Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia

Tumilowicz A, Habicht JP, Mbuya MNN, Beal T, Ntozini R, Rohner F, Pelto GH, Fisseha T, Haidar J, Assefa N, Wodajo HY, Wolde TT, Neufeld LM

October 2019 – Maternal & Child Nutrition

A theory‐driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross‐sectional survey data of caregivers of children 6–23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12–17 months were 32% (P < 0.001) and children 18–23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6–11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.

Micronutrient Deficiencies, Nutritional Status and the Determinants of Anemia in Children 0–59 Months of Age and Non-Pregnant Women of Reproductive Age in The Gambia

Petry N, Jallow B, Sawo Y, Darboe MK, Barrow S, Sarr A, Ceesay PO, Fofana MN, Prentice AM, Wegmüller R, Rohner F, Phall MC, and Wirth JP

September 2019 – Nutrients

Data on micronutrient deficiency prevalence, nutrition status, and risk factors of anemia in The Gambia is scanty. To fill this data gap, a nationally representative cross-sectional survey was conducted on 1354 children (0–59 months), 1703 non-pregnant women (NPW; 15–49 years), and 158 pregnant women (PW). The survey assessed the prevalence of under and overnutrition, anemia, iron deficiency (ID), iron deficiency anemia (IDA), vitamin A deficiency (VAD), and urinary iodine concentration (UIC). Multivariate analysis was used to assess risk factors of anemia. Among children, prevalence of anemia, ID, IDA, and VAD was 50.4%, 59.0%, 38.2%, and 18.3%, respectively. Nearly 40% of anemia was attributable to ID. Prevalence of stunting, underweight, wasting, and small head circumference was 15.7%, 10.6%, 5.8%, and 7.4%, respectively. Among NPW, prevalence of anemia, ID, IDA and VAD was 50.9%, 41.4%, 28.0% and 1.8%, respectively. Anemia was significantly associated with ID and vitamin A insufficiency. Median UIC in NPW and PW was 143.1 µg/L and 113.5 ug/L, respectively. Overall, 18.3% of NPW were overweight, 11.1% obese, and 15.4% underweight. Anemia is mainly caused by ID and poses a severe public health problem. To tackle both anemia and ID, programs such as fortification or supplementation should be intensified.

A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone: A food value-chain framework for improving future response strategies

Kodish SR, Bio F, Oemcke R, Conteh J, Beauliere JM, Pyne-Bailey S, Rohner F, Ngnie-Teta I, Jalloh MB, Wirth JP

September 2019 – PLOS Neglected Tropical Diseases

This study sought understand how the 2014–2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude. This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. During the humanitarian response,nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition sensitive interventions were not central to the initial response as EVD containment and survival took priority. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters.

Ebenezer Adjetey, BSc

Ebenezer Adjetey is an IT specialist, focusing on survey programming and data management for studies and surveys related to nutrition and public health. Ebenezer has programmed questionnaires and managed data for research trials related to infant and young child nutrition and iron-folate supplementation and adolescent girls in Ghana. As a consultant for GroundWork, he has programmed questionnaires for national nutrition and micronutrient surveys in Ghana, Uzbekistan, Jordan, and Somalia. Ebenezer is passionate about developing data collection systems that generate accurate, complete, and timely data. He is currently based in Accra, Ghana.

James P Wirth, PhD

James is an international nutrition specialist, focusing on the design and implementation of national public health and nutrition surveys, research on the determinants of stunting and anemia, and monitoring and evaluation reporting systems. James has conducted case control studies related examining the association between inflammation and enteropathy on child growth, and has conducted multiple national micronutrient and nutrition surveys. James is a member of the BRINDA (Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia) project, and has managed qualitative program evaluations related to food fortification and humanitarian response. He has worked in Angola, Azerbaijan, Bangladesh, Dominican Republic, Ethiopia, Ghana, Guinea, Gambia, India, Jordan, Kenya, Mozambique, Oman, Sierra Leone, Tanzania, Uganda, Vietnam, and Zambia. James is currently based in Geneva, Switzerland.

Respiratory infections drive hepcidin-mediated blockade of iron absorption leading to iron deficiency anemia in African children

Prentice AM, Bah A, Jallow MW, Jallow AT, Sanyang S, Sise EA, Ceesay K, Danso E, Armitage AE, Pasricha S, Drakesmith H, Wathuo M, Kessler N, Cerami C, Wegmuller R

March 2019 – Science Advances

Iron deficiency anemia (IDA) is the most prevalent nutritional condition worldwide. We studied the contribution of hepcidin-mediated iron blockade to IDA in African children. We measured hepcidin and hemoglobin weekly, and hematological, inflammatory, and iron biomarkers at baseline, 7 weeks, and 12 weeks in 407 anemic (hemoglobin < 11 g/dL), otherwise healthy Gambian children (6 to 27 months). Each child maintained remarkably constant hepcidin levels (P < 0.0001 for between-child variance), with half consistently maintaining levels that indicate physiological blockade of iron absorption. Hepcidin was strongly predicted by nurse-ascribed adverse events with dominant signals from respiratory infections and fevers (all P < 0.0001). Diarrhea and fecal calprotectin were not associated with hepcidin. In multivariate analysis, C-reactive protein was the dominant predictor of hepcidin and contributed to iron blockade even at very low levels. We conclude that even low-grade inflammation, especially associated with respiratory infections, contributes to IDA in African children.

The Gambia Micronutrient Survey 2018

National Nutrition Agency (NaNA)-Gambia, UNICEF, Gambia Bureau of Statistics (GBOS), GroundWork

March 2019 – Report Release, Banjul, The Gambia

The 2018 Gambia Micronutrient Survey (GMNS) is national and comprehensive micronutrient survey that was implemented in tandem with The Gambia’s 2018 Multiple Indicator Cluster Survey (MICS). The GMNS collected data on micronutrient deficiencies, anemia, and malaria in children 6-59 months of age, and non-pregnant women 15-49 years of age, and pregnant women. The GMNS also measured the prevalence of diet-related non-communicable diseases and conditions in non-pregnant women (e.g. overweight, obesity, diabetes, hypertension) and stunting, wasting, and underweight in children. The information generated by the GMNS will enable the government and international agencies to enhance existing national programs, such as vitamin A supplementation, and commercial fortification of wheat flour, rice, and vegetable oil. In addition, GMNS results will help nutrition stakeholders in The Gambia plan future nutrition and health interventions, in particular related to the double burden of malnutrition. The GMNS was conducted by the Gambia’s National Nutrition Agency (NaNA), UNICEF, GBOS, and GroundWork.

Measurement and interpretation of hemoglobin concentration in clinical and field settings: a narrative review

Karakochuk CD, Hess SY, Moorthy D, Namaste S, Parker ME, Rappaport AI, Wegmuller R, Dary O, & the HEmoglobin MEasurement (HEME) Working Group

February 2019 – Annals of the New York Academy of Sciences

Anemia affects over 800 million women and children globally. Defined as a limited or insufficient functional red blood cell supply in peripheral blood, anemia causes a reduced oxygen supply to tissues and can have serious health consequences for women and children. Hemoglobin (Hb) concentration is most commonly measured for anemia diagnosis. Methods to measure Hb are usually invasive (requiring a blood sample); however, advances in diagnostic and clinical chemistry over the past decade have led to the development of new noninvasive methods. Accurate diagnosis at the individual level is important to identify individuals who require treatment. At the population level, anemia prevalence estimates are often the impetus for national nutrition policies or programs. Thus, it is essential that methods for Hb measurement are sensitive, specific, accurate, and reproducible. The objective of our narrative review is to describe the basic principles, advantages, limitations, and quality control issues related to methods of Hb measurement in clinical and field settings. We also discuss other biomarkers and tests that can help to determine the severity and underlying causes of anemia. In conclusion, there are many established and emerging methods to measure Hb concentration, each with their own advantages, limitations, and factors to consider before use.

Consensus building around nutrition lessons from the 2014 – 16 Ebola virus disease outbreak in Guinea and Sierra Leone

Kodish SR, Simen-Kapeu A, Beauliere JM, Ngnie-Teta I, Jalloh MB, Pyne-Bailey S, Schwartz H, Wirth JP

February 2019 – Health Policy and Planning

To understand the nutrition challenges faced during the Ebola virus disease outbreak in West Africa, participatory workshops in Guinea and Sierra Leone were conducted in February 2017. Workshops followed the Nominal Group Technique, which is a methodological approach for idea generation and consensus building among diverse participants. Those findings were triangulated with qualitative interview data from participants representing government, United Nations bodies, civil society, nongovernmental organizations and local communities in both Guinea and Sierra Leone. In both countries, this research identified five key nutrition challenges, including reduced access and utilization of the health system, poor caretaking and infant and young child feeding practices, implementation challenges during nutrition response, household food insecurity and changing breastfeeding practices. (2) In Sierra Leone, organizational factors that facilitated this response included the use of standard operating procedures and psychosocial counselling. In contrast, in Guinea, hygiene assistance was distinctly important. Political will, Increased funding, food assistance and to a lesser extent, enhanced coordination, were deemed ‘most important’ response factors. Disease outbreaks pose widespread nutrition challenges to populations in resource-constrained settings where global health security is not a guarantee. These findings should be considered for emergency nutrition preparedness and inform evidence-based priority setting in the post-Ebola virus context of Guinea and Sierra Leone.

Jordan National Micronutrient & Nutrition Survey (JNMNS 2019)

Project Ongoing

In collaboration with the Jordan Health Aid Society-International (JHASi), GroundWork is conducting the Jordan National Micronutrient and Nutrition Survey (JNMNS 2019), a national micronutrient and nutrition survey that is being implemented in all governorates of Jordan and in Syrian refugee camps. The survey is funded by UNICEF and WFP, and is supported by the Ministry of Health (MOH) and the Department of Statistic in Jordan. Key collaborators of the JNMNS also include BioLabs, the American University of Beirut (AUB), and the University of Wisconsin. With guidance from MOH, GroundWork and JHASi are leading the planning of the survey, organizing for field and laboratory logistics, data entry and analysis, and reporting and dissemination.