Household-based food fortification for anaemia control in Sudan

By Erin Tansey and Dr. Ibrahim Bani

Erin Tansey started work as a programme officer for CARE in Bosnia in 1996. She moved on to work for UNHCR in Asia and Africa and has been a Technical Advisor for Emergencies for The Micronutrient Initiative in Johannesburg since 2005.

Dr. Bani is a medical doctor with many years of experience working in the area of Public Health. He is a consultant to The Micronutrient Initiative (MI) and provided much of the technical inputs into this project.

The Micronutrient Initiative (MI) would like to thank the Christian Blind Mission International Canada (CBMI) for their financial support for this pilot project. MI would also like to thank the Sudanese Red Crescent and the Sudanese Ministry of Health (National Nutrition Directorate) for their invaluable contributions to this project.

This article draws on a report prepared for the Christian Blind Mission International Canada (CBMI) by MI.

Nearly two million internally displaced people (IDPs) and refugees in Darfur are entirely dependent on the World Food Programme (WFP) distributions of food aid in order to survive. Micronutrient deficiency is considered a major problem in Darfur. As well as contributing to infant mortality, over 50% of all children 6-59 months are estimated to suffer from anaemia, while vitamin A deficiency is estimated at 36%. Although food rations provide some micronutrients, they are reportedly not enough to meet the needs of the most vulnerable populations - pregnant and lactating women and children under 5 years of age (CDC/WFP Emergency Nutrition Assessment, Sept 2004).

The Micronutrient Initiative (MI), together with the Sudanese Red Crescent Society (SRCS) and the Sudan Ministry of Health National Nutrition Directorate (MOH-NDD), set out to implement a pilot project to test the acceptability to IDPs of low cost micronutrient premixes and the feasibility of using it to improve micronutrient status in a camp in Darfur. There were major constraints to food sources other than the WFP ration during the project time period. Most IDP families had moved off their land and were unable to return to harvest any foodstuffs. The area around the camps is very arid and most IDPs did not have access to gardening space. Prices of food on the local market were also steadily increasing, making it very difficult for IDPs to make any purchases.

The project timetable was a four month period (January - April 2006) and had three inter-related components:

• Sourcing, procurement, supply (to the camp) and local storage of an appropriate multimicronutrient premix in quantities sufficient to meet the needs of the target population.
• Training of staff and distribution of the micronutrient premix to families.
• Monitoring and evaluation focused on acceptability and feasibility studies (to which an additional efficacy study was later added).

All the above were supported by technical assistance and project management from MI.

Sourcing micronutrient premix

The initial intent was to procure and deliver 2.1 million micronutrient sachets (SprinklesTM) to the specified camps in Sudan. However, as a result of the initial assessment and field visit, it became clear that due to the eating habits of the intended beneficiaries, the individual micronutrient sachets would not be appropriate. The eating culture/practice in Darfur is that a family eats from one single plate, with no individual bowls or plates for children. As such, individual sachets intended for children would have to be mixed into the single family pot, thereby diluting the content to such an extent that it would no longer benefit the child. MI decided it would be more appropriate to use a free-flowing micronutrient premix (Rahama) that would be added to the family pot and would benefit the entire family, not just children. The premix would be added to the sauce that accompanies the staple food (usually sorghum or wheat) and is added after cooking. The fortification would be carried out for a period of two months.

The free-flowing micronutrient premix, used by MI in its large school feeding projects in Asia, has been shown to be effective in reducing anaemia and iron deficiency in children under 5 years of age. A very similar premix composition was sourced for this project using three micronutrients (see table 1). This premix is also significantly less expensive than the individual sachets, mainly because there is no packaging for individual servings.

In practice, 500kg (25 bags of 20 kilograms each) of premix was produced in India, flown first to Khartoum and then to Nyala (air transport was used because of poor road conditions and security issues). An additional 100kg was later sourced to support an efficacy study (see next section). The premix was then distributed into individual family containers (10,000 plastic resealable containers were sourced in Sudan and transported to Darfur) by the SRCS and the MOH.

Efficacy study

As this was the first time that such a micronutrient premix was distributed in an emergency environment, an efficacy study was conducted by MI to review the impact on haemoglobin levels of women and children consuming the Rahama. Some 250 IDP families from the two camps were randomly selected and asked to take part in the study over a four month period. Baseline and post-intervention data were gathered from women and children (under 5 years) using a HemoCue¹ ® machine. A further 125 families in an IDP camp not receiving Rahama also took part in the study and were used as a control group.

Training

At the beginning of the project in January 2006, MI organised a two-day workshop for 65 people in Nyala for the SRCS and MOH staff and volunteers. MI considered the particular advantage of working with the SRCS was their network of volunteers who have worked throughout the country for over 20 years, who understood the local culture and speak the local language. Capacity building at community level would hopefully add to the sustainability of the project in the event of scaling up.

The workshop, conducted in Arabic, covered the basics about nutrition, including the importance of vitamins and minerals, especially Vitamin A, folic acid and iron, and information on their food sources. It also informed staff of the proper use of the Rahama premix for prevention and treatment of nutritional anaemia and other micronutrient deficiencies. Staff were given training on how to conduct a survey and gather data and how to hold focus group discussions. The Federal MOH-NND provided some of the support for this training, along with MI.

Table 1 Rahama content (with dextrose filler)
Nutrient	Micronutrient level per dose (0.25g) premix	% RNI* children 1-3 years	% RNI children 4-6 yrs	%RNI women of child-bearing age
Vitamin A (?g retinol equivalent)	150	38%	~40%	30%
Iron (mg)	14	100%	100%	25%
Folic Acid (?g)	50	33%	25%	10%

*Recommended nutrient intake

 

Table 2 Comparative data for the child group
Variable	Mean ± SD	P value
Child's weight (kg): Pre intervention Post intervention	13.4 ± 4.3 13.9 ± 2.5	0.229
Child's height (cms): Pre intervention Post intervention	92.2 ± 11.5 94.1 ± 12.4	0.09
Child's haemoglobin level (g/dl): Pre intervention Post intervention	10.9 ± 1.8 12.8 ± 4.2	0.01

 

Table 3 Comparative data for the mother group
Variable	Mean ± SD	P value
Mother's weight (kgs): Pre intervention Post intervention	50.9 ± 6.9 55.9 ± 8.9	0.08
Mother height (cms): Pre intervention Post intervention	155.5 ± 20 163.2 ± 6.3	0.09
Mother's haemoglobin level (g/dl): Pre intervention Post intervention	11.9 ± 1.9 13.0 ± 1.6	0.09 0.10

 

Table 4 Haemoglobin (Hb) levels in control group
Variable	Mean ± SD	P value
Women's Hb (g/dl): Pre intervention Post intervention	12.5 ± 1.9 12.7 ± 1.5	0.382
Child's Hb (g/dl): Pre intervention Post intervention	10.3 ± 1.4 11.0 ± 1.5	0.282

 

To support the efficacy study, 20 staff were given further training and undertook practice tests on how to use the HemoCue® machines, supervised by the MI technical consultant and the Federal MOH.

Graph 1 Overall acceptance of Rahama premix using Hedonic scale

Note on Hedonic Scale: As part of the acceptability test, the Hedonic scale was used. The scale is part of a sensory evaluation of a food or other product, and is a subjective test. The method measures the level of the liking of foods, or any other product and relies on peoples ability to communicate their feelings of like or dislike. Hedonic testing is popular because it may be used with untrained people as well as those with experience. A minimum amount of verbal ability is necessary for reliable results (O Mahony, 1986).

 

Graph 2 Overall acceptance of Rahama premix

 

Graph 3 Rahama premix colour change

 

Distribution to Families

In the first month of the project (26 March to 25 April 2006), 3,975 containers of premix were delivered by SRCS volunteers to individual households in Derig and Serif camps. During the family-level distribution, mothers/caregivers were sensitised about the reasons for consuming Rahama and its proper use, storage, etc. Volunteers then made monitoring visits every two weeks to each family for the entire two month intervention period. A total of 32,000 people were reached, or 3,975 families (varying in size from 5-10 members), with 4,800 women of child-bearing age and 13,984 children under 5 years of age.

Twelve SRCS supervisors and eight State MOH staff continued to conduct monitoring of the cases that took part in the efficacy study, using Rahama for a total of six months after the initial blanket distribution of two months.

Findings

Acceptability Baseline Study and Evaluation

Through focus groups, an acceptability baseline study on the overall attitudes, knowledge of good nutrition and current eating habits was carried out by the SRCS staff in the camps (see graphs 1-3 for summary results). Also, an acceptability questionnaire was prepared by MI and incorporated into the bi-weekly household data gathered by SRC during their monitoring visits. Analysis was carried out by MOH Khartoum.

The overwhelming majority of IDPs questioned found the premix easy to use and store and that it did not change the colour or taste of the food. Over 90% of the people interviewed said that they "accepted" this new premix. Several mothers also commented that their children were generally healthier while taking this premix. Overall, 191 families (63 families from Serif camp and 128 families from Derig camp) refused to use the Rahama during the second month of distribution. This represents less than 1% of families, and is likely due to a misunderstanding of the intended benefits of the premix.

Efficacy Study

MI and its partners conducted a baseline survey before the first distribution of premix in March 2006 in three camps. Two camps were due to receive the premix (2000 subjects or 250 families) and one camp was not and used as a control group (Otash camp with 1000 subjects or 125 families). The families were chosen at random from a list of refugee families.

The beneficiaries participating in the efficacy study continued to use the premix on a daily basis for a further four months in addition to the two months. The post-intervention survey was conducted in early December 2006, a full month after the beneficiaries stopped using the premix, after roughly 210 days of premix consumption. MI had hoped to conduct the survey immediately after the final distribution of premix, but several religious holidays in Sudan during that time made this impossible. The post-intervention data were then transferred to the Federal MOH Statistician for data entry.

The data analysis shows that there was a statistically significant increase in haemoglobin levels of children under 5 years of age (table 2) and also an increase in the haemoglobin levels of women (table 3). In the control camp, it was only possible to collect data from 39 families (31.2%) (table 4). The response rate in the control group was low due to several reasons, including some families had moved away from the camp and could not be located, while others refused to participate in the end line survey, as they were not offered any incentives. This could be a source of bias in interpreting these results and a secondary analysis of the data, looking at the reasons for non-response, is currently under-way.

Technical assistance and project management

As a result of the project, the SRCS's overall capacity to carry out projects in the field was strengthened. Over 50 SRCS volunteers now have a solid understanding of the importance of nutrition, and of micronutrients in particular, in the overall health and well being of women and children. These volunteers have also gained knowledge and experience of conducting focus group discussions and other means of collecting information.

Much of the technical support was provided by an MI consultant who is a medical doctor and who is from Sudan, and speaks Arabic. He carried out the 2-day training, prepared all the questionnaires for data collection and all the training material for the workshop. He provided much of the technical follow-up throughout the project and also acted as the liaison between MI and the Federal and State MOH.

MI's technical assistance/support also benefited both the Federal and State MOH, as they were part of the initial training on the use and importance of the Rahama, and on the use of the HemoCue® machines. This training has now increased the MOH's overall capacity to conduct nutritional surveys (as the HemoCue® machine is almost always used in nutritional surveys). Many nutritionists from the Federal MOH, who were not involved in this pilot project, took part in the final Lessons Learned workshop in Khartoum. In July 2006, once the acceptability study had been completed, a small 'Lessons Learned' workshop was also held in Nyala. Many nutritionists from the Federal MOH, who were not involved in this pilot project, took part in the final Lessons Learned workshop in Khartoum. This exercise brought up several useful suggestions that could be used for improving and scaling up this project or in future Rahama projects.

Issues and Lessons Learned

Improve Customs Clearance:

More attention must be paid to ensure the smooth passage through customs of premixes in order to ensure timely delivery. Staff need to work in advance with customs officials while, in the longer term, work may be needed to help amend customs clearance regulations to ease the import of micronutrient powders and premixes for food fortification.

Integrate premixes with the general food basket:

Once the premix cleared customs, a further delay occurred in transporting the premix to Nyala. In future, it will be important to advocate in advance for premixes and micronutrient powders to be considered as part of the general food basket, so that it can be transported using the existing transport systems. Using indigenous organisations like the SRCS, already involved in camp logistics, to distribute Rahama along with the general ration and to train and sensitise the population on the use and effectiveness of Rahama can greatly add to the sustainability of the project.

Select ferrous fumarate for use in areas with high temperature and humidity:

During the distribution of the premix into individual containers, black spots were found in the premix. After analysis, it was found that this was due to the fact that the chemical company used ferrous sulfate as the iron compound, which may show colour changes when exposed to excessive heat and humidity, despite good quality packaging. As this may affect acceptability, where supplies run the risk of exposure to extreme heat and humidity, orders for such supplies must specify the more stable (but more expensive) ferrous fumarate compound as the form of iron, as it is much less sensitive to heat and humidity.

Extend the expiry date of premixes to improve their utility in emergencies:

The standard expiry date on this product is 6 months. However, in order to maximise the value of this product in emergency settings, the shelf-life of the premix needs to be increased to a minimum of 12 months.

Intensify field level IEC and monitoring:

Briefing at the beginning of the project, as part of the process of obtaining the informed consent of families in the camps for participating in such an intervention, needs to be improved and intensified in future. In this instance, 191/3973 families in the blanket distribution refused to use the premix, as they did not really understand what it was for and wanted to know why it was "only" being given to the IDP population and not the local population. Five families (2% out of a total of 250 families taking part in the efficacy study) used their entire month's supply of premix in one week, as they used it in every meal, not just once a day. Although this did not result in any adverse effects on the health of any of those families, it demonstrated the need for more intensive information education and communication to ensure 100% correct use.

Costing:

The overall cost of this pilot project was roughly $150,000 Canadian dollars. However, much of this was spent on 'pilot' activities, such as the development of protocols, carrying out the acceptability study, etc. We estimate that the cost of distributing Rahama using an existing distribution system, would be less than $45,000 a year for 30,000 people, or less than $1.50 per person per year.

Conclusions

The feasibility study shows that even in a challenging environment such as Darfur, with ongoing security-related issues, that it is possible to conduct this type of project with the right partners on the ground. To achieve 90% acceptability of a new product in an IDP camp is very encouraging, and MI is excited by the possibility of expanding such a project to other parts of Sudan and/or to other displaced populations in Africa.

For further information, contact: Erin Tansey, email: etansey@micronutrient.org.za

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¹The HemoCue® Hemoglobin Systems is a method for quantitative haemoglobin assessment in the field. Any blood source (capillary, venous or arterial) can be used. The unbreakable, disposable cuvette collects the exact amount of blood and mixes the sample with the reagents automatically. The cuvette is placed into the portable analyzer. Results appear on the display screen in less than a minute. It uses only 10 ?L of blood. The machines can be used by non-laboratory personnel after a brief training session.