The Implementation of Home-Fortification with Nutrition Education and Micronutrient Powders (MNP) to Combat Anaemia and other Micronutrient Deficiencies in Rwanda
UNICEF Rwanda (2010 – present)
Micronutrient malnutrition, particularly among young children, continues to be a challenge worldwide; iron deficiency anaemia is the most prevalent micronutrient deficiency, affecting nearly 39% of children under 5 years of age1. Anaemia among young children contributes to frequent illnesses, decreased physical and cognitive development, and poor school performance, which greatly affects the capacity and ultimately the productivity of individuals as well as populations. The Government of Rwanda recognizes the importance of improving the nutritional status of young children and it has become a priority of their public health policies. While there has been significant improvement in the reduction of acute and chronic malnutrition in Rwanda, 44% of children under the age of five remain chronically malnourished (or stunted, low height for age), and 38% of children are anaemic2. The Rwanda Micronutrient Powder (MNP) project is aimed at supporting government initiatives that target the reduction of malnutrition with the focus on reduction of iron deficiency anaemia and stunting.
The ‘Implementation of In-Home Fortification and Nutrition Education to Combat Anaemia and Micronutrient Deficiencies among Children 6-23 months in Rwanda’ was supported by UNICEF, Concern Worldwide, Care International, World Vision, the World Food Program and the institutional advisors from the University of British Columbia (UBC), the Institute of Agriculture, Technology and Economics in Kibungo (INATEK), and the National University of Rwanda School of Public Health (NURSPH). It was a 3-phase intervention project designed to assess the feasibility and effectiveness of reducing anemia and stunting among children aged 6-23 months in Rwanda through introduction of home fortification with Micronutrient Powders (MNP) as part of improved complementary feeding.
Phase 1 of the project explored nutrition and infant and young child feeding (IYCF) knowledge, attitude and practices, particularly those related to anaemia and stunting, and the potential for the use of MNP at the household level. It also assessed social-economic, behavioral, familial, cultural, and structural factors that might affect decision-making of the population and possible constraints towards consumption of MNP. Information from Phase1 was used to identify appropriate communication channels and for the development of training tools and protocols for communities in the study areas.
Phase 2 was a 30-day pilot designed to evaluate the MNP and IYCF protocol among 60 households in two districts in Rwanda. It assessed the acceptability of the overall intervention protocols and materials used, not only for the introduction of Ongera (the Kinyarwanda name for the MNP), but also key IYCF messages for mothers and nutrition education programming for community health workers (CHWs).
Phase 3 was a 12-month implementation of MNP for all children 6-23 months of age in six districts. In order to assess a change in anaemia and IYCF practices over time, an effectiveness study was imbedded within the 12-month implementation period. Children within two of the interventions (n=600) districts who were receiving the MNP, were being compared to children in two comparison (n=520) districts, where the MNP distribution is not taking place. A baseline evaluation was conducted during April 2012 with mothers of study children surveyed prior to training on the use of MNP. Information was gathered on demographics, sanitation and hygiene practices, food intake, knowledge, attitudes and practices of appropriate breastfeeding and complementary feeding, and anaemia. Hemoglobin and anthropometric measurements were also taken for all of the children in the study population. Cascade trainings on the use of MNP for government officials, health facility staff and CHWs were also conducted throughout entirety of the study. In the fall of 2012, a midline evaluation was carried out. Mothers knowledge, attitudes, and the use of MNP was assessed, key indicators related to infectious disease and malnutrition were collected, as well as anthropometry and hemoglobin of all children in the study were measured.
The objectives of these phases were:
- Improved maternal and community health worker knowledge, attitudes, and practices related to IYCF and anaemia;
- New knowledge and use of MNP at the household level; and
- Reduction of anaemia among target population of children 6-23 months.
The endline evaluation of the MNP intervention project was carried out in May of 2013. Information gathered from the final evaluation was used to help guide and inform government policy on the nationwide use and distribution of MNP as well as other countries in sub-Saharan Africa. The project is currently in being scaled up at a national level, set to reach approximately 250,000 children 6-23 months of age in Rwanda.
The main objectives of the scale-up phase in Rwanda are a reduction in anaemia and micronutrient deficiencies among young children under 5 years of age and improved growth, particularly a reduction in the rates of stunting, among children under 5 years of age.
1 WHO/UNICEF/UNU: Iron Deficiency Anemia Assessment, Prevention, and Control World Health Organization, Geneva (2001)
2 National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International. 2012. Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA: NISR, MOH, and ICF International.