Integrating Micronutrient Supplementation

Module 4: Covariate Prediction

Overview

Guatemala’s Chispitas program distributes Multiple Micronutrient Powders (MNP) to children 6–59 months through the public health system. These sachets provide iron, zinc, and other micronutrients that complement dietary intake — a critical intervention in a population where maize-based diets often fall short of requirements.

To accurately model the relationship between nutrient intake and stunting risk, we must account for supplementation alongside dietary intake. This requires understanding not just program coverage, but actual consumption patterns: Did the household receive Chispitas? Did caregivers administer them? How much of each sachet was consumed?

This module integrates Chispitas contributions through a three-level adherence cascade:

  1. Access — Did the household obtain Chispitas?
  2. Administration — Did caregivers give sachets to the child?
  3. Dosing compliance — What proportion of each sachet was consumed?

Chispitas Program Context

Nutritional Composition

Each Chispitas sachet contains 15 micronutrients following WHO/UNICEF MNP specifications. For this analysis, we focus on iron and zinc — the micronutrients most relevant to stunting and directly comparable to biofortified maize improvements (Instituto de Nutrición de Centro América y Panamá et al., 2016).

Micronutrient Content per Sachet
Iron (ferrous fumarate) 10 mg
Zinc (zinc gluconate) 4.1 mg

Distribution Protocol

The program distributes 60 sachets every ~180 days, intended for daily consumption during 60 consecutive days. To convert this episodic pattern to average daily intake (compatible with 24-hour recall methodology), we apply a 1/3 adjustment:

  • Effective daily Fe: 10 mg × 1/3 = 3.33 mg/day
  • Effective daily Zn: 4.1 mg × 1/3 = 1.37 mg/day

Population and Variable Preparation

Target Population

Chispitas are indicated for children 6–59 months — old enough for complementary feeding (where sachets are mixed into food) but within the critical window for micronutrient intervention. Children under 6 months are excluded as exclusive breastfeeding is assumed during this period.

Adherence Variables

SIVESNU 2018 (Instituto de Nutrición de Centro América y Panamá, 2020) captures supplementation behavior through four key variables:

Variable Question Cascade Level
chispitas_vez Ever obtained Chispitas? Level 1: Access
chispitas_6mes Obtained in last 6 months? Level 1b: Recent access
chispitas_todo_parte Gave sachets to child? Level 2: Administration
chispitas_sobresdelpaquete How much of sachet consumed? Level 3: Dosing
NoteVariable Interpretation

For chispitas_6mes, NA values indicate no barrier reported (access maintained), not missing data. Only explicit “no” responses indicate access interruption. This interpretation follows the official SIVESNU 2018 report coding (INCAP, 2020).

Adherence Cascade Analysis

The cascade quantifies attrition at each stage from program access to actual consumption of micronutrient powder. Each level filters the population, and the final effective coverage is the one that remains after cumulative dropout.

Level 1: Lifetime Access

Table 1: Ever Obtained Chispitas
Ever Obtained Chispitas. Variable: chispitas_vez | Lifetime exposure to supplementation program
Ever Obtained Chispitas
Variable: chispitas_vez | Lifetime exposure to supplementation program
Response N (survey) Percentage
Yes, ever obtained 961 85.7%
No, never obtained 142 12.7%
Missing 13 1.2%
Don't know 3 0.3%
Prescribed but not obtained 2 0.2%
Source: SIVESNU 2018 | Note: Survey-weighted estimates using expanded sample.

Level 1b: Recent Access (Last 6 Months)

Table 2: Barriers to Access in Last 6 Months
Access Status in Last 6 Months. Variable: chispitas_6mes | Among households that ever obtained Chispitas
Access Status in Last 6 Months
Variable: chispitas_6mes | Among households that ever obtained Chispitas
Access Status N (survey) Percentage
Access in 6 months 896 93.2%
No access in 6 months 65 6.8%
Source: SIVESNU 2018 | Note: NA values interpreted as 'access maintained' per official SIVESNU report coding.

Level 2: Administration

Table 3: Dosing Compliance Status
Dosing Compliance Status. Variable: chispitas_todo_parte | Among households with Chispitas access
Dosing Compliance Status
Variable: chispitas_todo_parte | Among households with Chispitas access
Dosing Behavior N (survey) Percentage
Gave part or all of the sachets 866 93.1%
Missing 33 3.5%
Did NOT give any sachets 31 3.3%
Source: SIVESNU 2018 | Note: Analysis restricted to households with confirmed Chispitas access.

Level 3: Dosing Compliance

Table 4: Sachet Consumption Quantity
Sachet Consumption Quantity. Variable: chispitas_sobresdelpaquete | Among households that administered Chispitas
Sachet Consumption Quantity
Variable: chispitas_sobresdelpaquete | Among households that administered Chispitas
Quantity Consumed N (survey) Percentage
All 457 49.6%
More than half 115 12.5%
Half 105 11.4%
Less than half 242 26.2%
Missing 3 0.3%
Source: SIVESNU 2018 | Note: Full compliance (highlighted) indicates child received 100% of intended micronutrient dose.

Cascade Visualization

Sankey diagram tracing households across four left-to-right stages of the Chispitas adherence cascade: lifetime access, access in the last 6 months, administration to the child, and final adherence level. Nodes at each stage are labelled (for example "Ever obtained", "Access in 6 months", "Gave part or all", "Full adherence" versus "Partial adherence"), and the width of each flowing band is proportional to the number of households following that path. The bands narrow and split at successive stages, showing progressive attrition from broad program access down to full dosing compliance.
Figure 1: Adherence Journey: From Access to Compliance Patterns

Nutritional Integration

Adherence Factor Assignment

Children who received Chispitas are assigned adherence factors based on reported dosing compliance:

Table 5
Dosing Compliance % of Recipients Adherence Factor
All 49.6% 1.00
More than half 12.5% 0.75
Half 11.4% 0.50
Less than half 26.2% 0.25
NoteInterpreting Adherence Factors

These factors represent the proportion of each sachet consumed per administration event, not temporal adherence. A child receiving “half the sachet” daily receives approximately 50% of the intended micronutrient dose during supplementation periods.

The effective daily contribution combines the protocol adjustment (1/3) with individual adherence. For example:

  • Full compliance: 10 mg Fe × 1/3 × 1.00 = 3.33 mg Fe/day.
  • Half compliance: 10 mg Fe × 1/3 × 0.50 = 1.67 mg Fe/day.

Integration Summary

Table 6: Chispitas Supplementation Summary
Chispitas Supplementation Summary. Effective coverage and nutrient contribution (children 6-59 months)
Chispitas Supplementation Summary
Effective coverage and nutrient contribution (children 6-59 months)
Indicator Value
Total children (6-59 months) 1,121.00
Chispitas recipients 866.00
Recipients (%) 77.25
Mean adherence factor (all children) 0.56
Mean effective Fe contribution (mg/day) 1.85
Mean effective Zn contribution (mg/day) 0.76
Mean adherence factor (recipients only) 0.72
Source: SIVESNU 2018 | Note: Recipients = children with access who received part or all of sachets.
TipWhy Integrate into Non-Maize?

Chispitas are added to the non-maize intake component to maintain separation between dietary sources. This structure enables direct comparison: biofortification modifies the nutrient composition of maize, while supplementation modifies the non-maize totals.

Validation

Two side-by-side panels of overlaid violin and box plots, one for iron and one for zinc, each with intake in milligrams per day on the y-axis. Within every panel the "Before Chispitas" and "After Chispitas" distributions are compared side by side. The after-integration violins and box medians sit higher, showing that supplementation raises non-maize iron and zinc intake.
Figure 2: Distribution Comparison: Non-Maize Intake Before and After Chispitas Integration

Summary

Cascade Results

Level Filter Retention
Access (lifetime) Ever obtained Chispitas 85.7%
Access (6 months) Maintained access 93.2% of above
Administration Gave sachets 93.1% of above
Dosing Full compliance 49.6% of recipients

The weighted average adherence factor among recipients is 0.72. At the population level (including non-recipients), the mean adherence factor is 0.56.

Key Findings

  1. High program reach — 86% of children 6–59 months have accessed Chispitas at some point, indicating broad program reach.

  2. Administration gap — 7% of households with access did not administer sachets to children, representing an intervention opportunity.

  3. Partial compliance common — Among recipients, 49.6% consumed full sachets, 12.5% more than half, 11.4% half, and 26.2% less than half.

  4. SIVESNU vs official rates — Observed coverage in our sample exceeds official MSPAS reports (Ministerio de Salud Pública y Asistencia Social, 2023), likely due to SIVESNU sampling characteristics. This discrepancy will be adjusted during synthetic population generation.

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References

Instituto de Nutrición de Centro América y Panamá. (2020). Informe del Sistema de Vigilancia Epidemiológica de Salud y Nutrición -SIVESNU- agosto 2018 – abril 2019 – Módulo 2: Salud y nutrición infantil. INCAP.
Instituto de Nutrición de Centro América y Panamá, Food and Nutrition Technical Assistance III Project, & Proyecto Nutri-Salud/URC. (2016). Diplomado Nutrición materno-infantil en los primeros 1,000 días de vida. Unidad 4: Alimentación complementaria a partir de los 6 hasta los 24 meses. INCAP/FANTA/URC.
Ministerio de Salud Pública y Asistencia Social. (2023). Suplementación en niños menores 5 años 2013 a 2023. Portal de Datos Abiertos MSPAS Guatemala.