. 2017 Mar 15;3:27. doi: 10.1186/s40795-017-0147-1

Table 1.

Nutritional interventions, key bottlenecks and major causes of nutritional deprivations in ghana based on determinant analysis

Determinant	Identified Bottleneck (quantitative assessment)	Main Causes of Bottleneck (qualitative assessment)
*Early Initiation of Breastfeeding*	i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support ii. Effective coverage: Only 56.6% of mothers of children 0–2 years who gave birth in a health facility breastfed their infants within 1 hour of birth	Human Resource: Service Delivery Level-Inadequate integration of nutrition and breastfeeding component into Maternal and newborn care training Enabling Environment- Inadequate pre-service training on breastfeeding for frontline workers Effective coverage Service Delivery Level- Lack of support to mothers to breastfeed in first hour of birth, Poor staff attitude, Inhibitory Social Norms on Feeding after delivery (example prohibition of giving colostrum to the baby, inclusion of water in diet of newborn and keeping babies indoors for the first seven days), as well as preference for early introduction of formula by mother Enabling Environment-Poor enforcement of baby friendly policy in health facilities
*Exclusive Breastfeeding*	i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support ii. Effective coverage: Only 52.3% of children 0–5 months were exclusively breast-fed	Human resource Service Delivery Level- Unstructured orientation on exclusive breastfeeding counselling of frontline worker e.g. community health workers (CHW) not prioritized by sub-national health management teams Enabling Environment – Inadequate pre-service training on breastfeeding, and too many competing priorities at the higher levels of health delivery (Ministry of Health level and health training institutions) Effective coverage Service Delivery Level- inadequate engagement of family members by frontline workers during counselling at antenatal, postnatal, child welfare clinics and home visits. Enabling Environment- ineffective planning and conduct of home visits (mismatch between time of home visits and availability of service recipients) as well as financial and logistic constraints for effective transportation
*Iron and Folate Supplementation (IFA)*	i. Data availability- was a major bottleneck for the iron folate supplementation Determinant ii. Effective coverage: Only 59.4% of mothers with children 0–5 months took IFA for 90 or more days during pregnancy	Effective coverage Service Delivery Level- Frontline staff at the Antenatal clinic staff do not prioritize counselling on iron and folate supplementation during service provision, as well as non-compliance of pregnant women on iron folate supplementation (due to fear of side effects) Enabling Environment- National level health managers have not prioritized inclusion of iron folate supplementation data in health information management systems nationally. In addition weak supervision of frontline staff affects delivery of this service
*Vitamin A Supplementation* *(VAS)*	i. Initial Utilisation- Only 22.0% of children 12–59 months received Vitamin A supplementation (VAS) in semester 1 ii. Initial Utilisation- Only 19.9% of children 12–59 months received VAS in semester 2 iii. Effective coverage: Only 19.9% of children 12–59 months received two doses of VAS in a calendar year	Initial Utilisation and Effective Coverage Service Delivery Level- Limited counseling on the importance of vitamin A from frontline workers to caregivers, inefficient planned preventive & maintenance schedule for vehicles/motorbikes for outreach services and general inadequate coordination of training plans for frontline staff by health managers Enabling Environment – Absence of a national comprehensive Vitamin A supplementation strategy to reach children 12–59 months in routine services, limited data capture on children 0–59 months provided vitamin A in health information management systems and limited supervision and appraisal of frontline health workers using Vitamin A supplementation indicators
*Treatment and Management- Community based management of acute malnutrition (CMAM)*	Initial Utilisation- Only 32.5% of children 6–59 months with severe acute malnutrition (SAM) admitted for treatment at health facilities	Initial Utilisation: Service Delivery Level- Limited active surveillance on severe acute malnutrition within the communities (due to complaints of high workload by health workers), and inimical sociocultural beliefs among caregivers (that the cause and treatment of severe acute malnutrition is spiritual). In addition, there is limited frequency and intensity as well as targeting of cases of severe acute malnutrition with social mobilization as well as limited service access for treatment Enabling Environment – Gap between policy and implementation of the policy on free treatment for Children less than 5 years with severe acute malnutrition, Ineffective service integration, coordination and management of community based management of acute malnutrition
*Complementary Feeding (CF)*	i. Human resource: Only 21% of community health workers trained on complementary feeding counselling, support and communication ii. Effective coverage ^* : (This was assessed for all the 3 components of minimum acceptable diet) a. Only 6.9% of children 6–8 months were fed with minimum dietary diversity (with ≥ 4 food groups) b. In all 50.6% of children 6–8 months received age appropriate meal frequency in the past 24 hours c. Only 21.6% of children 6–8 months received iron rich diet in the past 24 hours	Human resource Service Delivery Level- Ineffective planning and management of pre-service and in-service training, high attrition of frontline staff due to transfers and movement for further education as well as poor targeting and selection of health workers for training. Enabling Environment – Limited priority and coordination at higher levels of the health care system on comprehensive infant and young child feeding and the content of curriculum of health training institutions do not adequately cater for the practical skill required by frontline workers to provide optimum services. Effective coverage Service Delivery Level- Unavailability of diverse foods sources and inequitable intra-household food distribution, as well as a generally low intake of high bioavailable iron-rich foods at the family level Enabling Environment – Limited resources for service provision, limited availability of affordable home fortified iron-rich products on the market in the country and inadequate inter-sectoral collaboration.

Determinant

Identified Bottleneck (quantitative assessment)

Main Causes of Bottleneck (qualitative assessment)

Early Initiation of Breastfeeding

i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support

ii. Effective coverage: Only 56.6% of mothers of children 0–2 years who gave birth in a health facility breastfed their infants within 1 hour of birth

Human Resource:

Service Delivery Level-Inadequate integration of nutrition and breastfeeding component into Maternal and newborn care training

Enabling Environment- Inadequate pre-service training on breastfeeding for frontline workers

Effective coverage

Service Delivery Level- Lack of support to mothers to breastfeed in first hour of birth, Poor staff attitude, Inhibitory Social Norms on Feeding after delivery (example prohibition of giving colostrum to the baby, inclusion of water in diet of newborn and keeping babies indoors for the first seven days), as well as preference for early introduction of formula by mother

Enabling Environment-Poor enforcement of baby friendly policy in health facilities

Exclusive Breastfeeding

i. Human resources: Only 21.0% of health workers in health facilities are trained on lactation management/breastfeeding counselling and support

ii. Effective coverage: Only 52.3% of children 0–5 months were exclusively breast-fed

Human resource

Service Delivery Level- Unstructured orientation on exclusive breastfeeding counselling of frontline worker e.g. community health workers (CHW) not prioritized by sub-national health management teams

Enabling Environment – Inadequate pre-service training on breastfeeding, and too many competing priorities at the higher levels of health delivery (Ministry of Health level and health training institutions)

Effective coverage

Service Delivery Level- inadequate engagement of family members by frontline workers during counselling at antenatal, postnatal, child welfare clinics and home visits.

Enabling Environment- ineffective planning and conduct of home visits (mismatch between time of home visits and availability of service recipients) as well as financial and logistic constraints for effective transportation

Iron and Folate Supplementation (IFA)

i. Data availability- was a major bottleneck for the iron folate supplementation Determinant

ii. Effective coverage: Only 59.4% of mothers with children 0–5 months took IFA for 90 or more days during pregnancy

Effective coverage

Service Delivery Level- Frontline staff at the Antenatal clinic staff do not prioritize counselling on iron and folate supplementation during service provision, as well as non-compliance of pregnant women on iron folate supplementation (due to fear of side effects)

Enabling Environment- National level health managers have not prioritized inclusion of iron folate supplementation data in health information management systems nationally. In addition weak supervision of frontline staff affects delivery of this service

Vitamin A Supplementation

(VAS)

i. Initial Utilisation- Only 22.0% of children 12–59 months received Vitamin A supplementation (VAS) in semester 1

ii. Initial Utilisation- Only 19.9% of children 12–59 months received VAS in semester 2

iii. Effective coverage: Only 19.9% of children 12–59 months received two doses of VAS in a calendar year

Initial Utilisation and Effective Coverage

Service Delivery Level- Limited counseling on the importance of vitamin A from frontline workers to caregivers, inefficient planned preventive & maintenance schedule for vehicles/motorbikes for outreach services and general inadequate coordination of training plans for frontline staff by health managers

Enabling Environment – Absence of a national comprehensive Vitamin A supplementation strategy to reach children 12–59 months in routine services, limited data capture on children 0–59 months provided vitamin A in health information management systems and limited supervision and appraisal of frontline health workers using Vitamin A supplementation indicators

Treatment and Management- Community based management of acute malnutrition (CMAM)

Initial Utilisation- Only 32.5% of children 6–59 months with severe acute malnutrition (SAM) admitted for treatment at health facilities

Initial Utilisation:

Service Delivery Level- Limited active surveillance on severe acute malnutrition within the communities (due to complaints of high workload by health workers), and inimical sociocultural beliefs among caregivers (that the cause and treatment of severe acute malnutrition is spiritual). In addition, there is limited frequency and intensity as well as targeting of cases of severe acute malnutrition with social mobilization as well as limited service access for treatment

Enabling Environment – Gap between policy and implementation of the policy on free treatment for Children less than 5 years with severe acute malnutrition, Ineffective service integration, coordination and management of community based management of acute malnutrition

Complementary Feeding (CF)

i. Human resource: Only 21% of community health workers trained on complementary feeding counselling, support and communication

ii. Effective coverage ^* : (This was assessed for all the 3 components of minimum acceptable diet)

a. Only 6.9% of children 6–8 months were fed with minimum dietary diversity (with ≥ 4 food groups)

b. In all 50.6% of children 6–8 months received age appropriate meal frequency in the past 24 hours

c. Only 21.6% of children 6–8 months received iron rich diet in the past 24 hours

Human resource

Service Delivery Level- Ineffective planning and management of pre-service and in-service training, high attrition of frontline staff due to transfers and movement for further education as well as poor targeting and selection of health workers for training.

Enabling Environment – Limited priority and coordination at higher levels of the health care system on comprehensive infant and young child feeding and the content of curriculum of health training institutions do not adequately cater for the practical skill required by frontline workers to provide optimum services.

Effective coverage

Service Delivery Level- Unavailability of diverse foods sources and inequitable intra-household food distribution, as well as a generally low intake of high bioavailable iron-rich foods at the family level

Enabling Environment – Limited resources for service provision, limited availability of affordable home fortified iron-rich products on the market in the country and inadequate inter-sectoral collaboration.