Improved Information and Educational Messages on Outer Packaging of Micronutrient Powders Distributed in Indonesia Increase Caregiver Knowledge and Adherence to Recommended Use

Barriers to and Facilitators of the Implementation of a Micronutrient Powder Program for Children: A Systematic Review Based on the Consolidated Framework for Implementation Research

BACKGROUND

As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions.

METHOD

Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process.

RESULTS

A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation.

CONCLUSION

Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.

Case Study of Municipal Waste and Its Reliance on Reverse Logistics in European Countries

The authors have examined municipal waste, its components and their integration with reverse logistics processes. Background: The theoretical part begins with a definition of municipal waste. Later, the integration between municipal waste and reverse logistics is provided, including presentation of the hierarchy of qualitative methods and models. Methods: The authors constructed a correlation matrix and applied a dynamic regression model to identify that the level of municipal waste impacts recycling of biowaste which demands reverse logistics. Results: The authors provided a dynamic regression model which could be applied for forecasting the size of recycled municipal waste into biowaste indicated in European Union countries. Conclusions: The variety of components in municipal waste prevents the increase of the recycling rates and has to be changed to ones that have higher recycling rates.

Lessons learned from implementing the pilot Micronutrient Powder Initiative in four districts in Ghana

Background

Micronutrient deficiencies affect many children in low-income settings due primarily to over-reliance on complementary foods low in nutrients. Home-fortification (HF) could improve children’s diet quality in these settings. The Ghana Health Service, supported by UNICEF, integrated the pilot Micronutrient Powder Initiative (MPI) into Child Welfare Clinic (CWC) services in four districts (Tain, Tolon, Talensi, and Ho West), whereby micronutrient powder (MNP) is supplied for HF for children aged 6–23 months attending CWCs. This study’s main aim was to identify the facilitators, barriers and “lessons learned” after 2 years of program implementation.

Methods

This was a qualitative cross-sectional study. MNP distributed and children enrolled were obtained from program records. Primary data were collected from November to December 2019 and included, by district: interviews with senior program staff; key informant interviews and focus group discussion with caregivers in each of 6 sub-districts; and discussions workshop with frontline staff from at least 10 health facilities. Besides field notes, all interactions were audio-recorded and transcribed verbatim. Qualitative data were analyzed using NVivo10.

Results

The MPI remains on-going, with about 2.5 million MNP sachets distributed to nearly 30,000 children within 90 district-months. Caregivers generally accept the MNP; reported positive responses in children include: “increased appetite”, “less frequent illnesses, “increased energy/strength”, “increased weight”, and “walking independently relatively early”. Main facilitators are: generally regular MNP availability; increased patronage of CWC services; various contact points for supplying MNPs; fairly strong social mobilization strategy; good integration of MPI with CWC services; “one-on-one” counselling for caregivers reporting side effects; and tracing caregivers to address concerns and monitor adherence. Main barriers are: lack of counselling materials; caregivers’ suspicions towards the program; absence of refresher training for frontline workers; and perceived MNP side-effects. Key lessons learned are: incorporating MNPs into CWC services is feasible, acceptable, and could reduce child micronutrient deficiencies in program districts; and MPI’s success requires stronger community sensitization, equipping frontline workers to advise caregivers and manage side-effects, and consciously identifying and managing logistical challenges.

Conclusion

Further research is needed to evaluate the effectiveness of the MPI in reducing micronutrient deficiencies among 6–23-months-olds in Ghana.