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Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Micronutrients and Human Health".

Deadline for manuscript submissions: 5 July 2026 | Viewed by 21622

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Special Issue Editors

Prof. Dr. Zulfiqar A. Bhutta

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Guest Editor

Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
Interests: research synthesis; implementation research; maternal, child, and newborn survival and health; micronutrient deficiencies; adolescent and reproductive health; displaced, marginalized, and refugee populations; global health
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Robert E. Black

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Guest Editor

Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
Interests: causes of child death, infectious diseases, zinc, and other micronutrient deficiencies; maternal and child undernutrition; evaluation of maternal and child health programs; implementation research; global health

Dr. Kristen M. Hurley

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Guest Editor

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Baltimore, MD 21205, USA
Interests: maternal and child health; child growth and development; early life interventions; micronutrient deficiencies; implementation science

Special Issue Information

Dear Colleagues,

Improving the coverage of micronutrient interventions in LMICs is urgent, given the persistent problem of maternal and child undernutrition combined with environment risks such as climate change and political unrest.

Decades of efficacious and effective research has demonstrated the safety and impact of micronutrient interventions in LMICs, with significant impacts on micronutrient deficiencies and improved birth outcomes. Many of these interventions have now been scaled up in different geographies through different delivery models.

While there is global recognition that these interventions are efficacious, many unanswered questions exist about how to effectively deliver and scale them across different contexts. Implementation research, with its methods and tools, can help identify, address, and resolve policy and implementation challenges impacting the coverage of micronutrient interventions.

Following a summary of the evidence, this Special Issue welcomes papers that document systematic approaches used to improve the implementation and impact of micronutrient policies, programs, and interventions.

Prof. Dr. Zulfiqar A. Bhutta
Prof. Dr. Robert E. Black
Dr. Kristen M. Hurley
Guest Editors

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Keywords

anemia
iron
folate
Vitamin A
micronutrient deficiencies
multiple micronutrient supplements
maternal nutrition
child nutrition
implementation research

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Published Papers (7 papers)

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Research

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25 pages, 1192 KB

Open AccessArticle

Determinants of Folate and Vitamin B₁₂ Deficiencies in Women of Reproductive Age: Insights from the 2018 National Nutrition Survey of Pakistan

by Junaid Iqbal, Kehkashan Begum, Rabia Zuberi, Muhammad Sajid, Sidrah Nausheen, Imran A. Chauhadry, Sajid Bashir Soofi and Zulfiqar A. Bhutta

Nutrients 2026, 18(7), 1128; https://doi.org/10.3390/nu18071128 - 31 Mar 2026

Viewed by 715

Abstract

Background: Anemia is a major public health issue, particularly among women of reproductive age (WRA) in low- and middle-income countries (LMICs). Pakistan’s National Nutrition Survey (NNS) 2011 showed a high prevalence of vitamin B₁₂ (B₁₂) and folate deficiency among WRA, necessitating further investigation in subsequent surveys. Methods: Blood samples from 31,828 WRA (15–49 years old) were collected using a stratified multi-stage sampling technique in NNS-2018. We conducted a secondary analysis using population-weighted logistic regression to assess the association of potential factors with B₁₂ and folate deficiency. B₁₂ (n = 4442) and folate (n = 12,662) samples were measured using an electrochemiluminescence immunoassay and a Centers for Disease Control and Prevention, USA (CDC)-approved microbiologic assay, respectively. Results: Folate deficiency was present in 44.7% WRA, and 20.2% had B₁₂ deficiency. Provincial distribution was associated with folate deficiency, i.e., Sindh (OR = 1.140, 95% CI 1.018, 1.285), Baluchistan (OR = 1.237, 95% CI 1.052, 1.453), and Islamabad (OR = 1.524, 95% CI 1.109, 2.092), while B₁₂ deficiency was prevalent in Islamabad (OR = 1.673, 95% CI 1.122, 2.497), Gilgit Baltistan (OR = 2.472, 95% CI 1.197, 5.106), and newly merged districts of KPK (OR = 1.584, 95% CI 0.977, 2.570). Rural residence (OR = 1.407, 95% CI 1.125, 1.760), obesity (OR = 1.649, 95% CI 1.282, 2.122), and overweight (OR = 1.560, 95% CI 1.262, 1.928) were associated with B₁₂ deficiency. Conclusions: Our results show regional and demographic differences in the prevalence of folate and B₁₂ deficiencies among WRA. This underscores the need for targeted nutritional interventions and further longitudinal studies to identify potentially associated factors. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

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27 pages, 916 KB

Open AccessArticle

Acceptability, Adherence, and Provision Through Antenatal Care: Evidence on Multiple Micronutrient Supplementation in Pakistan and Nigeria

by Jennifer Busch-Hallen, Jennifer Ayoub, Kimberly B. Harding, Shabina Raza, Osita Okonkwo, Babajide Adebisi, Loloah Chamoun, Khawaja Masuood Ahmed, Fazal Majeed, Abdul Latif, Ladidi Bako-Aiyegbusi, John Uruakpa, Samuel Obasi, Rilwanu Mohammed, Asim Shahzad Qureshi, Huma Habib, Huma Chishti, Nkechinyere Adinoyi, Jane Ezeonu, Sarah Anugwa, Lara Nasreddine, Colin Beckworth, Nadine Crossland, Chowdhury Jalal, Alison Greig, Mandana Arabi and Sarah N. Rowe Show full author list Hide full author list

Nutrients 2026, 18(7), 1101; https://doi.org/10.3390/nu18071101 - 30 Mar 2026

Viewed by 1220

Abstract

Background/Objectives: Globally, momentum is building around antenatal multiple micronutrient supplementation (MMS), with evidence that it is as effective as iron–folic acid supplementation in preventing maternal anemia and more effective in improving birth outcomes. In line with the World Health Organization 2020 recommendation and as part of a broader implementation research project, this study examines MMS acceptability, pregnant women (PW)’s adherence practices and experiences, and facilitators and barriers to acceptability, adherence, and provision of MMS within public ANC services in Pakistan and Nigeria. Methods: Following introduction of MMS by the Government of Pakistan in April 2022 (Swabi District) and the Government of Nigeria in December 2023 (Bauchi State), mixed-methods research was conducted using cross-sectional surveys (one in each country), focus group discussions (6 in Pakistan, 9 in Nigeria), and in-depth interviews (7 in Pakistan, 10 in Nigeria) with PW, family members, and facility- and community-based healthcare providers (HCPs). Results: Findings in both settings showed that MMS is widely accepted, and almost all women (>97%) started consuming the MMS they received. Adherence levels, assessed using both pill-count and self-reported measures, exceeded 70%. In both countries, perceived benefits were identified as a key enabler to MMS acceptability and adherence among PW, whereas perceived negative effects acted as a barrier. Facilitators of MMS provision included trusting relationships between PW and HCPs, while delayed antenatal care (ANC) initiation, anemia screening, and limited agency of PW were identified as barriers. Conclusions: This study provides findings to inform MMS scale-up across public ANC platforms in two low- and middle-income countries and contributes to global evidence on context-specific considerations for MMS implementation. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

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20 pages, 269 KB

Open AccessArticle

Exploring Behavioral Interventions to Enhance Adherence to Multiple Micronutrient Supplementation Among Pregnant Women in Cambodia: A Mixed-Methods Study

by Cassandra Sauer, Meng Sokchea, Sambo Sreang, Hou Kroeun, Vannary Hun, Aman Sen Gupta, Kim Rattana, Mary Chea and Mai-Anh Hoang

Nutrients 2026, 18(4), 583; https://doi.org/10.3390/nu18040583 - 10 Feb 2026

Cited by 1 | Viewed by 962

Abstract

Background/Objectives: Multiple micronutrient supplements (MMS) are more effective in improving maternal and birth outcomes compared to iron and folic acid (IFA) supplementation during pregnancy. High adherence to MMS is critical to achieving all the anticipated health benefits. Therefore, to ensure successful program implementation of transitioning to MMS in Cambodia, implementation research has been prioritized. The objective of this study was to assess the relevance, acceptability, utility and short-term, exploratory adherence outcomes of three behavioral interventions designed to support adherence to daily MMS intake and to promote healthy pregnancy practices. Methods: This mixed-methods study, conducted in four provinces in Cambodia, involved 12 focus group discussions (FGD) with 36 pregnant women who were exposed to three distinct behavioral interventions (family support, a tracking calendar, and educational videos). FGDs were held after three weeks of exposure to each intervention. Data was analyzed using a COM-B model, with inductive codes added to capture emerging themes. Results: Family support emerged as the most preferred and perceived as the most effective intervention, with participants consistently valuing the presence, encouragement, and practical assistance offered by husbands and other close family members. The second most preferred were educational videos, which were perceived to effectively convey key messages in an engaging, relatable way, overcoming literacy barriers. Finally, the calendar supported habit formation and appealed to first-time mothers but posed challenges for low-literacy users. Across interventions, findings reflect participants’ perceived effectiveness and preferences rather than comparative efficacy. Conclusions: This study provided insights into Cambodian women’s preferences and experiences with three distinct interventions designed to improve adherence over a short-term, 3-week exposure period per intervention. An integrated, multilevel approach that combines family-focused, educational, and system-level strategies is recommended for further piloting and scale-up, with longer-term studies needed to assess comparative efficacy for adherence and health outcomes. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

18 pages, 1385 KB

Open AccessArticle

Antenatal Care Attendance and Multiple Micronutrient Supplementation Intake: Perspectives from Women and Antenatal Care Service Providers in Rwanda

by Giulia Pastori, Kesso Gabrielle van Zutphen-Küffer, Shashank Sarvan, Yana Manyuk, Elvis Gakuba, Yashodhara Rana, Jack Clift, Kara Weiss, Bonnie Weiss, Xiao-Yu Wang, Aline Uwimana, Claude M. Muvunyi, Eliphaz Tuyisenge, Samson Desie, Melinda K. Munos and Sufia Askari

Nutrients 2026, 18(3), 373; https://doi.org/10.3390/nu18030373 - 23 Jan 2026

Viewed by 1248

Abstract

Background/Objectives: Emerging evidence suggests that multiple micronutrient supplements (MMS) provide additional benefits for maternal and neonatal health compared with iron and folic acid (IFA) supplements. To achieve effective coverage, acceptability, and adherence—and to inform a nationwide rollout of MMS—it is essential to understand the context-specific factors that shape implementation. This study evaluated the pilot implementation of MMS in Rwanda to identify key enablers, areas for improvement, and challenges related to antenatal care (ANC) attendance and MMS use. Methods: Data were collected through a survey of 3257 women who attended ANC services, seven focus group discussions with 35 ANC attendees, and key informant interviews with 20 ANC nurses and 21 community health workers. Results: Pregnant women reported high ANC attendance (74%) and MMS consumption (79%), largely driven by strong motivation and awareness of MMS benefits. Strategies to remember daily intake and to manage side effects supported adherence, as did reminders, motivation, and information from family members and healthcare providers. Limited patient-centered counselling, financial constraints, barriers to accessing ANC services, and product stock-outs were key areas for strengthening service delivery in Rwanda. Conclusions: Sustaining high ANC attendance and MMS adherence as the program transitions from the pilot phase to national scale-up is essential. Improving counseling quality and strengthening supply chains may reinforce ANC services and support sustained MMS adherence, with benefits for maternal and child health. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

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Review

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17 pages, 801 KB

Open AccessReview

Long-Term Effects of Multiple-Micronutrient Supplementation During Pregnancy, Lactation, and Early Childhood on the Cognitive Development of Children Aged 4–14 Years: A Systematic Review of Randomized Controlled Trials

by Arnold William, Carl Lachat, Dimitrios Petalios, Alice Deshons, Kokeb Tesfamariam Hadush, Mélanie Broin and Souheila Abbeddou

Nutrients 2025, 17(24), 3966; https://doi.org/10.3390/nu17243966 - 18 Dec 2025

Cited by 2 | Viewed by 2110

Abstract

Background: Inadequate nutrition, poor health care, and limited stimulation constrain early childhood development and cognitive potential. Micronutrient deficiencies during pregnancy and early life are prevalent in low- and middle-income countries (LMICs) and may impair cognitive outcomes. Maternal multiple-micronutrient (MMN) and point-of-use micronutrient powder (MNP) supplements improve birth outcomes and iron status, but their long-term cognitive impact remains unclear. This systematic review assessed the long-term impact of maternal MMN and early-childhood MNP supplementation on cognitive development among children aged 4–14 years in LMICs. Method: Following PRISMA guidelines (PROSPERO CRD42023459846), (cluster) randomized controlled trials were identified from six databases and gray literature (October 2023; updated July 2025). Records were managed in EndNote and screened in Covidence, and data were synthesized using Review Manager. Eligible studies examined MMN or MNP interventions during pregnancy, lactation, or early childhood, reporting cognitive, motor, or socio-emotional outcomes in children aged 4–14. Results: Ten studies met the inclusion criteria: six on maternal supplementation, three on early childhood interventions, and one combining both. Most were conducted in Asia, with one in Tanzania and one in Peru. Although most findings were not statistically significant, two large UNIMMAP-based trials indicated modest long-term improvements in procedural memory and intelligence, while one early childhood point-of-use MNP trial suggested enhanced pre-academic skills. Conclusions: Maternal MMN supplementation may modestly enhance specific domains of cognitive development, whereas evidence on the long-term effects of MMN and point-of-use MNPs on cognitive development remain limited, highlighting the necessity for further research. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

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15 pages, 249 KB

Open AccessReview

Acceptability of Antenatal Multiple Micronutrient Supplementation (MMS) Compared to Iron and Folic Acid (IFA) Supplementation in Pregnant Individuals: A Narrative Review

by Mihaela C. Kissell, Carolina Pereira, Filomena Gomes, Kidist Woldesenbet, Masresha Tessema, Hiwot Kelemu, Ramadhani Noor, Luz Escubil, Aishwarya Panicker, Ashutosh Mishra, Mai-Anh Hoang, Hou Kroeun, Cassandra Sauer, Meng Sokchea, Crystal D. Karakochuk, Masako Horino, Keith P. West, Jr., Akihiro Seita, Djeinam Toure, Umu H. Jalloh, Francis Moses, Aminata S. Koroma, Bakary Diarra, Ousmane Camara, Ouassa Sanogo, Kristine Garn and Martin N. Mwangi Show full author list Hide full author list

Nutrients 2025, 17(18), 2994; https://doi.org/10.3390/nu17182994 - 18 Sep 2025

Cited by 3 | Viewed by 5348

Abstract

Background/Objectives: Antenatal multiple micronutrient supplementation (MMS) improves birth outcomes more effectively than iron and folic acid (IFA) supplementation alone. However, the acceptability of MMS among pregnant individuals, a critical factor for adherence and program success, remains poorly defined and inconsistently assessed. This narrative review proposes a comprehensive definition of “acceptability” in the context of nutritional supplementation and evaluates the evidence on the acceptability of MMS compared to IFA in low- and middle-income countries (LMICs). Methods: We conducted a systematic literature search across Embase, Medline, and Scopus to identify studies (including grey literature) reporting on acceptability-related outcomes for MMS versus IFA among pregnant individuals. Studies exploring dimensions such as organoleptic properties, ease of consumption, side effects, cultural appropriateness, and socioeconomic factors were included. Results: Out of 1056 screened studies, five informed a novel multi-dimensional definition of acceptability. Six studies assessed acceptability-related characteristics. MMS was generally accepted across most organoleptic domains. Most studies reported fewer or comparable adverse side effects for MMS as compared to IFA. Studies consistently reported more perceived benefits for MMS than IFA. Facilitating factors included trust in health professionals, free provision, and family support. Barriers included poor taste or smell, fear of side effects, misconceptions, cost, and lack of family support. Conclusions: Antenatal MMS is widely acceptable in LMICs. Addressing socio-cultural, sensory, and socioeconomic factors is essential to increase uptake and adherence. This review provides a clear, standardized definition of acceptability to guide future research and inform effective program design. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

18 pages, 1535 KB

Open AccessReview

Scientific and Public Health Challenges in Folic Acid Supplementation: Insights from Brazil and Global Implications

by Marília Körbes Rockenbach, Ricardo Rohweder, Lavinia Schuler-Faccini, Maria Teresa Vieira Sanseverino and Thayne Woycinck Kowalski

Nutrients 2025, 17(17), 2752; https://doi.org/10.3390/nu17172752 - 26 Aug 2025

Cited by 4 | Viewed by 8574

Abstract

Folic acid supplementation during the periconceptional period is a well-established strategy to prevent neural tube defects (NTDs). However, emerging uncertainties surrounding optimal dosage, alternative folate forms, duration of use, and the role of genetic variability have sparked scientific and policy debates. In Brazil, these challenges are amplified by unique contextual factors, including the routine distribution of high-dose folic acid (5000 µg) through the public health system, social vulnerability, low adherence, and limited population-specific evidence for the country’s highly admixed population. This narrative review critically examined the scientific evidence and public health policies surrounding folic acid supplementation, with a focus on Brazil. We examined historical developments, international recommendations, and emerging controversies, including the emerging influence of misinformation. Despite the worldwide progress in NTD prevention, both local and global challenges persist, including delayed initiation, inconsistent adherence, and uncertainty regarding alternative supplementation regimens. Addressing these demands requires the development of context-specific guidelines, alongside coordinated strategies in provider training, public education, monitoring, and research investments to ensure effective, safe, and equitable folic acid supplementation. Full article

(This article belongs to the Special Issue Implementing and Evaluating Micronutrient Supplementation Interventions in Low and Middle Income Countries)

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