Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique

Abstract

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross‐sectional survey among caregivers of children 6–23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one‐fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Micronutrient powder programs: New findings and future directions for implementation science

“…The most systematic of these (Tumilowicz, Vossenaar, et al, 2019) applied the Tanahashi model of health service delivery, distinguishing the following steps (and their indicators): availability coverage (i.e. ever heard of MNP), accessibility coverage (ever received MNP), contact coverage (ever fed MNP) and effective coverage (recently fed MNP, indicating sustained use).…”

“…Interesting findings on complication of concurrently setting up two systems for distribution Attention is required to improve access and support continued use-frontline workers are key to support the latter (e.g. they developed a way to bypass the vouchers) related to continued use, as it helped address supply issues, answer questions, discuss issues and provide continued reinforcement (D'Agostino et al, 2019;Locks et al, 2019;Roschnik et al, 2019;Tumilowicz, Habicht, et al, 2019;Tumilowicz, Vossenaar, et al, 2019).…”

“…It could provide a way to give certain consumers access to MNP for free, as they receive a voucher, whereas other (more wealthy) consumers would be able to buy it. The experience described for Mozambique indicates that intro- with a novel distribution method (vouchers redeemable at shops in Mozambique; Tumilowicz, Vossenaar, et al, 2019).…”

Designing an ethnographic interview for evaluation of micronutrient powder trial: Challenges and opportunities for implementation science

“…As noted above, the research results we obtained by using an ethnographic approach are described in other papers in this supplement Tumilowicz, Habicht, et al, 2019;Tumilowicz, Vossenaar, et al, 2019). We gained insights from the perspective of caregivers that have not previously been reported in the literature.…”

“…year of life as they experience periods of illness and poor appetite, and progress through developmental stages that affect feeding behaviours (G. Pelto et al, 2019). In Mozambique, we identified challenges in access to obtaining the supplement that had not been foreseen in the design and implementation of the delivery system (Tumilowicz, Vossenaar, et al, 2019).…”