Household acceptance of fortified bouillon in northern Ghana

Abstract

Fortified bouillon cubes offer a scalable strategy to address micronutrient deficiencies in West Africa. However, success depends on household members’ perceptions and acceptance. This study assessed changes in perception and acceptance of fortified bouillon cubes over time and explored factors influencing these outcomes among non-index household members (NIHMs) from trial households in Northern Ghana.

This longitudinal mixed-methods study was nested within a double-masked randomised controlled trial. Households received micronutrient-fortified bouillon cubes (vitamin A, vitamin B12, folic acid, iron, zinc, iodine) or control cubes (iodine only) for nine months. One NIHM (≥15 years) per household (n = 1,047) was enrolled. Structured interviews were conducted during early (months 1–2; n = 731) and late (months 7–9; n = 796) phases. Composite perception (8 items) and acceptance (10 items) scores (range: 1–5; higher scores = more positive perceptions/greater acceptance) were derived from an 18-item validated instrument. Bayesian linear mixed-effects models assessed temporal changes and associated individual and household factors. Twenty-four focus group discussions (months 4–5) explored drivers and barriers.

Mean age of NIHMs was 40 ± 14.7 years; 59% were female. Perception scores increased over seven months, from 3.4 to 4.1 (adjusted posterior mean difference [aPMD] = 0.69; 95% credible interval [CrI]: 0.57, 0.81). Acceptance remained high (4.59 to 4.58; aPMD = –0.02; 95% CrI: –0.07, 0.03). No differences were observed between trial arms. At early timepoint, perception scores were lower among household heads compared with other household members, and lower among formal employees compared with farmers. Acceptance was higher among individuals from severely food-insecure households and lower among those from mildly food-insecure households. Focus groups revealed that perceived health benefits, sensory appeal, and cultural fit drove acceptance, while infertility-related myths and food colour changes were barriers.

Fortified bouillon cubes were accepted, with perceptions improving over time. Public education will be essential to address misconceptions.

ClinicalTrials.gov (NCT05178407); Pan-African Clinical Trial Registry (PACTR202206868437931). The authors confirm that all ongoing and related trials for this intervention are registered.

Introduction

Micronutrient deficiencies (MNDs) remain a major public health concern, particularly in low- and middle-income countries (LMICs), where they contribute to anaemia, impaired cognitive development, adverse birth outcomes, and increased susceptibility to infections [1–3]. Women of reproductive age (WRA) and preschool children are especially vulnerable. A pooled analysis of nationally representative data from 24 countries found that 56% of preschool children and 69% of WRA were deficient in at least one core micronutrient (defined as iron, vitamin A, and/or zinc for preschool children, and iron, folate, and/or zinc for WRA) [4].

In Ghana, MNDs are most pronounced in the northern belt regions, where more than 40% of WRA and preschool children are anaemic [5]. These deficiencies are primarily driven by low dietary diversity, a high burden of infections, and persistent socioeconomic inequalities [6–8]. The economic impact is also substantial, with annual losses exceeding 100 million US dollars due to increased healthcare costs and reduced productivity [9]. Addressing MNDs is essential to achieving Sustainable Development Goal 2, which aims to end all forms of malnutrition by 2030 [10].