The Effects of Deworming and Multiple Micronutrients on Anaemia in Preschool Children in Bangladesh: Analysis of Five Cross-Sectional Surveys

Anaemia is a major public health problem among children < 5 years of age in Bangladesh due to recurrent intestinal parasite infections. The aim of this study was to understand the association between combining deworming and MNP home fortification (MNP + Deworming) and the prevalence of anaemia among children < 5 years of age in Bangladesh. We used pooled data from five cross-sectional surveys and performed multivariable logistic regression and calculated crude and adjusted odds ratios (AORs) to quantify the association of anaemia with the exposure variables. A total of 9948 households were considered for this paper. In the unadjusted logistic regression, no significant association was detected between the effective MNP coverage and anaemia prevalence, but the associations were significant (p < 0.001) between the deworming and anaemia prevalence and between the MNP + Deworming condition and anaemia prevalence. In the adjusted model, children who were exposed to both deworming and effective MNP coverage were 30% (AOR 0.70; 95% CI 0.52, 0.94; p = 0.018) less likely to be anaemic compared with children who were unexposed to combined MNP + Deworming. The combined effects of deworming and MNP supplementation on the reduction in anaemia prevalence highlighted the importance of using integrated and multidisciplinary intervention strategies.

Exploring Behavioral Factors Affecting Nutritional Supplement Use Among Children in Honduras

Objective: This study explored social and behavioral factors associated with a home fortification of complementary foods program among families of undernourished children in 14 rural communities in Honduras. Design: We collected and analyzed survey data from a convenience sample of 196 households participating in a nutritional program using home fortification of complementary foods in 2017. The program supplied families with a soy-based atole powder fortified with micronutrients. A research team completed a face-to-face survey exploring social and behavioral factors associated with nutritional supplement use. Anthropometric measurements for participating children were abstracted from health clinic records of previous quarterly appointments. Setting: The study took place in San Jose del Negrito, Honduras. Participants: Participants were parents or guardians of children enrolled in the nutrition program. Results: Nearly half of participant families shared the nutritional supplement with other family members besides the index child, while 10% reported using the supplement as a meal replacement for the child. Low education level of mothers was associated with improper use of the supplement (p = 0.005). Poorer families were more likely to share the supplement (p = 0.013). Conclusions: These results highlight the challenges of programs using home fortification of complementary foods in the context of food scarcity. Findings highlight the importance of increasing rural children’s overall caloric intake, perhaps by increasing access to locally available protein sources. Results also suggest transitioning nutritional programs to family-based interventions to increase overall intended compliance to nutrition programming.

Implementation science in nutrition: a summary and synthesis

Objective:This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled ‘Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh’.Design:Commentary, summary and synthesis.Settings:Low- and middle-income country.Results:The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation’s effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme.Conclusions:Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.

Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh

Objective: We estimated the cost-effectiveness of home fortification with micronutrient powder delivered in a sales-based programme in reducing the prevalence of Fe deficiency anaemia among children 6–59 months in Bangladesh. Design: Cross-sectional interviews with local and central-level programme staff and document reviews were conducted. Using an activity-based costing approach, we estimated start-up and implementation costs of the programme. The incremental cost per anaemia case averted and disability-adjusted life years (DALY) averted were estimated by comparing the home fortification programme and no intervention scenarios. Setting: The home fortification programme was implemented in 164 upazilas (sub-districts) in Bangladesh. Participants: Caregivers of child 6–59 months and BRAC staff members including community health workers were the participants for this study. Results: The home fortification programme had an estimated total start-up cost of 35·46 million BDT (456 thousand USD) and implementation cost of 1111·63 million BDT (14·12 million USD). The incremental cost per Fe deficiency anaemia case averted and per DALY averted was estimated to be 1749 BDT (22·2 USD) and 12 558 BDT (159·3 USD), respectively. Considering per capita gross domestic product (1516·5 USD) as the cost-effectiveness threshold, the home fortification programme was highly cost-effective. The programme coverage and costs for nutritional counselling of the beneficiary were influential parameters for cost per DALY averted in the one-way sensitivity analysis. Conclusions: The market-based home fortification programme was a highly cost-effective mechanism for delivering micronutrients to a large number of children in Bangladesh. The policymakers should consider funding and sustaining large-scale sales-based micronutrient home fortification efforts assuming the clear population-level need and potential to benefit persists.

Effectiveness of various methods of home fortification in under-5 children: where they work, where they do not. A systematic review and meta-analysis

Context The common approaches of home fortification (HF) for prevention and/or treatment of micronutrient deficiencies are micronutrient powders (MNPs), foodlets, and lipid-based nutrient supplements (LNSs). There are mixed results for the impact of HF on growth and nutritional status of young children. Objective This systematic review was prepared in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate current evidence from randomized controlled trials including children younger than 5 years to assess the effect of strategies of HF on growth and micronutrient status. Methods The MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar databases were searched to July 2018. A total of 1301 studies were found in a preliminary search. After screening of titles and abstracts, 30 studies were selected. Results Treatment with MNPs, foodlets, and LNSs effectively increased hemoglobin concentrations by at least 2.52 g/L, 4.59 g/L, and 4.4 g/dL, respectively, as compared with a control. There was a significant decrease in risk of anemia development after foodlet intervention compared with a control or iron drops (odds ratio, 0.27; 95%CI, 0.10–0.74; P = 0.01). However, these interventions did not result in any significant improvement in z-scores for changes of height for age, weight for age, and weight for height. The results indicated that MNP (7.16; 95%CI, 0.31–14.01; P = 0.04) and foodlet treatment (4.92; 95%CI, 0.28–9.57; P = 0.04) could increase serum zinc levels. However, none of the home fortification methods improved vitamin A status in the target group. Conclusion Home fortification can be used as an effective method to improve hemoglobin, iron, and zinc status, although in this study it had no effect on vitamin A or anthropometric indicators of the target population. More investigations are warranted for newer approaches of HF to improve a broader range of micronutrients as well as child growth indices and for evaluation of the coverage, compliance, and consistency of such interventions at the population level. PROSPERO Registration No.: CRD42018109279