Implementation and Evaluation of Complementary Food ... - Nutridev

Optimizing Early Child Nutrition – Singapore - June 26, 2002Strategies in making complementary food programs workImplementation and Evaluation ofComplementary Food programsEfficacy and effectiveness studies,impact assessmentEvidence-based case studyJacques BergerInstitute of Research for DevelopmentFrance / Viet NamFunctions of evaluationFormative evaluationFine tuning program implementation To judge how the program is planned andexecuted To improve and develop program activitiesas they are carried out1

Functions of evaluationSummative evaluationMeasures the outcome / impact of the program To make decision about the program evaluated:change, expand or end the program. To address the specific questions of concern ofdecision makers. To satisfy the program sponsorsEvaluation of a programSystematic collection and delineation and use ofinformation to judge the correctness of thesituation analysis, critically assess theresources and strategies selected, to providefeedback of the process of implementation andto measure effectiveness and the impact of anaction program (Oshaugh, 1992).Links the evaluation activities to a specificprogram (Fasevie program)2

Target audience of the evaluation‣ Policymakers (National authorities)‣ Program managers‣ Community groups, leaders, mothers International organizations Donor agencies / sponsors International scientific communityEach target group may expect differentinformation3

Situation analysis‣ High prevalence of growth retardation, irondeficiency anemia and vitamin Adeficiency in infants and children inVietnam‣ National plans of Action for Nutrition1995 - 2000 / 2001 - 2010, andits corollary "National Plan of Action forFood Fortification in Vietnam 2001-2005".Local situation analysissurveys• Nutritional status deterioratesin early life• Too early introduction of foods• Insufficient use of special transitional foods• Use of inappropriate complementary foods oflow nutritional quality• Absence of appropriate quality, low costcomplementary foods• Weakness of nutritional knowledge (andpractices) of mothers4

Local situation analysissurveys• Weakness of income but interest forprocessed complementary foods• Willingness of local authorities• Strong “social network”• Interest of potential producers• Large range of local raw materials• Use of boiling water• Existing low-cost technology, large range ofpackaging producersObjective of the Fasevie programTo promote the use of adequate feedingpractices and complementary foods by infantsand young children in population with limitedeconomic resources in three provinces of thecentral region of Vietnam (Ha Tinh, Da Nang andQuang Nam) to reduce stunting by 10% andprevent micronutrient deficiencies in infants andyoung children in two years after start ofimplementation.5

Production activitiesTraining of workersInputProduction evaluation / quality control‣ HACCP: complete quality control systemDaily‣ Nutrient composition and microbiology(internal + external) Monthly+randomComposition (Micronutrients)IRD‣ Production monitoring: hygiene, safety,workers securityTwice monthly8

ProductsInstant floursmade with local raw materials:Rice (52%), soybean (21%), sesame (5%), sugar (15%),dried whole milk (5%), salt (0.7%), VM premix (1.3%)0.8 USD / 400 g0.4 USD / 250 gPreparation of gruel with appropriateviscosity, high energy density and digestibility, fortifiedwith Vitamins and MineralsProductsFood complementSoybean (87.7%), Ca3(PO4)2 (6.1%),salt (3.1%), food grade amylase, VMpremix (3.5%)Bot (younger infants)Rice flour + Favilase + watercooked for 15 mn0.35 USD / 150 gGruelsChoa (older children)Rice grains cooked for 1h inexcess of water + Favilasecooked for 10 mn9

Attraction of the products714 households, questionnaire‣ Taste, color (+ sensorial analysis)‣ Easiness of use‣ Text (informative) change‣ InstructionsPackagingLabelPrice (80% Ok)Promotion of complementary feeding throughcommunity volunteers network (social marketing)teamMedical Doctor + Trainerspecialized in nutrition educationProvinceMedical doctor ( health center) +Vice-president of Women UnionDistrict 1 main trainer + 1 WU volunteerSimple message: nature and consequences ofmalnutrition, importance of breast-milk and appropriatecomplementary feeding practices (EBF, CF)Commune1 WU volunteerVillage1 volunteer / 20 mothersHouseholds Individual visitsMessage adapted to the age ofinfants10

Social marketingTraining of volunteersNutrition Education manual11

Nutrition EducationmanualNutrition Educationmanual12

EvaluationFollow-up books(monthly indicators)followed by actionSustainability:10% margin on saleWorks for Favina not forFavilasePromotion of the food complement throughcanteen system (SM)To avoid competitionof instant flour withfood complement1. Only Favilase incanteens2. Both productsNutritional educationmanual13

EvaluationFollow-up books(monthly indicators)followed by actionSustainability:10% margin on salePromotion of instant flours throughmarketing networkSales workers (salary from the program for 4months)1500 boxes / month(500 Vnd margin)Sale retail shopsFollow-up: book ofsales coverage14

Integration of Fasevie approachFasevie products used by the Nationalmalnutrition program (Child and MotherProtection Center)Volunteers from Women Union participate toboth Fasevie and CMPC programsUse of the Fasevie products in emergencyprograms (WFP, International Plan, MSF)Summative evaluationMeasure the performance and the impact of theprogramThe final goal being to assess the effectivenessof the program, i.e. large-scale achievements ofintervention, which, under ideal controlledconditions, have a known efficacy15

Performance of the program‣ Provision indicators: sustainability ofproduction units, quality and availability ofproducts‣ Coverage indicators: proportion of thepopulation in the intervention districts thatbenefited from social marketing approachesIndividual visits: 600 to 1200 mothers / month‣ Utilization indicators: sale of the productsSale: 1000 to 2000 boxes of Favina / monthImpact of the programChanges (improvement) in health, nutritionalstatus and feeding practicesrelated to the programEfficacy studyEffectiveness study16

Efficacy studyTam Ky district, 36 villages randomly divided in 3 groups+ nutritioneducationFavina gruel Rice gruel Usual feedingwith Favilase practicesControl group 2 meals/day under supervision No intervention+ Nutrition educationSubjects: 5 months old breastfed infants , 128 per groupEfficacy studyDistribution of meals through canteens (7 AM- 6 PM)17

Efficacy studyDuration of enrolment / inclusion: 8 monthsDuration of intervention: 6 months, started December 2001Duration of follow-up: 6 to 12 monthsVariables: Blood sampling at baseline and after 6 months(Hb and serum Ferritin, Transferrin receptor,Retinol, Zinc) Anthropometry at the age of 5, 8, 11 and 17 monthsEfficacy study Quantity of instant flour / gruel with food complementconsumed Daily Morbidity Feeding practicesDailyWeekly Food consumption (Energy and nutrient intake)at 6, 7, 8 and 9 months of age Socio-economic situation of the householdInformed consent from mother / fatherAgreement of Scientific Committees of Medical Schooland NIN18

Hemoglobin distribution at baselineAnemia 66 %Hemoglobin (g/L) at baseline and after 6months of intervention120115Anemia T6 (%)14.311028.610557.11009590T0T6FavinaFavilaseControl19

part of integrated strategies‣ Multi-micronutrient supplementation of infants (IRIS 1)‣ Iron - Vitamin A fortification of biscuits for schoolschildren (Sight and Life)‣ Iron fortification of fish sauce (ILSI-CHP / ILSI-Japan)‣ Preventive weekly iron-folate supplementation in WRA(WHO)22