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Supplement: Proceedings of the XX International Vitamin A Consultative Group Meeting

Process Indicators for Monitoring and Evaluating Vitamin A Programs^{1 ,,2}

Helen Keller International Asia-Pacific Regional Office, Jakarta Selatan 12730, Indonesia

³To whom correspondence should be addressed. E-mail: mwbloem{at}compuserve.com.

	ABSTRACT

TOP ABSTRACT INTRODUCTION DISCUSSION LITERATURE CITED

 
Vitamin A deficiency disorders (VADD) are a major public health problem in many parts of the world and one of the leading underlying causes of childhood mortality. Therefore, VADD control programs can contribute to reaching the international development goal of reducing childhood mortality by two thirds by the year 2015. Although economic development leads to greater food consumption of animal products (the most bioavailable source of vitamin A), other strategies, such as high dose vitamin A capsule supplementation, fortification and food production programs have been developed to tackle the VADD problem independent of economic development efforts. In this article, we discuss the essential role of process indicators in monitoring and fine-tuning VADD control and prevention programs toward ensuring that such programs will be more effective and cost-effective.

KEY WORDS: • monitoring and evaluation • vitamin A deficiency disorders • process indicators • vitamin A capsules

	INTRODUCTION

TOP ABSTRACT INTRODUCTION DISCUSSION LITERATURE CITED

 
Vitamin A deficiency disorders (VADD)⁴ are a major public health problem in many developing countries. It has been estimated that VADD affects up to 250 million children and is one of the most important underlying causes of childhood mortality (1 ,2 ). The magnitude of VADD among women and its implications for maternal morbidity and mortality and work productivity have only recently been recognized (3 –7 ). VADD also contributes to anemia, which may further increase the risk of morbidity and mortality, slow cognitive development and lower work productivity (8 ,9 ).

Recognition of the role of vitamin A in lowering childhood mortality led to the establishment of goals endorsed at the 1990 World Summit for Children and the 1992 International Conference on Nutrition to achieve virtual elimination of VADD by 2000 (10 ,11 ). Three strategies are commonly promoted to combat VADD: supplementation with high dose vitamin A capsules, food fortification and dietary diversification (food-based production and food promotion) strategies. However, a broader approach—one that targets those affected at crucial periods throughout the life cycle (women,adolescents, children and infants ) and uses a combination of these different strategies—has been adopted by many countries and organizations to control VADD (12 ).

In preparing for the "end of the decade (1990) progress reports," there has been an increased need for information to measure global and country progress toward meeting these goals and targets. Yet, despite the heightened focus on improved vitamin A programming during the past decade, there have been few new innovative approaches to nutrition program monitoring and evaluation and little scientific literature combining program experience and monitoring and evaluation (13 ,14 ). Despite considerable progress, VADD remain a public health problem in many countries, and there is a need to set new goals and targets for eliminating VADD at the next World Summit. The International Vitamin A Consultative Group (IVACG) meeting in Vietnam in 2001 provided a forum in which participants discussed and debated action-oriented information systems that can produce information for action and ways to select useful indicators that will most effectively lead to these actions to achieve the VADD goals and targets.

In the past two decades there has been a significant shift toward supporting poverty alleviation as the overarching development goal. To develop better programs, several meetings were held at the end of the last century to establish seven international development goals (IDG). These IDG, to be achieved by the year 2015, were endorsed in 1999 at a meeting of the leaders of all United Nations member countries, including the Group of Eight (G-8, i.e., Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the United States) (15 ). Of the seven IDG, two are related to reducing mortality among children and women: reducing childhood mortality by two thirds and reducing maternal mortality by three fourths. Based on current knowledge about the effectiveness of vitamin A interventions in reducing childhood mortality—and, potentially, maternal mortality—vitamin A programs can contribute substantially to reaching the two IDG mentioned above (3 ,16 ).

Helen Keller International (HKI) has incorporated a broad array of indicators on VADD programs in its nutrition and health surveillance systems over the past decade. This paper presents a framework for identifying indicators based on a conceptual model, the information needs of different users, the different strategies being used, and the environment and resources within a given country. It describes how information can be used for multiple purposes: for describing a problem, for monitoring program activities and for understanding consumer demand.

Program evaluation requires output and process indicators. Whereas output indicators measure the impact of a program, process indicators measure progress at the different stages of program implementation. These indicators can be quantitative as well as qualitative, based on the needs of the groups involved in implementing a program—such as donors, implementing agencies and different levels of government. This paper specifically focuses on process indicators of vitamin A deficiency control programs. Although the vitamin A capsule supplementation program is the most widely used strategy to combat VADD, other strategies have been adopted or are being considered by various countries. These include food fortification, homestead food production and social marketing. These strategies have different implementers at the donor level and at the country (ministry) level. Therefore, this paper discusses process indicators for each of these strategies to combat VADD. The framework may prove applicable to other development programs in health and agriculture, including efforts to alleviate poverty.

	DISCUSSION

TOP ABSTRACT INTRODUCTION DISCUSSION LITERATURE CITED

 
Linking monitoring and evaluation to a conceptual framework

To design an effective monitoring and evaluation component, it is essential to understand the etiology of the public health problem and where in the conceptual framework the proposed strategies will have their potential effect. The etiology of VADD can be explained by using the conceptual framework developed by the United Nations Children’s Fund (UNICEF) (11 ). The conceptual framework delineates the layers of causality of a public health problem. Basic causes are generally economic, social and political; "underlying causes" are defined by access to food, caring practices and health and environmental circumstances. Food intake and diseases are considered direct causes of a public health problem.

Applying this conceptual framework to VADD (Fig. 1 ) reveals that household food production programs largely influence VADD by increasing food access (underlying cause). Broader food policy initiatives may influence VADD through the economic structure, resources, and control (basic causes) (11 ). Food fortification programs increase vitamin A at the food intake level (immediate cause), whereas supplementation programs improve the intake of vitamin A. Other factors in this conceptual model that are not generally part of specific VADD control programs, such as income generation, women’s empowerment, improved sanitation, and deworming, will likely influence VADD indirectly.

View larger version (30K): [in this window] [in a new window]   FIGURE 1 Conceptual framework for nutrition. VA, vitamin A.

View larger version (16K): [in this window] [in a new window]   FIGURE 2 Implementation level of the three main strategies to combat VADD.

    2. Fortification. Fortification programs are mainly implemented at the national level, although some initiatives may be coordinated among countries on a regional basis (e.g., salt iodization and sugar fortification). Depending on the food vehicle selected for fortification, the program is implemented by both government and the private sector at the central level, and production is likely to be centrally organized in a few factories or sites. International donors mainly provide financial and technical assistance at the national level and at fortification sites.

    3. Dietary diversification. Household food production and food promotion programs, such as homestead gardening, fishery, and poultry production schemes, may be designed or supervised at the national level in the context of other food and agricultural policies and programs. However, they are mainly implemented at a subnational level by agriculture extension agencies or nongovernmental organizations (NGO). International donors mostly provide financial support directly to NGO to support start-up costs and technical support.

Monitoring and evaluation process indicators for policy and program users

It is essential to understand the needs of the users (whom we designate as either providers or "consumers" in this paper) when designing the monitoring and evaluation component. Habicht’s approach (13 ,14 ) concentrates on generating information needed by users. Table 1 lists providers for the three different strategies. As Habicht points out, information needs may vary among different levels of program implementation and among different providers. The type and precision of the required information reflect the intended use of this information. For example, a donor agency may want to know vitamin A capsule coverage at the global level, but a provincial health officer may need to know whether he or she has to order more capsules for the next round of vitamin A distribution. At the global level, coverage can be used to measure progress toward achieving the goal of universal vitamin A capsule coverage, whereas the information for the provincial health officer can be used to fine-tune the program and prepare an estimate of capsule requirements.

Tables 2 3 4 present proposed process indicators for the three major vitamin A strategies, useful to both providers and consumers. Having identified that these different strategies involve different groups and different methods of implementation, it must be understood that process indicators are specific to each strategy, and there is not necessarily a common basis for comparing process indicators used in one intervention strategy with those used in another.

    2. Fortification. For fortification programs, national and industrial level process indicators include consumption patterns of fortified and fortifiable foods and the level to which they are being fortified. At the consumer level, household knowledge about which foods are fortified and alternative sources of vitamin A (including the vitamin A capsule) are useful.

    3. Dietary diversification. i) For household food production programs, useful information for providers may include estimates of the quantity of vegetables produced. This information can be used by national officials to refine their estimates of food availability. Estimates of vegetable production might be used to monitor the progress of program implementation at the subnational level by locally involved NGO. At the household level, estimates of the consumption of vitamin A–rich foods among children and women describe intrahousehold food allocation and can indicate household knowledge and behaviors about vitamin A. ii) For food promotion programs with a strong emphasis on information, education and communication (IEC), information useful to providers might include formative research findings on consumer knowledge and behaviors related to vitamin A–rich foods, the most effective channels for disseminating messages to increase the consumption of these foods, and the best media mix to reach the target audience (Table 5 ). This information can be used at the national level to develop an appropriate strategy for nationalizing the campaign. At the subnational level, it can be used to refine the messages to specific locales, perceptions, and practices. At the household level, information about which media channels are most effective in disseminating promotional and informative messages can be useful in further refining the development of media-specific messages, such as television or radio spots, banners, posters and printed materials.

In Indonesia, VADD have been recognized as a public health problem since the first prevalence survey conducted by the government of Indonesia, with technical assistance from HKI and the Johns Hopkins University in the 1970s (16 ,17 ). The government of Indonesia implements all three VADD control and prevention strategies: supplementation, fortification and dietary diversification. Several national and subnational surveillance systems are in place to monitor VADD programs.

    Vitamin A supplementation program. The Indonesian vitamin A supplementation program was one of the first to be established, and it has changed over the past three decades. It demonstrates that vitamin A supplementation programs can become sustainable when a government recognizes their effectiveness in combating VADD. Since 1994, the Indonesian government has included the cost of the vitamin A supplementation program in its national budget. The village-based integrated health post system (known locally as the Posyandu system) is the primary channel for distributing vitamin A capsules. Nationwide, an estimated 20 million preschool children are eligible for the program.

To increase and maintain high coverage rates, Indonesia uses a combined approach that informs both providers (to ensure a well-functioning distribution system, timely procurement of adequate capsules and health worker knowledge) and consumers (to ensure community awareness of the program) (18 ).

Indicators for these different program elements and related information are provided by the Nutrition and Health Surveillance System (NSS) and other national and subnational surveillance systems. These indicators have been used effectively to develop, refine and monitor the vitamin A supplementation program in Indonesia (19 ).

1. National, provincial, and district level coverage rates of vitamin A capsule supplementation. Vitamin A capsule coverage is the most basic process indicator for monitoring vitamin A capsule distribution programs. The current situation in Indonesia is complicated by the fact that the government has decided to decentralize procurement of vitamin A capsules. In response to the new roles provincial government officials have for procurement, coverage rates now need to be obtained at the provincial level to help identify where greater inputs and resources are needed and to engage the participation of provincial counterparts.

2. Number of capsules ordered (national, provincial and district levels). Attention is given to vitamin A capsule procurement to ensure that vitamin A capsule supplies do not become the limiting factor.

3. IEC indicators (health care facilities, household level). In addition to vitamin A capsule coverage rates, a number of other indicators are generated to raise awareness about the capsule distribution rounds. Data from the NSS were recently used to identify common channels of information for Indonesian households, including the most regularly watched television and radio stations and the prime viewing/listening times to launch public service announcements. Consumer knowledge about vitamin A and vitamin A–rich foods, the timing and location of the vitamin A campaign and consumer willingness to pay for vitamin A capsules are also being monitored through the NSS.

4. Health care service utilization indicators. Because the vitamin A supplementation program is linked with ongoing health care services (provided through Posyandu), information about access to health services is also being collected and used to monitor and support this program.

    Fortification. Indonesia has a long history of implementing pilot fortification projects. In the 1980s, Muhilal et al. (20 ) carried out a trial with monosodium glutamate fortified with vitamin A. The trial showed improved child survival, but efforts to scale up the program failed because of product discoloration and problems with stability and packaging under very humid conditions (2 ). In the past decade, the private sector has developed several fortified products, including instant noodles, powdered and condensed milk, cookies and candies (21 ,22 ). Despite the fact that the government is engaged in reducing other micronutrient deficiencies through fortification (e.g., salt iodization and wheat fortification with iron and zinc), a good vehicle for vitamin A fortification still has not been identified (22 ). As a response to the economic crisis that began in mid-1997, UNICEF, in close collaboration with the food industry, developed an affordable multiple micronutrient (including vitamin A) fortified, supplementary feeding product (Vitadele).

Two main indicators are used to monitor and evaluate fortification efforts.

1. Quality assurance and control of fortified products by the government. Because the Indonesian government currently is not fortifying staple foods with vitamin A, greater experience is available from Latin America (23 ,24 ).
   
2. Vitamin A intake from fortified foods, percentage of total vitamin A intake from fortified foods. One dietary intake method, known as 24-VASQ, uses a 24-h recall questionnaire to estimate vitamin A intake semiquantitatively but distinguishes four different sources of vitamin A (vegetables, fruits, animal foods and fortified foods) and estimates vitamin A content per ingredient instead of per dish (25 ). The contribution made by fortified food products to total vitamin A intake needs to be assessed. For example, certain brands of instant noodles in Indonesia are fortified with vitamin A and other micronutrients. However, a study in East Java showed that these fortified products do not contribute substantially to the total vitamin A intake of the poorest segments of society (22 ).
   

    Dietary diversification strategies. The Indonesian government has focused its dietary diversification strategy on health and nutrition education programs (26 ). Since the 1980s, social marketing campaigns have promoted both vitamin A capsule supplementation and consumption of vitamin A–rich foods. The early social marketing projects focused on consumption of dark green leafy vegetables, based on the early work of Oomen and Grubben (27 ). Between 1991 and 1994, an innovative pilot project was conducted that promoted consumption of eggs in addition to consumption of vitamin A–rich plant foods. Based on this initiative, the government of Indonesia expanded the pilot program to the entire province of Central Java in 1996. The social marketing campaign was initially successful; however, the increase in egg consumption initially achieved declined to preprogram levels after the start of the Asian economic crisis in mid-1997 (18 ,19 ). The following process indicators were found to be useful for monitoring and evaluating these programs.

1. Formative research reports and meetings to design an appropriate media mix. The formative research group consisted of experts from national (Jakarta) and provincial levels. The messages generated included aspects of local provincial culture as well as the general national culture. The input from national experts was essential in eventually scaling up this program to the national level.
   
2. Reports on the media mix and meetings to produce marketing materials based on the media mix and budget. The media mix is one of the critical components of any marketing strategy. In Indonesia, where televisions are common, the frequency and timing of promotional television spots are among the main determinants of an effective marketing campaign.
   
3. Report on the pretesting of marketing materials and meetings to review the media mix strategy and marketing materials.
   
4. Report on the final marketing materials produced (types and numbers of specific materials).
   
5. Report on coverage of each component of the media mix among the target population. Coverage, in this context, refers to the degree to which different media material, such as a television spot, reached different target groups.
   

Homestead food production programs, such as those being conducted in India and Bangladesh as part of their dietary diversification strategies, have not been a part of the national VADD control and prevention strategy in Indonesia. Nevertheless, the Bangladesh home-gardening program has generated valuable indicators for monitoring food production programs. The most appropriate indicators are summarized in Table 4 and are described in detail in a recent article by de Pee et al. (11 ).

VADD prevention and control are important for reaching the IDG of reducing childhood mortality by two thirds by the year 2015. Potentially, VADD control programs among pregnant women can contribute to the IDG of reducing maternal mortality.

We have described the purpose and selection of process indicators for VADD control and prevention strategies. Indicators are needed at different levels of administration and for each of the different intervention strategies and must precisely reflect the type of information required by different users. In addition, process indicators are important at the consumer level for impact analyses as well as for the sustainability of programs.

Because of the complex causality of VADD—the mix of strategies used to control and prevent VADD; the multiple target groups within a country program; and the interaction between the types and uses of information needed by households, communities, countries and global networks—simple information systems are likely to be inadequate. Therefore, comprehensive surveillance systems (18 ) or multiple data collection systems are essential for monitoring the progress of the three main strategies to combat VADD.

	ACKNOWLEDGMENTS

 
We acknowledge our governmental and institutional counterparts in the Asia Pacific region, particularly HKI staff who operate the Nutrition Surveillance Project in Bangladesh and the NSS in Indonesia.

	FOOTNOTES

 
¹ Presented at the XX International Vitamin A Consultative Group (IVACG) Meeting, "25 Years of Progress in Controlling Vitamin A Deficiency: Looking to the Future," held 12–15 February 2001 in Hanoi, Vietnam. This meeting was co-hosted by IVACG and the Local Organizing Committee of the Vietnamese Ministry of Health and representatives of United Nations technical agencies, the private sector, multilateral agencies and nongovernmental organizations in Vietnam, with funding from the government of Vietnam. The Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, U.S. Agency for International Development, assumed major responsibility for organizing the meeting. Conference proceedings are published as a supplement to the Journal of Nutrition. Guest editors for the supplement publications were Alfred Sommer, Johns Hopkins University, Baltimore, MD; Frances R. Davidson, U.S. Agency for International Development, Washington; Usha Ramakrishnan, Emory University, Atlanta, GA; and Ian Darnton-Hill, Columbia University, New York, NY.

² We thank the U.S. Agency for International Development, which has provided long-term support to vitamin A policy, research and programs, including monitoring and evaluation.

⁴ Abbreviations used: HKI, Helen Keller Institute; IDG, international development goals; IEC, information, education and communication; IVACG, International Vitamin A Consultative Group; NGO, nongovernmental organization; NSS, Nutrition and Health Surveillance System; UNICEF, United Nations Children’s Fund; VAC, vitamin A capsule; VADD, vitamin A deficiency disorders.

	LITERATURE CITED

TOP ABSTRACT INTRODUCTION DISCUSSION LITERATURE CITED

 

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