Micronutrient powder use in Arequipa, Peru: Barriers and enablers across multiple levels

Abstract

In Peru, nearly half of children aged 6–36 months were diagnosed with anaemia in 2017. To address this disease, the Peruvian Ministry of Health implemented a national programme in 2014, distributing free micronutrient powders (MNPs) to all children of this age. However, rates of childhood anaemia remain high. The aim of this study was to explore factors at all levels of the Social‐Ecological Model that affect MNP use and adherence in Arequipa, an Andean city with childhood anaemia rates higher than the national average. We conducted in‐depth interviews with 20 health personnel and 24 caregivers and 12 focus group discussions with 105 caregivers. We identified numerous barriers, including negative side effects (constipation, vomiting, and diarrhoea), poor taste of MNP, lack of familial and peer support for its use, insufficient informational resources provided by the health system, and limited human resources that constricted health personnel abilities to implement MNP programming successfully. Facilitators identified included concern about the long‐term effects of anaemia, support from organizations external to the health system, well‐coordinated care within the health system, and provision of resources by the Ministry of Health. We found that community or organizational and societal factors were key to limited MNP use and adherence, specifically the limited time health personnel have to address caregivers' doubts during appointments and the lack of informational resources outside of these appointments. Potential policy implications could be to increase informational resources available outside of individualized counselling by strengthening existing collaborations with community organizations, increasing media coverage, and providing group counselling.

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

“…remain, or do emerge from time to time. Previous studies on MNP have identified shortage of MNPs, lack of educational tools, and inadequate training as barriers to MPI implementation [ 20 , 21 , 36 ]. These challenges need to be consciously identified and managed, in order for the program to run effectively and thereby achieve its objectives.…”

Behavioral Insights Into Micronutrient Powder Use for Childhood Anemia in Arequipa, Peru

“…Negative experiences with MNP, such as side effects or bad taste, and the effect of negative comments from family and peers, have all been noted in previous studies. 7,13,15,[17][18][19]22 Although previous work has typically interpreted negative comments as lack of social support for MNP use and therefore proposed increased informational outreach to family members and peers as a solution, 17 our results highlight the importance of including specific behavioral guidance to family and peers to not to overemphasize prior complications and negative experiences.…”

“…[51][52][53][54] Hot-cold empathy gap is particularly relevant for understanding what happened when caregivers intended or planned to use MNP during child feeding but abandoned that plan in the moment when children resisted, refused, reacted strongly to taste, or experienced side effects such as diarrhea, all of which are commonly cited barriers in the literature. 7,13,15,18,19,[55][56][57][58][59] Awareness of the hot-cold empathy gap can provide a channel for improved program development. Given that people generally don't understand their actions as "statedependent," a possible intervention involves preparing caregivers for side effects that might cause anxiety.…”

“…7 Previous research on MNP use in Peru has found that confusion about MNP administration, MNP's unpleasant taste, side effects, lack of familial and peer support, and negative interactions with those who distribute MNP were barriers to adherence. 7,[13][14][15] Alternatively, key facilitators for MNP use were interpersonal support, concern about the long-term effects of anemia, and tailored counseling. 7,[13][14][15] Studies on MNP use in other countries confirm that these factors affect MNP program effectiveness.…”

“…7,[13][14][15] Alternatively, key facilitators for MNP use were interpersonal support, concern about the long-term effects of anemia, and tailored counseling. 7,[13][14][15] Studies on MNP use in other countries confirm that these factors affect MNP program effectiveness. [16][17][18][19][20][21][22][23] Previous research on MNP interventions have led to programmatic changes in other countries such as health care providers including warnings about possible side effects in their counseling to caregivers, recommendations to administer MNP on a flexible instead of fixed schedule, and promotion through educational campaigns with community health providers, among others.…”