Daily vs. Weekly Study
Among the first Sprinkles activities conducted at BRAC as part of Sprinkles program development was a
study that compared the efficacy of daily versus weekly use of Sprinkles among children 12-24 months of age in Kalinganj.
The intervention lasted 8 weeks and took place from September to December 2003 with the goal of identifying a suitable
dose-frequency of Sprinkles for infants in Bangladesh and assessing the compliance and acceptability of intervention through
focus group discussions (FGDs). In a subgroup of children (n=150) with initial hemoglobin <100 g/L, hemoglobin increased by 21 g/L
and 16 g/L (p=0.199) and anemia (defined as Hb <100 g/L) decreased by 85% and 62% (p=0.034) in the daily and weekly groups,
respectively (unpublished). Although the daily administration of Sprinkles (12mg Fe) seemed to have a better impact on anemia,
significant improvement of hemoglobin concentrations and reduction in anemia was also observed in the group who received
Sprinkles only once a week (30mg Fe). It is concluded from this study that both daily and weekly administration of Sprinkles are
efficacious in the reduction of anemia, but that daily administration had a relatively better effect on Hb and iron status and may
be more appropriate. Weekly use may have additional benefits at the population level including reduced program costs, but if not
adequately supervised, a weekly regimen can lead to lower effectiveness. In this study, 60% of mothers extremely liked and 30%
liked the Sprinkles intervention.
Flexible Administration study
Acceptability of the frequency of administration as revealed during focus group discussions in the daily versus weekly efficacy
study suggested that mothers preferred more flexible instructions for Sprinkles use rather than a medical model or prescribed
dosing regimen, whether daily or weekly. Therefore, a new study initiated in April 2004 is currently ongoing at BRAC-RED to test
the efficacy and effectiveness of the flexible administration of Sprinkles with the goal of determining an optimal model of
Sprinkles use and distribution. The study includes a mixed anemic and non-anemic population of infants 6-24 months of age. Each
child is randomized to either: Daily use of Sprinkles over 60 days (Group 1); Flexible use of 60 Sprinkles sachets over 90 days
(Group 2); or Flexible use of 60 Sprinkles sachets over 120 days (Group 3). Flexible administration means that mothers would be
told to use a given amount of Sprinkles sachets (12.5 mg Fe per sachet) over a specified period of time, but How often they give
Sprinkles to their infant during the intervention period is at their own discretion and convenience. However, all caregivers would
be told not to give more than one Sprinkles sachet per day to their child. Hemoglobin concentration is the primary outcome and
monthly monitoring visits will assess compliance by counting the number of unused and used sachets. An acceptability survey and
focus group discussions will be conducted at the end of intervention to assess mothers acceptance, attitudes and preferences
towards the different models of use.
National Workshop on Sprinkles
A consensus-building workshop was jointly organized by BRAC and IPHN on February 11, 2004 in Dhaka entitled, Home Fortification
of Weaning Food with Sprinkles: A New Strategy to Control Iron Deficiency Anemia among Infants and Young Children (16).
The workshop was sponsored by MI in Dhaka and HSC in Toronto. The objectives of the workshop were to review the interventions
for controlling IDA among infants, to share experiences of on-going Sprinkles activities and to formulate a strategy of
home-fortification to improve the iron and other micronutrient content of weaning foods in Bangladesh. The workshop was attended
by 51 participants representing governmental, non-governmental, UN and international agencies in Bangladesh. Special guests and
key note speakers included Mr. FH Abed (Founder and Chairman of BRAC), Prof. Mizanur Rahman (Director General of Health Services
in Bangladesh), Dr. Selina Ahsan (Joint Secretary, WHO and Public Health, Ministry of Health and Family Welfare) and Dr. Stanley
Zlotkin (Professor and Department Head of GI/Nutrition, HSC). The workshop was important to introduce Sprinkles to the Bangladesh
health and nutrition community and to mobilize support for nation-wide Sprinkles program development. Future scaling-up activities
on Sprinkles will include the partnership and support of MI and IPH
Formative Research
Extensive formative research was initiated by BRAC and HSC in December 2003 with the key objective of developing an effective
istribution model, proper communication strategy and culturally appropriate social marketing method and message for Sprinkles
in Bangladesh. The formative research will identify the target audience, barriers and facilitators to the intervention and the
social messages that should be conveyed. It consists of several stages and includes nine district areas throughout Bangladesh
which are representative of the diverse communities that exist throughout the country. A thorough understanding of the operational
issues such as the perceptions, beliefs and factors that may influence Sprinkles acceptance and use, will be gained through a
mainly qualitative approach which involves conducting household surveys, in-house observations, in-depth interviews with key
informants, two ‘trial improved practice’ stages (TIPS1 and TIPS2) and focus group discussions (FGDs). These ongoing activities
will provide an overall assessment of community child feeding practices, mothers’ nutritional knowledge and health seeking behavior. Mothers and key community members including health workers (shatho shebikas), nutritionists, religious leaders, rural medical practitioners, manufacturers and retailers will be asked about their attitudes and opinions towards Sprinkles’ use, mode of distribution and social marketing plan. Sprinkles will be first described and presented in a hypothetical context to respondents. A communication package for Sprinkles will then be developed after analysis and mothers will be given a two-month daily Sprinkles intervention to try. Ongoing continuous in-depth interviews with mothers will reveal key issues for the improvement of the Sprinkles program and communication package at each stage so that the implementation of Sprinkles will be available to all infants and young children and widely received by mothers, policy makers, health officials, community leaders and the general population.
