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This paper uses programme theory to assess, in the context of an effectiveness evaluation, the feasibility and acceptability of distributing micronutrient Sprinkles through a food-assisted maternal and child health and nutrition programme in rural Haiti. We laid out the steps related to programme delivery and household utilization of Sprinkles and used qualitative and quantitative methods to gather data on these steps. Methods included structured observations, checks of beneficiary ration cards, exit interviews, focus group discussions (FGD), individual interviews and survey data from the effectiveness evaluation. Results are as follows: (1) information on use of Sprinkles was provided before mothers first received them, as planned; (2) Sprinkles were re-packaged and distributed as planned and in the appropriate amount; (3) almost all mothers (96%) received two monthly rations of Sprinkles and received timely information on their use; (4) mothers understood instructions about use of Sprinkles and acceptance was high, and no selling of the product was reported or observed; and (5) mothers reported using Sprinkles as instructed, every day (63% in survey; 86% at exit interviews), and for the child only (99%). FGD with staff highlighted the acceptance of the intervention, with a reported 'modest' increase in workload. Within this well-established programme, it proved feasible to distribute Sprinkles and to ensure appropriate use by beneficiary mothers. Existing programme venues were suitable for distributing Sprinkles and educating mothers about their use. Use of programme theory helped to assess feasibility and acceptability of the Sprinkles intervention and provided useful information for programme replication or scale-up.

Background: Food-assisted maternal and child health and nutrition programmes usually target underweight children younger than 5 years of age. Previous evidence suggests that targeting nutrition interventions earlier in life, before children become undernourished, might be more effective for reduction of childhood undernutrition., Methods: We used a cluster randomised trial to compare two World Vision programmes for maternal and child health and nutrition, which included a behaviour change and communication component: a preventive model, targeting all children aged 6-23 months; and a recuperative model, targeting underweight (weight-for-age Z score <-2) children aged 6-60 months. Both models also targeted pregnant and lactating women. Clusters of communities (n=20) were paired on access to services and other factors and were randomly assigned to each model. Using two cross-sectional surveys (at baseline and 3 years later), we tested differences in undernutrition in children aged 12-41 months (roughly 1500 children per survey). Analyses were by intention to treat, both by pair-wise community-level comparisons and by child-level analyses adjusting for the clustering effect and child age and sex. This study is registered with ClinicalTrials.gov, number NCT00210418., Findings: There were no differences between programme groups at baseline. At follow-up, stunting, underweight, and wasting (using WHO 2006 reference data) were 4-6 percentage points lower in preventive than in recuperative communities; and mean anthropometric indicators were higher by +0.14 Z scores (height for age; p=0.07), and +0.24 Z scores (weight for age and weight for height; p<0.0001). The effect was greater in children exposed to the preventive programme for the full span between 6 and 23 months of age than in children exposed for shorter durations during this period. The quality of implementation did not differ between the two programmes; nor did use of services for maternal and child health and nutrition., Interpretation: The preventive programme was more effective for the reduction of childhood undernutrition than the traditional recuperative model.

We evaluated the effectiveness of a 2-mo treatment of Sprinkles containing 12.5 mg iron, 5 mg zinc, 400 microg vitamin A, 160 microg folic acid, and 30 mg vitamin C in reducing anemia among children 9- to 24 mo old in Haiti. Ten food distribution points (FDP) where children received take-home rations of fortified wheat-soy blend (WSB) were randomly allocated into 2 groups: 1) Sprinkles-WSB (S-WSB) (6 FDP; n = 254), receiving 30 sachets of Sprinkles monthly for 2 mo; and 2) WSB only (WSB) (4 FDP; n = 161), not receiving Sprinkles. At baseline, anemia prevalence [hemoglobin (Hb) < 100 g/L], adjusted for age and sex, was 54 and 39% in S-WSB and WSB groups, respectively. After the 2-mo intervention (1st follow-up), anemia, adjusted for baseline prevalence, age, and sex dropped to 24% in S-WSB (P < 0.001) and increased to 43% in WSB (P = 0.07). At 7 mo postintervention, anemia in S-WSB declined to 14%; 92% of children who were nonanemic at 1st follow-up remained so without further Sprinkles consumption. From baseline to 1st follow-up, mean Hb increased by 5.5 g/L and dropped by 1.0 g/L in the S-WSB and WSB groups, respectively (P < 0.001). From baseline to 2nd follow-up, mean Hb increased by 10.9 g/L in S-WSB (P < 0.001). Changes in mean Hb were greater for younger children (<21 mo at onset of intervention) (P < 0.05) and for children who were anemic at baseline (P < 0.001). In populations with a high prevalence of anemia, such as rural Haiti, 2 mo of Sprinkles are effective in reducing anemia among 9- to 24-mo-old children.