in the late 1990s, MNPs are sachets of powdered vitamins and minerals that can be added to complementary foods and given to children on a daily basis. Easy to use, MNPs do not change children’s dietary habits but can be added to semi-solid foods that are already part of a child’s diet. More importantly, MNPs boost children’s micronutrient intake and reduce their risk of iron deficiency and anaemia.

Reviewing the literature on adherence to MNPs

GAIN is doing its bit to harness the potential of MNPs. With funding from the Ministry of Foreign Affairs of the Netherlands, we are supporting the Federal Ministry of Health (FMOH) of Ethiopia and the Mozambique Ministry of Health (MISAU) to deliver pilot MNP programs in their countries.

As we are preparing to evaluate the two pilot programs, our researchers, in collaboration with scientists from the Research Triangle Institute (RTI) and Cornell University, carried out a study to better understand what is currently known about the factors that affect MNP adherence. Following a literature search that identified 35 studies and six program descriptions related to adherence to MNPs, our researchers conducted a thematic analysis to generate a list of factors that could influence adherence and then quantified the results through content analysis.

Perceptions, culture, and the environment influencing MNP adherence

The findings of the study are discussed in a recent paper Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results  published in the Current Developments in Nutrition Journal.

The results show that the main factors influencing adherence to MNPs were:

  1. Caregivers’ perceptions of positive change as a result of MNP use

Indeed, caregivers who perceive positive changes in their children’s health for example, less diarrhoea or increased appetite as a result of MNP intake were more likely to continue to add MNPs to their children’s diets. However, a study in the Kakuma Refugee Camp in Kenya included in the review found that children’s increased appetite in households where food rations were insufficient could raise further nutritional challenges.

  1. Caregivers’ perceived child acceptance of food with MNP

Many caregivers take their cues from children when it comes to MNPs. For example, studies in Nepal, Peru, and Indonesia showed that mothers whose children rejected food mixed with MNPs were less likely to perceive the benefits of MNP intake or to continue to use the sachets. However, there is room for trial and error. For example, research in India showed that caregivers mixed MNPs with different foods to find the best ones in which the powdered nutrients would go undetected by children. Indeed, a caregiver in India stated “When I mix it (MNP) with rice and curry, nobody identifies that something is added to the food. (The child) eats without any complaint.”

  1. Caregivers’ forgetfulness

In many cases, children don’t get a chance to get fussy about MNP-spiked food. That is because caregivers forgot to add the powdered minerals and vitamins to their diets. Close to a third of the reviewed studies found that caregivers preferred a flexible administration regime, which they could integrate into their daily routine, as opposed to fixed schedules during which to add MNPs to their children’s diets. Reminder cards and encouraging caregivers’ agency in administering the MNPs were identified as successful tactics to increase adherence in Nepal and Bangladesh.

Implications for MNP programs  

Alongside these three main factors, the reviewed studies suggest that caregivers’ existing infant and young child feeding practices, their knowledge and beliefs, as well as the physical and social environments they live in influence their adherence to MNPs. These findings entail important programmatic implications, which GAIN will incorporate into its MNP programmes and associated evaluations. Indeed, knowledge and perception of MNPs are significant, but so are cultural and environmental factors. For example, restrictions on women’s mobility outside the home in Bangladesh may impact the continuous use of MNPs in certain households; equally, cultural beliefs associating MNPs with medicine may affect adherence to MNPs.

Download the full study here

Read more about our micronutrient powder program in Mozambique here

Find out more about GAIN’s MIYCN program here

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Published 12 July 2017