ORIGINAL ARTICLE Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control H Ip 1 , SMZ Hyder 2 , F Haseen 3 , M Rahman 3 and SH Zlotkin 4 1 Formerly affiliated with the Department of Nutritional Sciences, University of Toronto and Program in Metabolism and Integrated Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada; 2 Program in Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada and Department of Public Health Sciences, University of Toronto, Toronto, Canada; 3 Research and Evaluation Division, BRAC, Dhaka, Bangladesh and 4 Division of Gastroenterology, Hepatology and Nutrition and Program in Child Health Evaluative Sciences, Department of Paediatrics and Research Institute, The Hospital for Sick Children, Toronto, Canada and the Departments of Paediatrics, Nutritional Sciences and Public Health Sciences, University of Toronto, Toronto, Canada Background/Objectives: Despite repeated public commitments and availability of various forms of iron supplements, rates of anaemia in developing countries remain high. A major reason for this lack of success has been poor adherence. The objective of this study was to compare the effectiveness of daily and flexible administration of micronutrient Sprinkles on adherence, acceptability and haematological status among young children in rural Bangladesh. Subjects/Methods: A sample of 362 children (haemoglobin (Hb)X70 g l 1 ) aged 6–24 months were cluster-randomized to receive 60 sachets of Sprinkles either (i) daily over 2 months; (ii) flexibly over 3 months; or (iii) flexibly over 4 months. With a flexible regimen, mothers/caregivers decided how frequently to use Sprinkles without exceeding one sachet per day. Adherence was assessed monthly by counting the number of sachets used and acceptability was evaluated through focus group discussions. Haemoglobin was measured at baseline, at the end of each intervention period and 6 months post-intervention. Results: Mean percent adherence was significantly higher in the flexible-4-month group (98%) compared to the flexible- 3-month (93%) and daily-2-month (88%) groups (Po0.01). Most mothers found flexible administration to be more acceptable than daily due to perceived benefits of use. Hb at the end of intervention was significantly higher in the flexible-4-month group compared to the daily group (P ¼ 0.03). Anaemia prevalence decreased by 65% in the flexible-4-month group compared to 54% in the flexible-3-month and 51% in the daily-2-month groups. Percent of cured children who maintained a non-anaemic status 6 months post-intervention was significantly higher in the flexible-4-month (82%) and flexible-3-month (80%) groups than the daily-2-month (53%) group (Po0.05). Conclusions: The adherence, acceptability and haematological response to flexible administration over 4 months were found preferable to daily. European Journal of Clinical Nutrition (2009) 63, 165–172; doi:10.1038/sj.ejcn.1602917; published online 26 September 2007 Keywords: Sprinkles; anaemia; flexible administration; children; Bangladesh; iron deficiency Introduction In South Asia, 60–75% of under-5 children suffer from anaemia (ACC/SCN, 2004; BBS/UNCF, 2004). Among the multiple causes of anaemia, iron deficiency due to insuffi- cient dietary intake is the most common cause (Gibson et al., 1998; UNICEF/UNU/WHO/MI, 1999). The consequences of iron-deficiency anaemia (IDA) may include impaired cogni- tive, motor and behavioural development (Lozoff et al., 2000, 2003; Grantham-McGregor and Ani, 2001). Therefore, effective public health strategies are needed to prevent and treat the problem. Although iron supplementation with ferrous sulphate drops and syrup has been the primary therapeutic intervention for IDA in infants, iron drops have not proven to be effective as a large-scale public health Received 20 March 2007; revised 20 June 2007; accepted 6 August 2007; published online 26 September 2007 Correspondence: Dr SH Zlotkin, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8. E-mail: Stanley.Zlotkin@sickkids.ca European Journal of Clinical Nutrition (2009) 63, 165–172 & 2009 Macmillan Publishers Limited All rights reserved 0954-3007/09 $32.00 www.nature.com/ejcn