A PROPOSAL FOR THE INTEGRATION OF FORTIFICATION INDICATORS INTO THE NATIONAL NUTRITION SURVEILLANCE SYSTEM IN AFGHANISTAN

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1 REPORT A PROPOSAL FOR THE INTEGRATION OF FORTIFICATION INDICATORS INTO THE NATIONAL NUTRITION SURVEILLANCE SYSTEM IN AFGHANISTAN VERSION 2 Submission date: 11 December 2017 Revised submission date: 24 January 2018 DISCLAIMER This document is developed by the Global Alliance for Improved Nutrition (GAIN) for activities supported by the U.S. Agency for International Development (USAID), under the terms of Grant No. GHA-G The contents are the responsibility of GAIN and do not necessarily reflect the views of USAID or the United States Government. 1

2 Table of Contents Background... 3 Indicator definitions... 4 Data collection methods and tools... 4 Data analysis and interpretation... 8 Integration within the national nutrition surveillance system

3 Background High prevalence of malnutrition and micronutrient deficiencies among women and children continues to be a major challenge in Afghanistan. A sentinel site-based National Nutrition Surveillance System (NNSS) was operationalized in Afghanistan in 2013 by the Ministry of Public Health (MoPH) with support from the World Health Organization (WHO) and the United Nations Children s Fund (UNICEF) 1 (NNSS 2017). The NNSS provides timely and reliable information to the government and other partners to assess quality, coverage and impact of nutrition interventions, and to provide evidence for the development of, and resource mobilization for, relevant nutrition programs and policies. The NNSS is implemented in 175 facility-based and 868 community-based sentinel sites across all 34 provinces in the country. Currently, health facilities routinely collect the following indicators: anthropometry (stunting, wasting, underweight, low birth weight), micronutrient deficiency (anemia among pregnant women during the first antenatal visit, neural tube defects from total births), child feeding practices (early initiation of breastfeeding, exclusive breastfeeding, continuation of breastfeeding up to 24 months of age), health indicators associated with illness (diarrhea, ARI, fever, and measles among children less than 2 years of age), and program coverage of vitamin A supplementation among children less than 2 years of age. Additionally, community sites collect the following indicators: mid-upper arm circumference and edema in the same group of children. There is interest among the MoPH, WHO and UNICEF to expand the NNSS to additionally collect indicators on coverage of fortified food vehicles included in the national large-scale food fortification program. The information will provide timely and meaningful information for decision making related to program coverage, potential impact, and to define any improvement or complementary measures needed across diverse sub-population groups. In Afghanistan, salt iodization began in 2003 and became mandatory in 2009, and voluntary fortification of wheat flour and oil/ghee fortification began in National standards for wheat flour and oil/ghee were endorsed by the Supreme Council for Standards in May 2014 but are yet to become mandatory. This document provides an overview of potential fortification indicators and data collection methods that could be integrated in the NNSS to track national fortification program coverage over time in Afghanistan. 1 Ministry of Public Health Afghanistan National Nutrition Surveillance System Bulletin. Issue 9, June

4 Indicator definitions Three indicators of coverage defined according to the Tanahashi coverage framework 2, are proposed. Further details pertaining to the development and testing of these coverage indicators in relation to large-scale food fortification programs are published elsewhere Coverage of the food vehicle: the household consumes the food vehicle; 2. Coverage of the fortifiable food vehicle: the household consumes a food vehicle that is industrially produced and clearly branded (i.e. made by formal factories); and 3. Coverage of the fortified food vehicle: the household consumes a food vehicle that is confirmed to be fortified based on program monitoring data (i.e. it contains any content of added nutrients above intrinsic levels). The indicators are reported as the proportion of households meeting the criteria out of the total number of surveyed households. Data collection methods and tools Data are collected by questionnaire interview administered to the person most knowledgeable about food purchasing and preparation in the household. Table 1 provides an excerpt of a fortification module that has been developed and successfully tested in many countries. The module ascertains whether the household uses a food vehicle to prepare foods at home that is fortifiable and has a producer clearly recognized in the label. The module is repeated for each fortified food vehicle assessed by the surveillance system. It is recommended that the module is translated into the local language(s) and pretested in the areas where it will be administered to ensure that the questions and response options apply to the local context, ensuring the meaning and flow of the questions do not change. 2 Tanahashi, T Health Service Coverage and Its Evaluation. Bulletin of the World Health Organization 56 (2): Aaron, GJ, Friesen, VM, Jungjohann, S, Garrett, GS, Neufeld, LM, and Myatt, M Coverage of Large-Scale Food Fortification of Edible Oil, Wheat and Maize Flours Varies Greatly by Vehicle and Country but is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in Eight Countries. Journal of Nutrition 147 (Suppl): 984S 94S. 4

5 Table 1: Fortification module NO QUESTIONS AND FILTERS CODING CATEGORIES SKIPS F1 Does your household use cooking oil to prepare foods or add to foods at home? Yes...1 No..0 If 0, skip to F4 F2 got cooking oil, where did you get it from? Purchased Made it at home Received from relative/friend/food aid 3 Other (specify):...88 Don t know/remember.99 If 2, skip to F4 F3 got cooking oil, what was the brand? Not branded....1 [BRAND 1]...2 [BRAND 2]...3 [BRAND 3]...4 [BRAND N]...N Other (specify)...88 F4 Does your household prepare foods using wheat flour at home? Yes...1 No..0 If 0, skip to F7 F5 got wheat flour, where did you get it from? Purchased Made it at home Received from relative/friend/food aid 3 Other (specify):...88 Don t know/remember.99 If 2, skip to F7 F6 got wheat flour, what was the brand? Not branded....1 [BRAND 1]...2 [BRAND 2]...3 [BRAND 3]...4 [BRAND N]...N Other (specify)...88 F7 Does your household use salt? Yes...1 No..0 If 0, end module F8 got salt, where did you get it from? Purchased Made it at home Received from relative/friend/food aid 3 Other (specify):...88 Don t know/remember.99 If 2, end module F9 got salt, what was the brand? Not branded....1 [BRAND 1]...2 [BRAND 2]...3 [BRAND 3]...4 [BRAND N]...N Other (specify)

6 F1, F4, F7: Does your household use [FOOD VEHICLE]? This purpose of this question is to find out whether the [FOOD VEHICLE] is a staple food in the household, meaning that anyone in the household, not only the respondent, uses it to prepare foods at home. - Select "Yes" if the respondent tells you the household uses [FOOD VEHICLE], regardless of how often they use it and regardless of whether they currently have it in the house or not. - Select "No" only if the respondent tells you that the household never uses [FOOD VEHICLE]. In this case the rest of the questions related to that food vehicle will be skipped. F2, F5, F8: got [FOOD VEHICLE], where did you get it from? This question will ask about the last time the household got the [FOOD VEHICLE], regardless of whether they currently have it in the house or not. The purpose of the question is to find out if the [FOOD VEHICLE] the household got the last time is fortifiable (i.e. made by formal factories) or not. - Purchased: this means the item was purchased from a retail shop, a supermarket or a wholesaler. They could have also purchased it from another household who buys and resells products. The important thing is that they got it from a source that was not made at home (i.e. it was industrially produced by formal factories). - Made it at home: produced at home/home farm/family factory. This does NOT have to be the household s house. For instance, the household could have bought the food from another household in the community that makes that food in their home. - Received from relative/friend or food aid: donation/gift from a friend or relative or food aid program that was not made at home (i.e. it was industrially produced by formal factories). - If the option is not on the list, select Other and type in the source of the [FOOD VEHICLE]. This question must be carefully pre-tested and other response options may need to be added to differentiate between fortifiable and non-fortifiable based on the definition of fortifiable used in the country. In some countries, non-fortifiable may be defined simply as being home-produced while in others it may also encompass food vehicles obtained from small-scale or informal producers who produce less than a specified volume annually. The interviewer needs to properly probe. 6

7 F3, F6, F9: got [FOOD VEHICLE], what was the brand? This question will ask about the last time the household got the [FOOD VEHICLE], regardless of whether they currently have it in the house or not. The purpose of this question is to collect information that can be used to link the household to a fortification level based on triangulation with other program monitoring data sources that collect information on added nutrient levels in food vehicles by brand. Locally available brands of a food vehicle are to be inserted in the response options in alphabetical order to make it easier to find the reported brand. - If the brand the household got is not on the list, select Other and specify the name of the brand. - If the brand the household got is reported to be from an open/bulk source, probe to determine the brand name. If unknown, select Don t know/remember. - If the brand the household got was packaged but without a brand name, select Not branded. To populate the list of brands, investigators are encouraged to check with the businesses associations in the country for a list of the domestically produced and imported brands of each food vehicle that are available in the markets. (In the case of Burkina Faso, GAIN already has a list of available brands for each food vehicle from a market assessment survey that was conducted in August 2017). Additional information on available brands in the market can be collected during pre-testing, if necessary. The prepopulated list of brands is also important to help interviewers with probing. For instance, some salt brands might have similar names such as, Deltasal sel de mer iodé and Deltasal sel de mer fin iodé. The interviewer can probe to find out which of the two brands the respondent is referring to. Additional data required: Additional data on food sample nutrient analyses is needed to confirm the brand as fortified. These data can be collected from program monitoring or through measurement in a few composite samples of each food vehicle per cluster collected as part of the surveillance system activities. For households that cannot report a brand name, average added micronutrient content of unbranded samples by cluster/district/region may be applied. 7

8 Data analysis and interpretation The coverage indicators are reported as the proportion of households meeting the criteria out of the total number of surveyed households and are repeated for each of the fortified food vehicles. 1. Coverage of the food vehicle (e.g. edible oil): Calculation: Household consumes vehicle if F1 = 1 Illustrative interpretation: Nationally, 98% of households consume edible oil. 2. Coverage of the fortifiable food vehicle (e.g. edible oil): Calculation: Household consumes fortifiable vehicle if F2 2 Illustrative interpretation: Nationally, 95% of household consume fortifiable edible oil. Assumptions: i. It is assumed that food vehicles that are not made at home are made by formal factories. 3. Coverage of the fortified food vehicle (e.g. edible oil): Calculation: Household consumes fortified vehicle if brand reported in F3 is confirmed to be fortified, based on triangulation with other program monitoring data or measurement in composite food samples collected and analyzed as part of the surveillance system. Illustrative interpretation: Nationally, 65% of household consume fortified edible oil. 8

9 Figure 1. Illustrative figure of fortification coverage indicator results The indicators proposed here were collected for the first time as part of a nationally representative, cross-sectional, Fortification Assessment Coverage Toolkit (FACT) survey conducted by the Global Alliance for Improved Nutrition (GAIN) and the Organization for Sustainable Development and Research (OSDR) in Additional examples of how these indicators can presented and interpreted can be found in the survey report. 4 Integration within the national nutrition surveillance system The proposed fortification coverage indicators will be integrated into the existing surveillance framework (objectives, design, frequency). Consequently, recommendations related to the sampling methodology and frequency of data collection and reporting are beyond the scope of this document. This proposal will be shared with key stakeholders within MoPH, WHO and UNICEF as well as other international experts working in fortification assessment, including USAID, for further discussion and refinement. 4 Global Alliance for Improved Nutrition Fortification Assessment Coverage Toolkit (FACT) Survey in Afghanistan, Global Alliance for Improved Nutrition: Geneva, Switzerland. (under review). 9