Cws Mnp Program

CWS MNP PROGRAM LESSONS OF A MICRONUTRIENT POWDERS SUPPLEMENTATION

PROGRAM AND FORMATIVE STUDY

HOME FORTIFICATION WORKSHOP

JAKARTA – 8 MAY 2014

Overview

• Background

• CWS Indonesia MNP Program

(implementation strategy and result)

• CWS – HKI – UNICEF MNP Formative

Research in Timor Leste

• Lesson Learnt

• Founded in 1946

• Mission: end hunger, promote peace and justice

• Supported by 37 member communions

• Program areas: food, water, assisting refugees and the vulnerable

• Active in more than 30 countries

cwsglobal.org

Background

2003 – CWS nutrition rehabilitation program

– micronutrient supplementation, nutrition

promotion and education in Indonesia.

– 2003 – 2006 in collaboration with HKI brought

VitalitaTM, MNPs tailored to Indonesia’s context

– 2007 – 2008 CWS delivered MNPs to around

4,700 children in post-tsunami areas of Sumatra

– 2008-2009, CWS delivered VitalitaTM to around

5,300 children in three districts with support from

H.J. Heinz Foundation and Heinz ABC Indonesia.

Background

Initial results of earliest MNP work

• positive impact on children nutritional

status

• significant cuts in anemia (based on

hemoglobin measurement) in TTS and

Nias District.

• Anemia cut by 15 percent in TTS, 11

percent in Nias

Background

• 2011: CWS proposed to H.J. Heinz Foundation to continue supporting the VitalitaTM Program as we have seen the positive

• Beside two previous areas – TTS (East Nusa Tenggara Province and Nias (North Sumatera Province), CWS proposed new intervention area in Central Sulawesi Province

Background

• Chronic malnutrition (36.1%) and acute

malnutrition (14.8%) amongst under-5

children in Central Sulawesi

(National Basic Health Research 2010)

• Chronic malnutrition (29.5%) and acute

malnutrition (19%) in Poso District (National Basic Health Research 2007)

CWS INDONESIA - VitalitaTM

PROGRAM

The goal

… to improve nutritional

status of children

under-5 years of age

through sustainable

community market-

based micronutrient

powder supplements

PROGRAM IMPLEMENTATION

STRATEGY

VitalitaTM Implementation Strategy

• Program duration: March 2011 – June 2012

(it was planned for 3 years 2011 – 2014)

• Target group: children 6 – 59 months

• Target area:

– 30 villages, 5 sub-districts, TTS District,East

Nusa Tenggara

– 32 villages, 3 sub-districts, Poso District, Central

Sulawesi Province

– 12 villages, 3 sub-district, Nias, North Sumatera

VitalitaTM Implementation Strategy Composition Amount

Vitamin A 400 µg RE

Vitamin C 30 mg

Vitamin D 5.0 µg

Vitamin E 5 mg a-TE

Vitamin B1 0.5 mg

Vitamin B2 0.5 mg

Vitamin B6 0.5 mg

Vitamin B12 0.9 µg

Folic Acid 150 µg

Niacin 6 mg

Iron 10 mg

Zinc 4.1 mg

Copper 0.56 mg

Iodine 90 µg

Maltodextrin* 5.0 mg

VitalitaTM Composition

Heinz ABC donated the products


• VitalitaTM distribution and consumption:

– Delivered through government health facilities

and community integrated health posts

(Posyandu)

– Caregivers received 90 sachets of VitalitaTM in

6 months.

– Caregivers were advised to add the VitalitaTM

to their children’s meal everyday or every

other day – whichever is most convenient


• Social marketing for

VitalitaTM and health

nutrition promotion

– Development of IEC

materials (flipchart,

brochure, flashcard and

Q&A cards)

– Nutrition information session

– Cooking class


• Social marketing for VitalitaTM and health

nutrition promotion

– Development of IEC materials (flipchart,

brochure, flashcard and Q&A cards)

– Nutrition information session

– Cooking class

• Trainings for staff/ cadres/ health workers/

women’s groups

– Nutrition trainings for cadres and health workers

– Livelihood trainings for mothers


Other supporting activities:

• Deworming medications were given to

children greater than 23 months of age

when they came to clinics.

• Home visit and counseling


VitalitaTM M&E strategy

• Baseline survey (10 – 16 October 2011)

– Cross sectional study

– Sample size: 300 HHs with U5 children

– Location: 3 sub-districts of intervention areas

• Program monitoring

– Conducted by CWS staff, midwives and cadres

– Home visit for 10% of the total children

– Data on: #VitalitaTM distributed, consumed,

perceived changes, perceived challenges



• Feasibility study for market-based VitalitaTM

– to gather in-depth information on the local

government agencies, parents and other

stakeholders’ perceptions on VitalitaTM

– To determine the capacity of a potential market-

based VitalitaTM program

– February – March 2012

– Qualitative study

– Poso District and TTS District



• Feasibility study for market-based VitalitaTM

• 27 in-depth interviews with mothers (13 in Poso and 14 in TTS)

• 2 in-depth interviews with nutritionist in District Health Office

• 5 in-depth interviews with midwives in Puskesmas

• 5 in-depth interviews with PKK in sub district office

• 6 in-depth interviews with cadres

• 6 FGDs with mothers, one FGD conducted in each sub-district in Poso and TTS. In total there were 45 FGD participants. 6-9 mothers were involved in each FGD.

– Data on acceptability, willingness to purchase, potential distribution channels and capacity

RESULTS AND DISCUSSION

Program results

• By the end of June 2012, a total of 934,905 Vitalita sachets had been distributed to a total of 11,954 children under the age of five. – 300,180 Vitalita sachets had been distributed to 3,329

children in Poso

– 529,995 sachets had been distributed to 7,394 children in TTS

– 104,730 sachets to 1,231 children in Nias

• About 70-80% of Vitalita was consumed by the children (Poso 70.9%, TTS 86%, and Nias 73%) by the end of June 2012.

• On average children consume Vitalita every other day, therefore while the program finished in June 2012, the remainder of Vitalita sachets is still being distributed, and consumed by children.

Results and Discussion

Program results

• 79.8% of children (N=3198) consumed at

least 60 sachets of VitalitaTM in 6 months.

• Mothers fed their children food mixed with

VitalitaTM daily (46.8%) or every other day

(53.2%) (N=3050).


Program results

• To support the social marketing and the health & nutrition promotion – 250 flipcharts

– 12,300 promotional brochures

– 1,000 food and nutrition flash cards

– 750 Q & A cards

• They were produced and distributed to Posyandu, cadres, midwives, mothers and other stakeholders to support the information, education and communication activities (IEC).


Program results

• A series of health and nutrition trainings –

focusing on IYCF, were conducted for 496

health workers and cadres in 3 locations.

• Livelihood trainings were conducted for

544 mothers – focusing on art and craft

using plastic materials, like used VitalitaTM

sachets .


Mothers’ Report on Child Feeding

Behavior During MNP Supplementation


66,3

26 24,3

26,9

60,1

37,9

3,9

9,4

35,2

2,7 4

1,7 0,3 0,4 0,9

0

10

20

30

40

50

60

70

1st monitoring month(N=2775)

2nd monitoring month(N=2826)

3rd monitoring month(N=2646)

Better appetite

Less prone to illness

Active, cheerful

Lost appetite

Susceptible to illness

Weak, sluggish

Mothers’ Perceives Challenges in

Feeding Food Mixed with MNP


76,9

40,1 39,8

12,0

45,3

16,1

3,9 3,3

33,2

5,6 8,9 8,8

1,7 2,3 2,2

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

1st Monitoring Month(N=2827)

2nd Monitoring Month(N=2416)

3rd Monitoring Month(N=1832)

Changes in food color

Changes in food taste

Changes in food smell

Difficulty in feeding the food

Others

VitalitaTM Market-based Feasibility Study

• Acceptability

– Most mothers were aware about the importance

giving vitamin to children for their.

– The concept of adding MNPs to ready-to-eat

meal was new in Poso but acceptable.

– VitalitaTM acceptance was good with special note:

• Improve the product, so it won’t change the food color

and taste.

• VitalitaTM in syrup or chewable table is preferable as it

is considered easier to feed to children related to the

first point



• Willingness to purchase

– Mothers willing to buy VitalitaTM with price

range of Rp500 – 1000 (equal to 5 – 10 US

cents)

– Daily or weekly purchasing was preferable

due to economic ability



• Potential distribution channel and its capacity

– Mothers considered VitalitaTM as medication, so they prefer that it is distributed through government health facilities/workers and cadres. These people are considered as the trusted source of health information and easy to be accessed.

– Health workers and cadres considered that they need more trainings in small business management before implementing market-based VitalitaTM


CWS-HKI-UNICEF MNP Formative

Research in Timor Leste

Objective:

To explore contextual factors that could

influence acceptance, delivery, and use of

micronutrient powders (MNP) in Aileu

District, Timor-Leste.

Methodology

• Study area: 3 villages, Laulara Sub-district, Aileu District

• A qualitative study: – 4 FGDs with mothers of children 6 – 23 months

– 56 IDI and Key Informant Interview (KII) • Mothers (n=18)

• Fathers (n=14)

• Grandmothers (n=14)

• Health workers (n=8)

• Catholic Catechists (n=2)

– A 14-days usability trial (a short-term feeding of MNP to 45 children) – followed by home visit, interview the mothers, and key stakeholders (at the end of the usability trial)

Methodology

• Study timeframe: Dec 2010 – September

2011

– FGDs and IDI: 28 March – 8 April 2011

• to understand the sociocultural factors that influence

breastfeeding and complementary feeding practices

• to explore caregivers’ knowledge and perceptions

regarding anemia, iron and vitamin A

• to assess if caretakers knew about or had ever used

MNP, whether they would like to use the product,

• to elicit their preferences for the name, packaging

design, promotional messages, and distribution

channels of MNP

Methodology

– The usability trail: 26 April – 13 May 2011 • to assess product acceptance, potential

difficulties, perceived health benefits, and side effects of MNP

• To assess family and community members responses on the MNP supplementation – whether it should be continue or not.

• The study reviewed and approved by the Cabinet of Health Research and Development – the ethical review board of MOH TL.

Methodology

• Usability trial – 14 days of MNP supplementation

– 45 children

– Inclusion criteria • children of 6 – 23 months of age

• Not severely wasted – based on MUAC ≥ 115 mm

• Did not suffer from fever

• Had slept under a bednet in the 24 hours before the trial

• Had participated in SISCa (Servisu Integrado Saude Comunitaria) at least once in the 3 months prior to the study

– Daily consumption

Methodology

• Usability trial

– Each child was provided with 14 sachets of MNP and an insecticide-treated bednet.

– Daily consumption

– Prior to the usability trial, mothers/caregivers were informed about the MNP composition and benefits, how to tear and mix the MNP to the food, and as well as an on-site demonstration on how to mix and feed MNP to their children.

– Same information were also provided to community health volunteers, government health workers, Catholic catechists, and head of villages

– Home visit on day 1-3, day 7-9 and , and day 14-17

Methodology

• Study materials: – FGD guideline

– IDI set of question

– MNP information sheet written in Tetun and Mambae

– A short video demonstrating how to mix MNP with food

– Different MNP sachets (MixMe, Babyfer(Ghana), SuppleForte (Canada and Israel), Vitalita(Indonesia), Chispitas (Bolivia), Sprinkles plus (Heinzin India), and others used in China, Haiti, Mongolia,and Nepal.

– A chart of seven colors (green, red, blue, yellow, orange, purple, and brown) with different color gradation

– MNP – MixMe (DSM): 15 vitamins and minerals

MNP PRODUCT USED IN THE STUDY

Various MNP Packaging

Color Set with Different Gradation

Results

Results

• Preferred distribution channel:

– SISca and or government health facilities

• Forty four out of the 45 mothers who participated in the usability trial said they would continue giving MNPs to their children.

• More than half of the mothers (69%) were willing to buy MNPs for their children. The preferred price range for each sachet of MNPs by these mothers was 0.5 to 5 US cent. The remaining mothers said they will not buy MNPs and preferred them to be free because they do not have the funds to do so.

LESSONS LEARNT AND NEXT

STEP

Lessons Learned

and Next Steps

STRENGTH

• Using Posyandu or SISCa (Servisu Integrado Saude Comunitaria) for the distribution point helps in reaching the children and increases the attendance of monthly growth monitoring

• Engagement of government health workers and cadres is crucial for product acceptability. It is also important for institutionalizing the program.

• Intensive nutrition education, home visit and counseling is crucial to increase the acceptance and compliance

• Tailored product packaging and name will increase the acceptance too

CHALLENGES – Product supply chain

– Financial challenge for free distribution – however it is also a challenge to create market-based MNP in a very poor community.

– Simple, practical, inexpensive but accurate micronutrients measurement tools to assess the micronutrient deficiencies and program impact

– Reaching out remote areas

– Food insecure areas

– Changes in food color and taste, in particular when it is mixed with smaller amount of food.

Lessons Learned and Next Steps

OPPORTUNITIES

– At some extent, mothers are aware the

importance of micronutrients supplementation –

i.e vitamin A

– The needs and markets are high

– We have a scientific proven product for home

fortification – MNP

– We have the momentum for SUN


What we can do?

• NGOs

– Support the government MNP Program by • Enhance social marketing to create demands and

product acceptance.

• Support outreach to the remote areas

• Support the promotion of proper MIYC feeding and care

– Work on economic empowerment, in particular for women

– Support government on nutrition-sensitive actions, i.e. nutrition-sensitive agriculture


What we can do?

• Private sector

– ensures product/supply chain

– provide expertise in product marketing

– build capacity for small business management

– use company CSR to invest in nutrition-specific

and /or nutrition-sensitive actions


Special thanks to

the Heinz Foundation

for their support!

Cws Mnp Program

Documents

Transcript of Cws Mnp Program