Assessing indicators of programme coverage
Indicators of large-scale interventions to improve micronutrient status are often included in a micronutrient survey. This allows the investigation of the relationship between micronutrient status and access to interventions. Results can be applied to improve programmes and policies, as well as to understand impact. Nationally relevant intervention indicators should be incorporated and can include questions about the knowledge and use of fortified foods, micronutrient supplements, and point-of-use fortification (for example, micronutrient powders, or MNP) by the intended user group.
Coverage of interventions such as vitamin and mineral supplementation, point-of-use fortification and deworming can be assessed in a micronutrient survey, in a variety of ways. The most common way to obtain information is via self-reporting. Some questions, for example if or when a particular health service was received, can be validated through examination of medical records, child health cards or immunization records. The documentation varies by country, and each type has its limitations Documents may not be completed reliably to reflect the true coverage or timing of the intervention of interest, especially when the intervention is part of a mass campaign where the priority is to deliver interventions to the largest possible number of eligible participants in a given time period. Self-reporting by adults, and caregiver recall for children, are subject to several biases including socially desirable reporting and potential errors associated with long recall periods. Recognizing this, coverage data are often collected using different sources within a single survey. These data are then reported separately, compared and triangulated with other data sources.
Coverage of vitamin and mineral supplementation
Two crucial issues to consider when collecting data on the provision or consumption of vitamin and mineral supplements are the potential for confusion between the objective of the supplements (prevention or treatment), and the timing of the survey. When assessing access to and coverage of a national supplementation programme, it is helpful to show the participant an example of the exact supplement.
Supplementation with vitamins and minerals is usually specific to certain population groups and, depending on the programme, the same supplement could be intended for prevention or for treatment. For example, iron-folic acid supplements might be provided periodically to all adolescent girls to prevent iron deficiency. However, the same or a different-looking supplement may be provided as treatment when an individual is clinically diagnosed with anaemia or iron deficiency. Similarly, it is common for children 6–59 months of age to receive high-dose vitamin A capsules every two years, however clinicians may also administer capsules as part of routine care for acute illness. The questionnaire should include questions that differentiate between the use of supplements for prevention and as part of clinical care. Often the interviewer will ask to see the supplement bottle used by the participants, and is trained to record the micronutrients contained or the brand name shown on the label.
Questions requiring recall about supplements should be based on a time period that reflects the particular programme cycle and on evidence-based expectations for reliable recall. For reporting on the use of antenatal iron and folic acid supplementation (in tracking progress towards the Global nutrition target of reducing anaemia among women of reproductive age), it has been suggested to ask women about their consumption of iron-containing supplements during a current or past pregnancy within the last two years.1 When assessing the coverage of high-dose vitamin A supplementation for children, the Global Alliance for Vitamin A (GAVA) recommends using data from post-event coverage surveys rather than from household surveys.2 There is a transient increase in serum retinol following high-dose vitamin A supplementation. Thus, when assessing vitamin A status in a survey, it is important to time the survey so that a sufficient amount of time has passed since the last vitamin A supplementation campaign.
Coverage of point-of-use fortification
In many countries, point-of-use fortification (also called ‘home fortification’) is used to improve the nutritional status of children under 5 years of age or the status of school age children. This is most often done through the use of micronutrient powders (MNP). Depending on the scope of the intervention, the survey may include questions related to the use of MNP. Where MNP are provided in only a limited area of the country, the expected positive responses for their use may be too low to have relevance in the proposed survey.
When the use of MNPs is assessed as part of a micronutrient survey, questions are usually included on both receipt of the product and intake of MNP sachets by the intended population group. Other useful questions might concern the receipt of counselling on correct use of the MNP and the perceived benefits and side effects. An example of a module for MNPs can be found in the MNP questionnaire template tool online tool.
Coverage and quality of fortified or fortifiable foods
Many countries implement large-scale food fortification to achieve optimal intake of a range of micronutrients. Fortifiable foods generally refer to commonly consumed food items (usually staple foods or condiments) that can be produced on a large scale, meaning at least 20 metric tons per day, by companies with the technical and financial capacity to add micronutrients in line with voluntary or mandatory fortification regulations and policies. Examples of such foods include flours (usually wheat or corn), cooking oil, sugar, food grade salt and other condiments (such as bouillon, soy sauce and fish sauce). It is common to include indicators of household use of foods that are fortified or fortifiable, as well as indicators of consumption among groups that are more vulnerable to certain deficiencies. There are two categories of foods to consider incorporating into surveys: those mandated to be fortified according to national policies and regulations, and those that are potentially fortifiable and are likely to reach the main population of interest. Relevant issues to consider when selecting programme indicators to collect on large-scale fortifiable foods are shown in Box 2.1.
Many surveys collect a small sample of the fortifiable food from households to test for the presence and concentration of micronutrients. This is most commonly done to assess household coverage of iodized and adequately iodized salt, but it can also be done with edible oil, flour and other products. The planning team may decide to provide a replacement sample or a small monetary contribution to the households. This can be particularly important in settings where not providing a replacement or contribution will affect response rates or may adversely affect the family, for example by leaving them with no oil for cooking for the day and no resources to get more. Food replacements or monetary contributions need to be included in the overall budget and field logistics plan.
The presence of iodine in salt has been routinely tested in the field using specially developed rapid test kits. However, these kits are not quantitative and do not provide reliable estimates of salt iodine concentration. Various methods are being explored for salt and other means that involve collecting and analysing individual and composite samples, with various qualitative and quantitative protocols to assess micronutrient content.
Comprehensive information on testing iodine in salt can be found in the UNICEF document Guidance on the monitoring of salt iodization programmes and determination of population iodine status. 3
Box 2.1. Factors to consider when deciding on the type and wording of programme indicators for large-scale fortifiable foods
- Do fortification regulations apply to only a specific type of the fortifiable food, or do typical industry practices mean that certain product types are more likely to be fortified?
- If fortified wheat flour regulations are applied only to high extraction (“white”) flour or flour used to bake bread, then indicators need to be designed for that product type accordingly.
- Salt iodization quality can vary widely by salt type. Where a range of salt grain types are consumed, it is necessary to distinguish the main type of salt used in a household. Where a sample is collected for quantitative assessment of iodine, laboratory personnel should also determine and record the salt type according to clear standards.
- Are there labeling or specific logo requirements for fortified products?
- Observation of, or questions about food labels could be used to assess the use of a fortified product. For example, the national policy may require use of a specific logo in order to support demand and consumer choice to fortified foods. This means that logo or labeling information will also indicate compliance with national policies. However, not all products will be in their original packaging and some products may be falsely labeled.
- Is there extensive home production of the fortifiable product, or is it mainly commercially produced?
- Home produced staple foods are generally not fortified, unless there was hammer mill level fortification. Therefore, a question about the source of the product is helpful so only the relevant data about commercially produced foods will be analysed to determine industry compliance.
- Questions on brand name, manufacturer, and country of origin are also useful for internal program management, although it is generally not acceptable to present nutrient content analyzed by a salt manufacturer in a publicly available report.
- Is (or was) there a communication component to the overall national fortification strategy?
- If such a component exists or existed in the past, then consider including questions about respondent knowledge and awareness of the fortified product as well as the source of this information. In addition, including a question on whether the respondent looks for the fortified product at purchase may provide useful information for monitoring the communication component.
- Is the fortifiable staple product used by the food industry to produce processed foods or condiments with a large market across different consumer groups?
- If so, then questions about consumption of these specific processed foods or condiments could be included in the questionnaire. For example, bouillon is a major source of (potentially iodized) salt in many West African countries, and subsidized Baladi bread is an important source of fortified flour in Egypt.
Supplies for collecting and storing food samples need to be considered in addition to those for biologic specimens. Generally, simple collection containers can be used—resealable plastic bags for dry food products and containers with screw tops for edible oil. Some foods, such as bread, involve additional logistical considerations because the bread must be weighed to assess water content at the point of collection and at the laboratory, and will become mouldy within a few days or weeks. In general, food samples should be stored and transported to the laboratory in cool conditions and protected from direct sunlight.
Additional details on food sample collection techniques, storage and transport considerations, analytical methods and presentation of resulting data can be found in the “Analysis of Food Samples” online tool.
WHO, UNICEF. Developing and validating an iron and folic acid supplementation indicator for tracking progress towards global nutrition monitoring framework targets. Final report June 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. (https://apps.who.int/iris/bitstream/handle/10665/274372/9789241514637-eng.pdf, accessed 20 March 2020). ↩
GAVA monitoring of vitamin A supplementation. A guide for national progamme managers. Ottawa: Micronutrient Initiative; 2017 (http://www.gava.org/content/user_files/2017/08/GAVA-national-vas-monitoring-guide-2.pdf; accessed 20 March 2020). ↩
Guidance on the monitoring of salt iodization programmes and determination of population iodine status. New York: United Nations Children’s Fund; 2018 (https://www.unicef.org/nutrition/files/Monitoring-of-Salt-Iodization.pdf, accessed 15 June 2020). ↩