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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 Implementation Strategy
• 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
VitalitaTM Implementation Strategy
• Social marketing for
VitalitaTM and health
nutrition promotion
– Development of IEC
materials (flipchart,
brochure, flashcard and
Q&A cards)
– Nutrition information session
– Cooking class
VitalitaTM Implementation Strategy
• 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
VitalitaTM Implementation Strategy
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 Implementation Strategy
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
VitalitaTM Implementation Strategy
VitalitaTM M&E strategy
• 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
VitalitaTM Implementation Strategy
VitalitaTM M&E strategy
• 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).
Results and Discussion
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).
Results and Discussion
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 .
Results and Discussion
Mothers’ Report on Child Feeding
Behavior During MNP Supplementation
Results and Discussion
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
Results and Discussion
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
Results and Discussion
VitalitaTM Market-based Feasibility Study
• 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
Results and Discussion
VitalitaTM Market-based Feasibility Study
• 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
Results and Discussion
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
Results
Results
Results
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
Lessons Learned and Next Steps
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
Lessons Learned and Next Steps
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
Lessons Learned and Next Steps
Special thanks to
the Heinz Foundation
for their support!