The lancet series nutritional interventions in Ghana: A determinants analysis approach to inform nutrition strategic planning

  • BMC Nutrition, Volume 3, No. 1, Year 2017

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Study Justification:
– Malnutrition is a leading cause of mortality and morbidity among children in low- and middle-income countries.
– Ghana has a high burden of stunting among children.
– The aim of this study is to use data-driven planning methods to analyze nutritional interventions in Ghana and inform nutritional strategic planning.
Highlights:
– The study used a mixed methods approach, combining quantitative data analysis and qualitative phenomenological analysis.
– Key findings include low coverage of frontline health workers trained on lactation management and breastfeeding support, low initiation of breastfeeding within one hour of birth, and low adherence to iron folate supplementation during pregnancy.
– Other findings include low coverage of vitamin A supplementation, low admission rates for severe acute malnutrition treatment, and inadequate dietary diversity for infants.
– Barriers to nutrition coverage in Ghana include inadequate training for staff, low prioritization and coordination at higher levels, and weak integration of services at lower levels.
– The study provides workable strategies to improve nutrition services in Ghana.
Recommendations:
– Increase training for frontline health workers on lactation management and breastfeeding support.
– Promote early initiation of breastfeeding within one hour of birth.
– Improve adherence to iron folate supplementation during pregnancy.
– Increase coverage of vitamin A supplementation.
– Improve admission rates for severe acute malnutrition treatment.
– Enhance dietary diversity for infants.
Key Role Players:
– Regional Deputy Director of Public Health
– Regional Public Health Nurse
– Regional Nutrition Officer
– Regional Health Information Officer
– Nutrition Unit of the Ghana Health Service
– Representatives from development partners (UNICEF, WHO, WFP)
Cost Items for Planning Recommendations:
– Training programs for frontline health workers
– Supplies and resources for lactation management and breastfeeding support
– Awareness campaigns and education materials for promoting early initiation of breastfeeding
– Iron folate supplementation programs
– Vitamin A supplementation programs
– Treatment facilities and resources for severe acute malnutrition
– Nutrition education and counseling programs for caregivers
– Monitoring and evaluation systems for tracking progress and impact

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed methods approach, including quantitative data generated by the Determinants Analysis Tool and qualitative data from group discussions. The study provides specific percentages and statistics on various nutrition interventions in Ghana. However, the abstract does not mention the sample size or representativeness of the participants, which could affect the generalizability of the findings. To improve the evidence, the abstract should include information on the sample size and how the participants were selected to ensure a representative sample. Additionally, providing more details on the methodology, such as the specific data collection methods and analysis techniques, would enhance the strength of the evidence.

Background: Malnutrition is a leading cause of mortality and morbidity among children in low- and middle-income countries. Ghana is one of 36 countries with the highest burden of stunting, globally. The aim of this work is to use data driven planning methods to conduct in-depth analysis on the Lancet series nutrition interventions in Ghana to inform nutritional strategic planning. Methods: A mixed methods approach was employed for this national nutritional assessment conducted in May 2016. Quantitative data on nutritional interventions were generated by application of the Determinants Analysis Tool and phenomenological approach was employed to explain the causes of barriers identified. Outputs from the tool were analyzed by simple descriptive statistics and data from group discussions were assessed by thematic content analysis. The base line years for this assessment were 2014 and 2015. Results: Overall in Ghana, 21.0% of frontline health workers are trained on lactation management and breastfeeding counselling and support, 56.6% of mothers of children 0-2 years initiated breastfeeding within one hour of birth, and 59.4% of mothers with children 0-5 months took iron folate supplementation for 90 or more days during pregnancy. In addition, only 19.9% of children 12-59 months received two doses of vitamin A supplementation in a calendar year, and 32.5% of children 6-59 months with severe acute malnutrition were admitted for treatment at health facilities. In all, among infants 6-8 months old, 6.9% were fed with minimum dietary diversity, 50.6% received age appropriate meal frequency and 21.6% received iron rich diet. Inadequate pre-service and in-service training for staff, low prioritization and coordination (at higher levels) and weak integration of services (at lower levels) were key barriers to nutrition coverage in Ghana. Conclusion: Data driven analysis and planning based on proven nutritional interventions in Ghana demonstrated gaps and barriers and garnered workable strategies to improve nutrition services.

Mixed methods approach were employed for this national nutritional assessment conducted in May 2016. Quantitative data on nutritional interventions was generated by application of the Determinants Analysis Tool and phenomenological approach was employed to explain the causes of barriers identified. Four participants (Regional Deputy Director of Public Health, Regional Public Health Nurse, Regional Nutrition Officer and Regional Health Information Officer) were purposively selected from each of the ten administrative regions in the Ghana due to their background and role in nutrition services. In addition local facilitators (Nutrition Unit of the Ghana Health Service) and representatives from some development partners (including UNICEF, WHO and World Food Programme (WFP) participated. Ghana has ten administrative regions, and officers from all ten regions were included to provide a nationwide representation. The national assessment was undertaken in the Ashanti Region of Ghana for three days to assess barriers to coverage of nutrition services and included desk review, group discussions and key informants interviews. Facilitators assisted in the desk reviews, conduct of interviews and provided mentoring and coaching on capturing major issues and recording of key points from the group discussion. Main causes of identified bottlenecks to the nutritional interventions were thematically analysed through a phenomenological approach under service delivery factors and enabling environment factors through group discussions. Phenomenological approach was used to allow a deeper understanding of an event or phenomenon by looking at the story of the group who experienced a shared lived experience or phenomenon [16]. Six teams made up of regional, national and international personnel were formed in line with the key interventions to provide qualitative explanation and assessment of the outputs from the tool. The Determinants Analysis framework is premised on the notion that effective coverage of services is influenced by four main factors or determinants namely: supply, demand, quality and environment. The Ten Determinant Model Tool produces a graphical output (Fig. 1) that facilitates identification of the key bottlenecks. Graphical presentation of the determinants analysis framework. Description of figure: The figure describes the supply side, demand side and effective coverage determinants and how bottlenecks are determined Overall, the Ten Determinant Model used for this nutrition assessment in Ghana had FOUR Domains with TEN Determinants: Enabling Environment (Social Norms, Management/Coordination, Legislation/Policy and Budget/Expenditures); Supply (Commodities, Human Resource and Access); Demand (Initial Utilisation, Continuous Utilisation/Knowledge) and Effective Coverage/Behaviour [17, 18]. Identification of the low bars on the supply-determinant side of the graph as well as a sharp drop from one bar to the next on the demand and quality-determinant side of the graph enables managers to identify and prioritize bottlenecks to the effective health service coverage. The Ten Determinant Model is based on Microsoft Excel sheets linked together with sections for data inputs linked to outputs. Input data produce simple bar graphs that display the determinants of health service coverage and thus facilitate identification of key bottlenecks that influence effective coverage (illustrated in Fig. 1). The section for data input is fully linked with the section that displays the outputs. The tool directly utilised data from District Health Information Management System (DHIMS), Multi-Indicator Cluster Survey (MICS) Reports [19], Demographic and Health Surveys (DHS) [20] and other sources of data including programme monitoring and review reports. The DHIMS is a tool for collection, validation, analysis, and presentation of aggregate statistical data, tailored to integrated health information management activities in the Ghana Health Service. Six key nutrition tracer interventions based on The Lancet Series-Maternal and Child Nutrition [15], were selected as, Community Management of Acute Malnutrition (CMAM), Complementary Feeding, Early Initiation to Breastfeeding, Exclusive Breastfeeding, Vitamin A Supplementation, and Iron-Folic Acid Supplementation. Each intervention was assessed based on a particular delivery platform (as individualized facility based services or schedulable and outreach services or as family oriented practices and community based services) to enable accurate identification of barriers and bottlenecks. In this analysis, minimum acceptable diet for complementary feeding was assessed using two sub components-minimum dietary diversity and age appropriate meal frequency as specified in the Ministry of Health National Nutrition Policy of Ghana [12]. Each of the six thematic groups had a moderator and a recorder. Data from group discussions were organized and described using manual thematic content analysis for qualitative data. Each group worked on a different theme to eliminated the issue of duplication and repetition of information among the groups. Quantitative data were analyzed with simple descriptive statistics (i.e. proportions and percentages) by Microsoft Excel 2013. The base line years for this assessment were 2014 and 2015 and national coverage targets were used as the benchmark to assess these coverage indicators. Outputs from the tool were analyzed by simple descriptive statistics such as frequency, proportions and ratios. The determinants analysis principles were applied to identify bottlenecks. Causality analysis were conducted to identify barriers resulting in these bottleneck. This formed the basis in determining strategies to remove the bottlenecks on nutritional deprivation in Ghana. All data used was aggregated data at national level and had no link to individuals. In all cases, documentations and computerized records were kept secure and accessible to persons directly involved in developing the operational plans. The Ghana Health Service Ethics Review Committee and office of the Policy, Planning, Monitoring and Evaluation Division of the Ghana Health Service gave approval for documentation and dissemination of the Determinant Analysis process in Ghana.

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Based on the provided description, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthening Training Programs: Develop and implement comprehensive pre-service and in-service training programs for frontline health workers on lactation management, breastfeeding counseling, and support. This will ensure that health workers have the necessary knowledge and skills to provide effective maternal health services.

2. Improving Coordination and Integration: Enhance coordination and integration of maternal health services at both higher and lower levels. This can be achieved through better collaboration between different stakeholders, such as the Ghana Health Service, UNICEF, WHO, and the World Food Programme. Strengthening coordination will help streamline efforts and ensure that services are delivered efficiently.

3. Increasing Awareness and Education: Implement targeted awareness and education campaigns to increase knowledge and understanding of the importance of maternal nutrition and interventions. This can be done through community-based programs, mass media campaigns, and the involvement of community leaders and influencers.

4. Enhancing Access to Nutritional Supplements: Improve access to essential nutritional supplements, such as iron folate supplementation and vitamin A supplementation, for pregnant women and young children. This can be achieved by strengthening supply chains, ensuring availability at health facilities, and addressing any barriers to access.

5. Promoting Minimum Dietary Diversity: Implement strategies to promote minimum dietary diversity for infants and young children. This can include providing education and support to caregivers on the importance of a diverse diet, as well as ensuring the availability of nutritious foods at affordable prices.

6. Addressing Barriers to Treatment: Identify and address barriers to the treatment of severe acute malnutrition in children. This can involve improving the referral system, training health workers on the management of severe acute malnutrition, and ensuring the availability of therapeutic foods at health facilities.

These innovations, if implemented effectively, can help improve access to maternal health services and contribute to reducing malnutrition and improving maternal and child health outcomes in Ghana.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health in Ghana is to implement the strategies identified through the determinants analysis conducted in the Lancet series nutritional interventions. These strategies include:

1. Strengthening pre-service and in-service training for frontline health workers on lactation management, breastfeeding counseling, and support.
2. Promoting early initiation of breastfeeding within one hour of birth among mothers of children aged 0-2 years.
3. Increasing the uptake of iron folate supplementation for 90 or more days during pregnancy among mothers with children aged 0-5 months.
4. Enhancing the coverage of vitamin A supplementation for children aged 12-59 months, ensuring that they receive two doses in a calendar year.
5. Improving the admission of children aged 6-59 months with severe acute malnutrition for treatment at health facilities.
6. Encouraging the feeding of infants aged 6-8 months with a minimum dietary diversity and iron-rich diet, and ensuring age-appropriate meal frequency.

In addition to these specific interventions, it is crucial to address the identified barriers to nutrition coverage in Ghana, such as inadequate training for staff, low prioritization and coordination at higher levels, and weak integration of services at lower levels. By addressing these barriers and implementing the recommended strategies, access to maternal health can be improved, leading to better nutrition outcomes for mothers and children in Ghana.
AI Innovations Methodology
Based on the provided description, the methodology used to simulate the impact of recommendations on improving access to maternal health in Ghana is as follows:

1. Mixed Methods Approach: A mixed methods approach was employed, combining quantitative and qualitative data collection methods. This approach allows for a comprehensive understanding of the barriers and bottlenecks to nutrition services in Ghana.

2. Determinants Analysis Tool: The Determinants Analysis Tool was used to generate quantitative data on nutritional interventions. This tool helps identify the key determinants of effective coverage of services, including supply, demand, quality, and environment.

3. Phenomenological Approach: A phenomenological approach was used to explain the causes of barriers identified. This approach involves exploring the lived experiences and perspectives of the participants to gain a deeper understanding of the phenomenon under study.

4. Data Collection: Data was collected through desk reviews, group discussions, and key informant interviews. Participants included regional and national personnel, as well as representatives from development partners. The data collection process took place over three days in the Ashanti Region of Ghana.

5. Data Analysis: Quantitative data from the Determinants Analysis Tool was analyzed using simple descriptive statistics, such as proportions and percentages. Qualitative data from group discussions was analyzed using thematic content analysis.

6. Identification of Bottlenecks: The Ten Determinant Model, based on Microsoft Excel sheets, was used to identify bottlenecks to effective health service coverage. Low bars on the supply-determinant side of the graph and sharp drops on the demand and quality-determinant side of the graph indicated key bottlenecks.

7. Strategy Development: Based on the identified bottlenecks, strategies were developed to remove barriers and improve nutrition services in Ghana. These strategies were informed by the data-driven analysis and planning conducted.

8. Ethical Considerations: The research process followed ethical guidelines, with approval from the Ghana Health Service Ethics Review Committee and the office of the Policy, Planning, Monitoring and Evaluation Division of the Ghana Health Service. Data was aggregated at the national level and kept secure and accessible to authorized personnel.

By following this methodology, the impact of recommendations on improving access to maternal health in Ghana can be simulated and informed decision-making can be facilitated to enhance nutrition services and address the identified gaps and barriers.

Statistics:
Citations: 6
Authors: 8
Identifiers:
DOI: 10.1186/s40795-017-0147-1
Research Areas:
Community Interventions, Disparities, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Ghana
Study Design:
Case Study, Cross Sectional Study, Phenomenological Study, randomised-control-trial
Study Approach:
Mixed-methods, Qualitative, Quantitative
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