Reaching vulnerable populations in low-resource settings with effective business solutions is critical, given the global nature of food and nutrition security. Over a third of deaths of children under 5 years of age are directly or indirectly caused by undernutrition. The Lancet series on malnutrition (2013) estimates that over 220,000 lives of children under 5 years of age can be saved through the implementation of an infant and young child feeding and care package. A unique project being undertaken in Ghana aims to bring in two elements of innovation in infant and young child feeding. The first involves a public-private partnership (PPP) to develop and test the efficacy and effectiveness of the delivery of a low-cost complementary food supplement in Ghana called KOKO Plus TM . The second involves the testing of the concepts of social entrepreneurship and social business models in the distribution and delivery of the product. This paper shares information on the ongoing activities in the testing of concepts of PPPs, social business, social marketing, and demand creation using different delivery platforms to achieve optimal nutrition in Ghanaian infants and young children in the first 2 years of life. It also focuses on outlining the concept of using PPP and base-of-the-pyramid approaches toward achieving nutrition objectives.

The work reported here assesses the coverage achieved by two sales-based approaches to distributing a complementary food supplement (KOKO Plus™) to infants and young children in Ghana. Delivery Model 1 was conducted in the Northern Region of Ghana and used a mixture of health extension workers (delivering behavior change communications and demand creation activities at primary healthcare centers and in the community) and petty traders recruited from among beneficiaries of a local microfinance initiative (responsible for the sale of the complementary food supplement at market stalls and house to house). Delivery Model 2 was conducted in the Eastern Region of Ghana and used a market-based approach, with the product being sold through micro-retail routes (i.e., small shops and roadside stalls) in three districts supported by behavior change communications and demand creation activities led by a local social marketing company. Both delivery models were implemented sub-nationally as 1-year pilot programs, with the aim of informing the design of a scaled-up program. A series of cross-sectional coverage surveys was implemented in each program area. Results from these surveys show that Delivery Model 1 was successful in achieving and sustaining high (i.e., 86%) effective coverage (i.e., the child had been given the product at least once in the previous 7 days) during implementation. Effective coverage fell to 62% within 3 months of the behavior change communications and demand creation activities stopping. Delivery Model 2 was successful in raising awareness of the product (i.e., 90% message coverage), but effective coverage was low (i.e., 9.4%). Future programming efforts should use the health extension / microfinance / petty trader approach in rural settings and consider adapting this approach for use in urban and peri-urban settings. Ongoing behavior change communications and demand creation activities is likely to be essential to the continued success of such programming.

Inadequate protein quality may be a risk factor for poor growth. To examine the effect of a macronutrient–micronutrient supplement KOKO Plus (KP), provided to infants from 6 to 18 months of age, on linear growth, a single-blind cluster-randomised study was implemented in Ghana. A total of thirty-eight communities were randomly allocated to receive KP (fourteen communities, n 322), a micronutrient powder (MN, thirteen communities, n 329) and nutrition education (NE, eleven communities, n 319). A comparison group was followed cross-sectionally (n 303). Supplement delivery and morbidity were measured weekly and anthropometry monthly. NE education was provided monthly. Baseline, midline and endline measurements at 6, 12 and 18 months included venous blood draws, diet, anthropometry, morbidity, food security and socio-economics. Length-for-age Z-score (LAZ) was the primary outcome. Analyses were intent-to-treat using mixed-effects regressions adjusted for clustering, sex, age and baseline. No differences existed in mean LAZ scores at endline (−1·219 (sd 0·06) KP, −1·211 (sd 0·03) MN, −1·266 (sd 0·03) NE). Acute infection prevalence was lower in the KP than NE group (P = 0·043). Mean serum Hb was higher in KP infants free from acute infection (114·02 (sd 1·87) g/l) than MN (107·8 (sd 2·5) g/l; P = 0·047) and NE (108·8 (sd 0·99) g/l; P = 0·051). Compliance was 84·9 % (KP) and 87·2 % (MN) but delivery 60 %. Adjusting for delivery and compliance, LAZ score at endline was significantly higher in the KP v. MN group (+0·2 LAZ; P = 0·026). A macro- and micronutrient-fortified supplement KP reduced acute infection, improved Hb and demonstrated a dose–response effect on LAZ adjusting consumption for delivery.

BackgroundOnly 13% of Ghanaian infants 6–23 months have a minimum acceptable diet. The study examined the effect of a macro‐ and micro‐nutrient fortified complementary food supplement (KokoPlus™) on growth and nutritional status of Ghanaian infants.MethodsIn a cluster randomized study, 38 communities were randomly assigned to three arms: KokoPlus™ and nutrition education (KP), Micronutrient powder and nutrition education (MN) and Nutrition education alone (NE) (n=301 infants/group). KP and MN received the same micronutrient dosage. Supplements were to be delivered weekly with instructions to use one sachet daily. Monthly nutrition education sessions included recipe demonstration and emphasized breastfeeding, complementary feeding and WASH practices. Baseline (B), midline (M) and endline (E) data collected at 6, 12 months and 18 months of age respectively. Research protocol included a venous blood draw, dietary assessment, SE status, morbidity, WASH and food security at B, M and E, monthly anthropometry assessments and weekly morbidity assessment and compliance with protocol. Length for age (LAZ), Weight for age (WAZ) and Weight for height (WLZ) Z‐scores were computed using the 2006 WHO‐MGRS growth reference. Serum hemoglobin, retinol binding protein, ferritin, zinc, C‐reactive protein and alpha glycoprotein, IGF‐1 and cortisol were assessed. Iron markers were corrected for infection. Analysis was intent to treat and included post hoc compliance modeling with mixed effects linear regressions adjusting for community clustering, age, baseline outcome measure, maternal height or maternal BMI.ResultsMean LAZ scores at B time point were −0.74 ±1.02, −0.74 ±0.97 and −0.64 ±1.01 and E time point were −1.219 ± 0.06, 1.211 ± 0.03, and −1.266 ± 0.03 in groups KP, MN and NE respectively. At E, serum hemoglobin was significantly higher in the KP (114.02 ± 1.87 g/L) than MN (107.8 ± 2.5 g/L) or NE (108.8 ± 0.99 g/L) correcting for acute infection. Compliance (% of delivered supplement consumed) for KP and MN were 86.2% and 88.4% respectively; however, only 60% of supplement delivery was achieved. Post hoc modeling showed significant associations between higher supplement consumption with LAZ gain and serum zinc levels in KP, but not MN, indicating potential effects of KP masked by incomplete supplement delivery.ConclusionsA macronutrient‐micronutrient fortified complementary food supplement significantly improved hemoglobin in infants with no acute infection but showed no significant difference in LAZ scores. Modeling using intended delivery rates and observed compliance shows significant improvement in LAZ and serum zinc implying a dose response effect of the intervention. Further work optimizing delivery and uptake of this intervention is required to validate this finding.Support or Funding InformationThis study was supported by Ajinomoto Inc and JICA.

BackgroundIn Ghana, 13% of infants 6–23 months have an acceptable diet and linear growth fails to meet WHO standards. Interventions using micronutrient powders, cereal‐legume blends and lipid nutrient supplements have shown variable results. The effect on linear growth of a macro‐ and micro‐nutrient fortified complementary food supplement (KokoPlus) was examined in a single blind cluster randomized controlled trial conducted in Central region, Ghana.MethodsOf 61 communities in 3 districts, 38 communities were selected (population < 1000) and randomly allocated to (A) KokoPlus and nutrition education, (B) Micronutrient powder and nutrition education, (C) Nutrition education alone (n=301 per group). All supplements had the same micronutrient composition and were delivered on a weekly basis; mothers were instructed to use one sachet daily. Monthly nutrition education sessions emphasized breastfeeding, appropriate complementary feeding, water, hygiene, sanitation practices and recipe demonstrations. Infants were recruited at age 6 months and baseline data (B) collected following informed consent with midline (M) and endline (E) at 12 months and 18 months respectively. Data included dietary intake, socio‐economic characteristics, morbidity, water, hygiene and sanitation practices, food security at B, M and E, anthropometric data monthly and morbidity and compliance weekly. A venous blood draw (< 5ml) was collected at B, M and E.ResultsHeight for age Z scores (HAZ) were estimated using the 2006 WHO growth reference on 892 infants who completed the study. All analyses were intent to treat and included mixed effects linear regression modeling accounting for clustering adjusted for age, height, baseline HAZ and maternal education. No differences were found in baseline characteristics across the three groups. Over the 12‐month study period, change in HAZ score was −0.49 in A, −0.52 in B and −0.54 in C (p >0.05). Compliance for A and B was 86% and 88% respectively. Delivery of supplements was suboptimal (~60% of intended delivery for both groups) actual consumption was half of expected (186 of 365). Adjusting for actual supplements consumed revealed a significant difference between A and B groups in HAZ scores especially as consumption increased. Modeling the data for 86% compliance and 100% delivery yielded a difference of 0.2 HAZ‐score between A and B (p=0.026).ConclusionsA 12‐month intervention of a macronutrient‐ micronutrient fortified complementary food supplement showed no significant difference in HAZ scores. The findings are confounded by incomplete delivery of the supplements to study participants, modeling using the intended delivery rates with observed compliance showed a marked improvement in Z‐scores with a potential dose response effect of the macro‐micronutrient intervention. Further work optimizing delivery and uptake of this intervention is required to validate this finding.Support or Funding InformationThis study was supported through a grant from Ajinomoto Inc, Japan.