ABSTRACT:

Introduction:

Anemia in children is a public health issue, and the current strategies include treatment and iron supplementation, but their level of adherence or compliance is unknown.

Objective:

To consider the adherence to multiple micronutrient powders and the associated factors.

Methods:

Epidemiological study of active surveillance through sentinel facilities in 2,024 children aged 6 to 35 months treated in health facilities of the Ministry of Health of Peru, from October to December 2014. Household visits were conducted in which counting of multiple micronutrient powders was applied and determined an adherence of consumption ≥ 90% envelopes, besides a form on the associated factors (anemia knowledge, iron-rich food, side effects, dosage regimen, drugs used, and motivation) was applied. Descriptive statistics, χ² test, Odds Ratio with a 95% confidence interval (CI), and binary logistic regression or adjusted Odds Ratio (aOR) were used.

Results:

Of all, 79.1% participants were aged 6 to 23 months; 75.9% received multiple micronutrient powders; and the adherence was equivalent to 24.4% (95%CI 22.3 - 26.6). The factors: continue supplementation (OR = 3.5; 95%CI 1.7 - 7.5); no nausea (OR = 3.0; 95%CI 2.0 - 4.3); no use of antibiotics (OR = 2.5; 95%CI 1.7 - 3.6); and intention to continue treatment (OR = 2.3; 95%CI 1.3 - 4.1) were associated with adherence. The variables: thought of continuing treatment (aOR = 2.6; 95%CI 1.1 - 6.1); presence of side effects, but no discontinuation of the treatment (aOR = 2.5; 95%CI 1.4 - 4.3); no use of antibiotics (aOR = 2.0; 95%CI 1.1 - 3.4); and belief that not only drugs cure anemia (aOR = 1.6; 95%CI 1.0 - 2.6) were associated in the multivariate analysis.

Conclusion:

There was a low prevalence of adherence to a demanding cut-off point (≥ 90% of envelopes of multiple micronutrient powders), and the associated factors are associated with absence of infections, side effects, and mother's beliefs.

Keywords:
Medication adherence; Micronutrient; Child; Anemia; Peru

INTRODUCTION

According to the Demographic and Health Survey of Peru¹1. Instituto Nacional de Estadística e Informática. Perú - Indicadores de resultado de los programas estratégicos, 2007-2013. Resultados preliminares. Lima; 2014., anemia in children aged 6 to 35 months had a small decrease in the last 7 years, from 56.8 (2007) to 46.4% (2013). In the last 10 years, the equity themes that became essential for the regional and supported development were developed in Latin America²2. Almeida C. Reforma del sector y equidad en América Latina y el Caribe: conceptos, agenda, modelos y algunos resultados de implementación. Rev Geren Polit Salud 2005; 4(9): 6-60.. Since 2010, we have been living under a health universal assurance in Peru (under the Law 29344), and the health system has implemented strategies to decrease public health issues, among them children's anemia.

The prevention of child's iron deficiency begins in the prenatal care and during breastfeeding. It has been discussed in literature the maternal deficiency on the neonate's iron condition, and the most relevant data seem to indicate that children of mothers with iron-deficiency anemia are born with decreased storages of such substance³3. Donato H, Cedola A, Rapetti M, Buys M, Gutierrez M, Parías R, et al. Anemia ferropénica. Guía de diagnóstico y tratamiento. Arch Argent Pediatr 2009; 107(4): 353-61.. After 6 months of breastfeeding, iron intake is not appropriate⁴4. Alcaraz G, Bernal C, Aristizábal M, Ruíz M, Fox J. Anemia y anemia por déficit de hierro en niños menores de cinco años y su relación con el consumo de hierro en la alimentación. Turbo, Antioquia, Colombia. Invest Ed Enferm 2006; 24(2): 16-29., therefore food should be reinforced, because if these children do not receive proper treatment, they will have their skills reduced⁵5. Reboso C, Cabrera E, Rodríguez G, Jiménez S. Anemia por deficiencia de hierro en niños de 6 a 24 meses y de 6 a 12 años de edad. Rev Salud Publica 2005; 31(4): 306-12., present growth delay, low body weight, and wasting⁶6. Wang J, Wang H, Chang S, Zhao L, Yu W, Man Q, et al. The influence of malnutrition and micronutrient status on anemic risk in children under 3 year old in poor areas in China. PLoS One 2015; 10(10): 1-13.. Treatments based on the administration of ferrous sulfate against anemia have been cost-effective. A review has found that the consumption of daily supplements is more effective than weekly intakes to improve the hemoglobin levels⁷7. Cenbranel F, Dallazen C, González-Chica D. Efetividade da suplementação de sulfato ferroso na prevenção da anemia em crianças: revisão sistemática da literatura e metanálise. Cad Saúde Pública 2013; 29(9): 1731-51.^. However, this treatment as a public health intervention would mainly cause low adherence and side effects⁸8. Moráis A, Dalmau J, Comité de Nutrición de la AEP. Importancia de la ferropenia en el niño pequeño: repercusiones y prevención. An Pediatr (Barc) 2011; 74(6): 415e1-e10.^,99. Suchdev P, Shah A, Jefferds M, Eleveld A, Patel M, Stein A, et al. Sustainability of market-based community distribution of Sprinkles in western Kenya. Maternal Child Nutr 2013; 9(Suppl 1): 78-88., although studies have showed high adherence (32 to 90%)¹⁰10. De-Regil L, Suchdev P, Vist G, Walleser S, Peña-Rosas J. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age (Review). Evid Based Child Health 2013; 8(1): 112-201. when using multiple micronutrient powders (MMN), including flexible and daily regimens (Bangladesh) (88 to 98%)¹¹11. Ip H, Hyder S, Haseen F, Rahman M, Zlotkin S. Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control. Eur J Clin Nutr 2009; 63(2): 165-72..

The World Health Organization states that therapeutic adherence is the level in which the behavior of a person, medication use, food diet compliance, and performance of lifestyle alterations correspond to the recommendations agreed with the sanitation care provider¹²12. Instituto Nacional de Salud. Estrategias para incrementar la distribución y adherencia a los multimicronutrientes en polvo en niños y niñas de 6-36 meses en el Perú. Nota técnica. Lima: EVIPNET OMS; 2011., which is also applied in children. A Cochrane review has demonstrated that the MMN, also called Chispitas^(r) or Sprinkles, reduce the rate of anemia in 31% and iron-deficiency in 51% when compared with placebo¹⁰10. De-Regil L, Suchdev P, Vist G, Walleser S, Peña-Rosas J. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age (Review). Evid Based Child Health 2013; 8(1): 112-201.. MMN are an important strategy and an option to solve and prevent anemia in Asia, Africa, and in prioritized communities in developed countries¹³13. Pasricha SR, Drakesmith H, Black J, Hipgrave D, Biggs BA. Control of iron deficiency anemia in low- and middle-income countries. Blood 2013; 121(14): 2607-17.. The locations that have widely implemented the MMN, such as Mongolia, were seen with a high rate of compliance (76.6% of the parents or guardians want to continue their use)¹⁴14. Vanchinkhuu S, Norov B, Bat G. Home fortification in large-scale programs. Introducing a micronutrient powders program in Mongolia. In home fortification with micronutrient powders (MNP); sight and life. MNP Suppl 2013; 27(2): 18-22.. In Bolivia, 69% of the guardians are still supplying the MMN¹⁵15. MacLean A, Jalal C, Loayza M, Neufeld L. Home fortification in large-scale programs. Chispitas in Bolivia: Experience and Case Study. In home fortification with micronutrient powders (MNP); Sight and Life. MNP Suppl 2013; 27(2): 31-3..

Due to the high prevalence of anemia in children, the Peruvian government with international support implemented, between the years of 2009 to 2011, a pilot program in three regions of the country to supplement children's diets with MMN¹⁶16. Zamora G, Meneses D, De-Regil LM, Neufeld L, Peña-Rosas JP, Sinisterra OT. Consideraciones sobre la elaboración de las directrices de nutrición de la organización mundial de la salud y su implementación. Arch Latinoam Nutr 2015; 65(1): 1-11.. Then, the program was extended to other regions through a progressive implementation, and, in 2014, the globalization of the supplementation began with an estimated population of 1,400,000 children aged 6 to 35 months¹⁷17. Ministerio de Salud del Perú. Plan Nacional para la Reducción de la Desnutrición Crónica Infantil y la prevención de la anemia, periodo 2014-2016. Resolución Ministerial 258-2014/MINSA del 31 de marzo de 2014. Perú; 2014.. To do this, the respective directive was officially published together with other activities such as counseling and monitoring¹⁸18. Ministerio de Salud del Perú. Directiva 056 MINSA/DGSP-V-01. Directiva sanitaria que establece la suplementación con multimicronutrientes y hierro para la prevención de anemia en niñas y niños menores de 36 meses. Resolución Ministerial 706-2014/MINSA del 19 de setiembre del 2014. Perú; 2014., and this regimen was initially applied as a supplement, which will also be used for anemia treatment¹⁹19. Ministerio de Salud del Perú. Guía Técnica: guía de práctica clínica para el diagnóstico y tratamiento de la anemia por deficiencia de hierro en niñas, niños y adolescentes en establecimientos de salud del primer nivel de atención. Resolución Ministerial 028-2015/MINSA del 16 de enero de 2015. Perú; 2015..

A study conducted in Apurímac (Peru, in 2010) including 664 children aged 6 to 35 months evaluated the proper consumption of MMN, which reached 4.1% in children who consumed less than 30 envelopes and 14.5% in those that consumed between 30 or less than 60 envelopes. Therefore, the authors found out that not only we need to deliver or consume the necessary amount, but also ensure the proper consumption process²⁰20. Huamán-Espino L, Aparco JP, Núñez-Robles E, Gonzáles E, Pillaca J, Mayta-Tristán P. Consumo de suplementos con multimicronutrientes chispitas(r) y anemia en niños de 6 a 35 meses: estudio transversal en el contexto de una intervención. Rev Peru Med Exp Salud Pública 2012; 29(3): 314-23.. Another study conducted in Ayacucho, Andahuaylas, and Huancavelica found that 20.5% of the patients discontinued the supplementation²¹21. Munayco C, Ulloa-Rea ME, Medina-Osis J, Lozano-Revollar CR, Tejada V, Castro-Salazar C, et al. Evaluación del impacto de los multimicronutrientes en polvo sobre la anemia infantil en tres regiones andinas del Perú. Rev Peru Med Exp Salud Pública 2013; 30(2): 229-34.. In Kenya (2013), the factors associated with adherence to MMN included: early age (higher prevalence of children aged 6 - 23 months than 24 - 35 months, adjusted Odds ratio (aOR = 1.5; p = 0.02), more than two quintiles of socioeconomic level (aOR = 1.7; p = 0.04), home care (aOR = 2.8; p < 0.001), and promotion of free consumption, calendars, cups, and T-shirts (aOR = 1.7; p = 0.04)⁹9. Suchdev P, Shah A, Jefferds M, Eleveld A, Patel M, Stein A, et al. Sustainability of market-based community distribution of Sprinkles in western Kenya. Maternal Child Nutr 2013; 9(Suppl 1): 78-88.. The objective of this study was to consider the adherence to MMN and its factors associated in children aged 6 to 35 months cared in the Ministry of Health institutions from 12 regions in Peru, from October to December 2014.

METHODS

TYPE OF STUDY AND OUTLINE

This is an epidemiological study of active surveillance sentinel facilities²²22. Samaja J. Muestras y representatividad en vigilancia epidemiológica mediante sitios centinelas. Cad Saúde Pública Rio Janeiro 1996; 12(3): 309-19.^,2323. Donis J. Tipos de diseños de los estudios clínicos y epidemiológicos. Av Biomed 2013; 2(2): 76-99.. A specialized surveillance²⁴24. García C, Aguilar P. Vigilancia epidemiológica en salud. Arch Med Camaguey 2013; 17(6): 784-805. of children cared in institutions from the Ministry of Health was carried out to choose the facilities, considering their distribution and space-population representativeness²²22. Samaja J. Muestras y representatividad en vigilancia epidemiológica mediante sitios centinelas. Cad Saúde Pública Rio Janeiro 1996; 12(3): 309-19.. According to the plan to decrease anemia, 65.0% of the children aged 6 - 35 months should have received MMN in 2014.

SELECTION OF SENTINEL FACILITIES

The main information from 2013 of the institutions that reported data of children's anemia to the National Center of Food and Nutrition (CENAN) of the National Institute of Health (NHI) was collected. A total of 4944 institutions were included: 108 hospitals, 1083 health centers, and 3753 health clinics. Micro-field areas of information with enough sensitivity to monitor the supplementation with MMN were considered. Such facilities presented a rate of anemia similar to the region and had a similar territorial relation, that is, if the area was from the countryside and had a 45% prevalence of children's anemia, institutions in the same place that had a similar proportion of anemia and that historically sent information to CENAN were searched. Therefore, the facility with the largest population was chosen and, by following the same criterion, we achieved 34 institutions: 3 hospitals, 22 health centers, and 9 health clinics that had a space-population representation based on the urban-rural and regional scope from 12 regions in Peru.

SAMPLE

Data were collected from October to December 2014. The 34 institutions registered a total amount of 4896 children in the growth and development offices (CRED). The inclusion criteria were children aged 6 - 35 months, cared in the last 30 days, with a located home, whose mother or guardian accepted to participate in the study; whereas children diagnosed with non-iron deficiency anemia of any other etiology were excluded, thus corresponding to a total of 2024 children chosen by convenience.

VARIABLES

Age (in months), educational level of the mother or guardian, altitude of sea level, kind of health institution (health clinics, health center, or hospital), and the scope (urban or rural) were measured. The factors associated with adherence include:

The Ministry of Health of Peru approved the MMN structure: 12.5 mg of elemental iron, 5 mg of zinc, 160 µg of folic acid, 300 µg of retinol (RE) equivalents of vitamin A, and 30 mg of vitamin C¹⁸18. Ministerio de Salud del Perú. Directiva 056 MINSA/DGSP-V-01. Directiva sanitaria que establece la suplementación con multimicronutrientes y hierro para la prevención de anemia en niñas y niños menores de 36 meses. Resolución Ministerial 706-2014/MINSA del 19 de setiembre del 2014. Perú; 2014.. To establish the adherence to MMN, an evaluation of what was received and consumed in the last 30 days was carried out, using the following formula:

The child was considered an adherent when such proportion was equal to or higher than 90%²¹21. Munayco C, Ulloa-Rea ME, Medina-Osis J, Lozano-Revollar CR, Tejada V, Castro-Salazar C, et al. Evaluación del impacto de los multimicronutrientes en polvo sobre la anemia infantil en tres regiones andinas del Perú. Rev Peru Med Exp Salud Pública 2013; 30(2): 229-34..

PROCEDURES

The documentation and guidance were sent to the Health Departments of the regions chosen by CENAN. The field team was trained, and a pilot study was conducted to use the techniques and procedures with such team. The investigators visited each nominated health center and coordinated it with the institution staff. The information was obtained from the CRED area, which is usually ruled by nurses, to determine the total amount of children through the care notebook, nominal standard, Health Information System (HIS), Nutritional Condition Information System (SIEN), CRED card, or other equivalents. After collecting all information, the visitations were planned with three possibilities: all the institutions with less than 30 children were visited; in the institutions with more than 30 children, 30 of them were randomly chosen and nine others were included; in the facilities with more than 30 children that were found in dispersed regions, we proceeded to zoning and division into populated centers or urbanizations, taking by chance regions with more than 30 children. Then, a route of visitations was done and, in some cases, the institution staff provided support; in other cases, the investigators did it independently. The mothers or guardians were identified and the objectives of the study were reported to them before the study. After their acceptation, we applied the informed consent and the forms of data record and observation of documents and counting of MMN envelopes. Structured interviews were carried out to obtain information about the general variables and the associated factors. Data forms and the record sheet of adherence to MMN were used as instruments. The supervision of investigators was implemented in the field; the CENAN staff verified the quality of registrations; each investigator received a supervision visit with the exception of three areas that received a second supervision. A specific app was developed so that investigators could type all information. The forms in physical medium were sent to CENAN for information processing.

ETHICAL ASPECTS

In 2014, due to the increase of anemia in children younger than 5 years old in Peru, as a response, the Ministry of Health implemented a plan to decrease child chronic malnutrition and prevent anemia, which was published by the ministerial resolution 258-2014/MINSA (March 31, 2014), considering anemia a public health issue. CENAN is in charge of the sentinel surveillance of the adherence to MMN in such plan.

This study is part of the implementation of such strategy, because it did not have a surveillance system for this event. The General Administration of CENAN approved this activity. Due to this need and because we are dealing with surveys, the evaluation had minimal risk. The ethical principles were applied in the investigation to the participating mother, who were also offered educational reports on anemia and were asked to inform the health institution after their participation ended. The principle of autonomy was followed in the entire process. The study comprised of volunteers, and all participants signed the informed consent. The information was obtained confidentially, that is, the identification data were not used for the study, no blood samples were taken, and data were collected from CRED cards and from interviews with the mothers or guardians.

DATA ANALYSIS

The information was processed in the IBM database, SPSS, version 20. To estimate the adherence to MMN, the adherence formula with its respective 95% confidence intervals and χ² statistical or Fisher's exact tests were applied based on a statistical significance level of p < 0.05. The Odds Ratio (OR) with its 95% confidence intervals (crude OR) was applied in the bivariate analysis. The variables with significant results in the bivariate analysis (p < 0.05) were included for the binary logistic regression analysis, following the introduction method. The model was validated through Hosmer-Lemeshow test, with p > 0.05 as the significant value. Cox and Snell R² and Nagelkerke R² were applied to determine the variance explained with the factors. The global percentage of the model and the χ²-test of the omnibus were used for the significance of the factors, as well as the adjusted OR with its corresponding 95% confidence intervals. Finally, the ROC curve indicated the model's predictive value with its lower and upper limits and its level of significance of p < 0.05.

RESULTS

A total of 79.1% children were aged 6 - 23 months, 34.4% between 6 to 11 months, and 44.7% between 12 to 23 months. Of all, 57.7% mothers or guardians had a secondary educational level; 56% children came from an altitude of less than 1000 meters above sea level (masl), and 23% at one between 3001 and 4000 masl. A total of 70.8% were from health centers and 60.3% were from the rural area (Table 1).

Among the 2204 children aged 6 - 35 months evaluated, 75.9% had received the MMN (n = 1536); the adherence proportion was of 24.4% in those receiving MMN (95%CI 22.3 - 26.6%), which was a significant value (p < 0.001). The adherence was higher in mothers who did not have an educational level (46.2%). There were no differences regarding children's age (p = 0.299), sea level altitude (p = 0.191), health institution (p = 0.152), and urban and rural regions (p = 0.185) (Table 1).

The factors associated with adherence were:

The logistics regression model indicated four factors associated with adherence to MMN: no use of antibiotics (aOR = 2.0; 95%CI 1.1 - 3.4); if the child had any side effects, the mother did not discontinue treatment (aOR = 2.5; 95%CI 1.4 - 4.3); if the family believed the child should continue with the supplementation (aOR = 2.6; 95%CI 1.1 - 6.1), and lack of believe that anemia is only cured with drugs (aOR = 1.6; 95%CI 1.0 - 2.6). This model was considered appropriate (Hosmer-Lemeshow test = 2.063; p = 0.914), and explained 6 - 9% of the problem variance (Table 2), even though it had a good predictive power (area under the ROC curve = 0.659), thus indicating that these factors differentiate the adherent child from the non-adherent child well (Figure 1).

DISCUSSION

Treatment with iron salts is ideal to decrease the rate of anemia rate. The consumption of MMN significantly reduces the rate of anemia in children. A technical report published by the INS indicated that the MMN reduced the rate of anemia in 31% and the iron deficiency in 51%¹²12. Instituto Nacional de Salud. Estrategias para incrementar la distribución y adherencia a los multimicronutrientes en polvo en niños y niñas de 6-36 meses en el Perú. Nota técnica. Lima: EVIPNET OMS; 2011.. However, a study conducted in Colombia (2014) in children aged 6 - 24 months showed that MMN administration in non-controlled situations did not present an improvement in the hemoglobin levels²⁵25. Attanasio OP, Fernández C, Fitzsimons EO, Grantham-McGregor SM, Meghir C, Rubio-Codina M. Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial. BMJ 2014; 349: g5785.. The supplementation with MMN improved children's anemia in Kenya, but its use is more difficult due to incorrect dosage, equipment, low insurance coverages, and worries on the side effects associated with the dosage and safety²⁶26. Suchdev PS, Ruth LJ, Woodruff B, Mbakaya C, Mandava U, Flores-Ayala R, et al. Selling Sprinkles micronutrient powder reduces anemia, iron deficiency, and vitamin A deficiency in young children in Western Kenya: a cluster-randomized controlled trial. Am J Clin Nutr 2012; 95(5): 1223-30.. In Argentina (2013), a study on the adherence to ferrous sulfate in children younger than 42 months found that the causes of non-adherence were digestive intolerance (38%) and forgetting the treatment (36%). Adherence of mothers was studied in the group of children who were taking iron for at least 1 month or had stopped taking in it during the 6 months before the day of the interview²⁷27. Christensen L, Saguassero Y, Cuesta C. Anemia y adherencia a la suplementación oral con hierro en una muestra de niños usuarios de la red de salud pública de Rosario, Santa Fe. Arch Argent Pediatr 2013; 111(4): 288-94..

Among the 2024 studied children, 75.9% received MMN, and this rate was higher than the expected for the same year (65%); but it was estimated this would get to 95%¹⁷17. Ministerio de Salud del Perú. Plan Nacional para la Reducción de la Desnutrición Crónica Infantil y la prevención de la anemia, periodo 2014-2016. Resolución Ministerial 258-2014/MINSA del 31 de marzo de 2014. Perú; 2014. in 2016. Thus, it indicates that for the study months, the coverage was higher than the expected.

The rate of adherence was 24.4% (95%CI 22.3 - 26.6). According to a report from the World Health Organization, there is not a "gold standard" to measure the behavior of adherence. Therefore, to determine the adherence to MMN, the use of a new counting of the consumed envelopes can be a strategy, which is recommended both in the household visit and in the clinics. However, new counting errors are common and open space characteristically to the overestimation of the behavior²⁸28. Organización Mundial de la Salud, Organización Panamericana de la Salud. Adherencia a los tratamientos a largo plazo: pruebas para la acción. Washington D.C.: OMS; 2004., which can be complemented with other instruments, such as standardized tests. The patient should consume a 100% rate of the recommended amount, which is not very practical, but it is the main point for the ideal determination of the therapeutic adherence. This was tried to MMN cases in which the cut-off point varied from 75 to 100% of the consumption.

An evaluation carried out by the CENAN found that 25% of the children from the urban region and 32.1% from the rural region older than 1 year consumed the MMN completely (90 or more envelopes). It also indicated that in children that finished more than 75% of the dosage, there was a decrease of anemia¹²12. Instituto Nacional de Salud. Estrategias para incrementar la distribución y adherencia a los multimicronutrientes en polvo en niños y niñas de 6-36 meses en el Perú. Nota técnica. Lima: EVIPNET OMS; 2011.. A review with studies from Bangladesh, Kenya, and Nepal about programs with MMN concluded that the prevalence of anemia was smaller in children aged 6 - 24 months that consumed more than 75% of the MMN compared to those that had an adherence < 75% (50.0 versus 61.0%)²⁹29. Rah JH, dePee S, Kraemer K, Steiger G, Bloem MW, Spiegel P, et al. Program experience with micronutrient powders and current evidence. J Nutr 2012; 142(1): 191S-6.. Another study showed a cut-off point of 80%³⁰30. Rosado JL, González KE, Caamaño Mdel C, García OP, Preciado R, Odio M. Efficacy of different strategies to treat anemia in children: a randomized clinical trial. Nutr J 2010; 9: 40.. Adherence is more difficult to be complied with when treatments are longer and happen on a daily basis, thus an investigation compared three regimens for MMN: a group consumed them for 4 months on a flexible basis, another during 3 months in the same basis, and the last one during 2 months on a daily basis. The rate of children who consumed all prescribed envelopes (100% adherence) was higher in the flexible group of 4 months (86.4%) compared to the flexible group of 3 months (58.4%) and the group of 2 months on a daily basis (13.5%)¹¹11. Ip H, Hyder S, Haseen F, Rahman M, Zlotkin S. Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control. Eur J Clin Nutr 2009; 63(2): 165-72.. The results show that the process of adherence is complex and requires the effort of the mother or guardian and of the family, with supervision of the health team²⁸28. Organización Mundial de la Salud, Organización Panamericana de la Salud. Adherencia a los tratamientos a largo plazo: pruebas para la acción. Washington D.C.: OMS; 2004..

The strategies to improve adherence include simplification of the regimens, counseling sessions, reminding systems, health team supervision and motivation, family therapy, psychological therapy, and phone monitoring. There is a tendency of combining more than one strategy to reinforce the message and increase the impact. For the specific case with the MMN, some options are the communicational educative intervention, family and community's participation, reinforcement of the monitoring, supervision²⁰20. Huamán-Espino L, Aparco JP, Núñez-Robles E, Gonzáles E, Pillaca J, Mayta-Tristán P. Consumo de suplementos con multimicronutrientes chispitas(r) y anemia en niños de 6 a 35 meses: estudio transversal en el contexto de una intervención. Rev Peru Med Exp Salud Pública 2012; 29(3): 314-23., and strengthening of the surveillance systems³¹31. Selva L, Ochoa A. Acciones para la prevención y control de la anemia por deficiencia de hierro en niños hasta cinco años. Rev Cub Salud Pública. 2011; 37(3): 200-6..

We have found some factors that can improve effectiveness in medical clinics, in home visits, or in educational sessions in this study. In the medical clinics, we recommend verifying if the child had nausea, took antibiotics and had difficulties in receiving MMN, as well as on how to achieve that he/she does not discontinue treatment due to side effects. These can be decreased if the MMN is consumed together with the meals, although some studies have showed that the absorption is decreased in 40% in such cases³²32. Short M, Domagalski J. Iron deficiency anemia: evaluation and management. Am Fam Physician 2013; 87(2): 98-104..

In home visits, which is a high-impact activity, we suggest the inclusion of five questions that could facilitate the adherence: intends to continue treatment with the child; his/her plans include finishing treatment; his/her family believes treatment should be continued; he/she has received good care in the health institution; and if the child consumes chicken blood. This should be applied together with a reinforcement regimen of the main points: continuing the supplementation and the treatment are healthier to the child, among others.

The importance of iron, iron-rich foods, iron supplementation, the correct form of MMN intake and signals of children's improvement must be incorporated into the educational sessions. A person's nutritional iron condition depends on the balance determined through the interaction between the content on the diet, bioavailability, losses and requirements by growth³3. Donato H, Cedola A, Rapetti M, Buys M, Gutierrez M, Parías R, et al. Anemia ferropénica. Guía de diagnóstico y tratamiento. Arch Argent Pediatr 2009; 107(4): 353-61., which should be part of the mothers' educational process.

A proposal of indicators of the clinic process could be the rate of children whose families believe they should continue the treatment and the rate of children with MMN without prescription of antibiotics. The rate of children who presented side effects and discontinued treatment should be verified in home visits. In the educational sessions, the rate of mothers or guardians who believe anemia is not cured only with medications should be reviewed.

We consider this as the first approximation to the factors that are associated with adherence to MMN, because it was a sentinel surveillance sample, and thus a sample by convenience. The rates found have differences regarding their level of significance, so we recommend the conduction of analytical studies with representative samples by regions that would allow us to find the factors based on each context. However, due to the size of the sample, we were able to find the most characteristic factors, considering we live in a multicultural and multilingual country, which allows corresponding to the historical and cultural reality of each area.

CONCLUSIONS

There was a low prevalence of adherence to a demanding cut-off point (≥ 90% of envelopes of multiple micronutrient powders), and the associated factors are associated with absence of infections, side effects, and mother's beliefs.

ACKNOWLEDGEMENTS

We thank the sentinel surveillance team of the National Center of Food and Nutrition, National Institute of Health (INS/CENAN): Héctor Chávez, Oscar Miranda, and Milagros Llanos; the computing support of Carlos Cosser; the field team: Daniel lbuqerque, Ana Zelada, Irina Hizo, Andrea Campos, Mercedes Apaza, Haydeé Sullcaray, Paola Ortega, Ingrid Santander, Sandra Calderón, Zumaya Limache, and Corina Cuellar; and the supervision team: Sulma Vásquez, Mariela Contreras, Amanda Satalaya, Ana Escriba, Lucy de la Cruz, and Rolando Maldonado.

References

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