Supplementary feeding programmes, food fortification, supplementation, school feeding, food-for-work and nutrition education and consumer awareness programmes are the types of targeted programmes most commonly used to improve nutrition.
Supplementary feeding programmes are relatively large programmes in which a substantial number of beneficiaries are covered through the support of donors, international agencies and local governments. Such programmes are primarily designed to distribute food among children between the ages of six months and six years in order to improve their nutritional status or to prevent deterioration in their health and nutrition, both under emergency conditions and in response to chronic food and nutrition insecurity and structural vulnerability.
Such programmes normally target their interventions administratively by selecting the target groups according to geographic location, age or income level. The programmes might select the most disadvantaged rural areas and/or the poorest urban slums. The most common criterion for selecting eligible children is the child's nutritional vulnerability, and anthropometric measurements such as weight-for-age or weight-for-height indices are often used to establish eligibility for programme participation.
Many supplementary feeding programmes involve distributing a take-home food ration to mothers through health centres, on a weekly basis or less frequently. In some countries, the programme is well integrated into the primary health care services in which immunization, oral rehydration, family planning, health and nutrition education, growth monitoring and various other preventive and curative services are offered at the same time. Some programmes also include feeding children who attend day care centres, or feeding severely malnourished children attending nutrition rehabilitation centres; others distribute food rations to pregnant and lactating mothers. In take-home food programmes, recipes can be demonstrated to help families learn how to use unfamiliar foods, increase variety in home meals and prepare meals for weaning-age and sick children. These programmes can also demonstrate the type and amount of food to feed young children or other vulnerable family members.
In supplementary feeding programmes it must be ensured that the ration provided is consumed personally by the intended beneficiary in order to derive a direct benefit from the programme. Leakage may take place within the household. Foods provided by the programme should be based on local food habits and cultural practices, to reduce programme leakage. Intra-household leakage can also be reduced through food selection, if specific household members are targeted for supplementary feeding.
The following are some of the special concerns related to supplementary feeding programmes:
The fortification of food as a public measure to improve nutrition and to reduce or eliminate nutritional deficiencies has been widely practised for many years by a number of developed countries. The most common examples are the fortification of salt with iodine; wheat flour with iron, vitamins B1 and B2, and niacin; and milk and margarine with vitamins A and D. Milk preparations and various types of weaning foods have also been successfully fortified with micronutrients, especially in industrialized countries. The net result of fortification programmes in these countries has been the elimination or near disappearance of many micronutrient deficiencies. In developing countries, alongside massive campaigns to fortify salt with iodine, the fortification of wheat and maize flour with iron is being promoted (Mexico, Brazil, Venezuela, Central America) as well as the fortification of sugar with vitamin A (Guatemala). In some countries fortification is obligatory, and standards and norms have been established by law. In other countries fortification is not obligatory, but instead relies on strong partnership among the food industry, government and consumer interest groups.
The choice of food vehicle is important in these programmes, and is part of the self-targeting process. To ensure that the target population will benefit from a food fortification programme, an appropriate food must be selected. The selected food vehicle must be the most widely used food item or a staple food that is consumed throughout the year by a large portion of the population that is at risk of a particular deficiency. In order to reach different segments of the population who may have different dietary habits, selecting more than one food vehicle is often necessary.
Successful fortification of a staple food affects everyone, including the poor, pregnant women, young children and populations that can never be completely covered by social services. In addition, fortification reaches secondary at-risk groups, such as the elderly and those who have an unbalanced diet.
Food fortification is usually socially acceptable, requires no change in food habits, does not alter the characteristics of the food, can be introduced quickly, can produce nutritional benefits for the target population quickly, is safe, and is the most cost-effective way of reaching large target populations that are at risk of micronutrient deficiency. Experience shows that food fortification is sometimes opposed for professional reasons (concern about overdoses) or on human rights grounds (consumers should be fully informed about the fortification, or should have a choice of a fortified or non-fortified food). Unless fortification is obligatory by law, the food industry may be reluctant to fortify their product, out of fear of insufficient market demand for fortified foods or concern about consumer perceptions that the food product has been altered. Food fortification also raises production costs through such expenses as initial equipment purchases, equipment maintenance, increased production staff needs and quality control and assurance facilities.
The establishment of standards and norms, as well as the monitoring of quality control and assurance, are usually the responsibility of government and require staff and laboratory facilities. Adequate quality control and assurance mechanisms are essential (as demonstrated by the Pakistan example presented in the Annex), and are more difficult and costly to implement when a large number of small producers are involved, as in the case of salt producers in many countries. Thus, the development and implementation of food fortification programmes must be accompanied by consumer education and awareness raising, social and political mobilization, the establishment of strong inter-institutional partnerships (including those within the food industry), and food and nutrition policy advocacy.
In the Netherlands, people did not accept the universal distribution of iodized salt, as it was felt that it denied consumers the right of choice. This led to the presence of both non-iodized and iodized salt in the market. In Montevideo, Uruguay, three kinds of fortified salt - non-iodized salt, salt fortified with iodine, and salt fortified with iodine and fluoride - are available and sold at the same unit price. In the Islamic Republic of Iran, however, the universal distribution of iodized salt was accepted by the population and even led to a price increase of this product in some instances, indicating that it was considered a "superior good".
The following are some of the special concerns related to food fortification programmes:
Supplementation can be an important way of preventing and controlling specific micronutrient deficiencies. It is usually considered a short-term measure to be used while longer-term programmes are being developed and implemented, or it is applied therapeutically. For example, supplementation is used as an emergency action for displaced populations. Vitamin and mineral (iron, calcium, folic acid) supplementation programmes are mainly targeted to cover such high-risk groups as pregnant women, infants and toddlers, adolescents and women of child-bearing age. Iron supplementation is the largest and most commonly implemented supplementation programme in many countries. It is usually carried out through maternal and child health (MCH) and local health services, and sometimes through primary health care (PHC) programmes at the community level. Vitamin A supplementation is often undertaken in conjunction with periodic vaccination campaigns.
Supplementation programmes integrated into existing health programmes offer excellent opportunities for rapid and cost-effective action. To be effective, supplementation needs to be implemented systematically and to cover the target population fully. Training of health staff in proper supplement administration and education of the target population on the importance of compliance are fundamental for success.
While many supplementation programmes have been successful, some have not been effective. Several factors are responsible for this, including: inadequate coverage of the population in need of services; lack of political commitment and financial support; deficiencies in the supply and distribution of supplements at health centres; the cultural and health beliefs of providers and recipients; inadequate training of providers; inadequate education of recipients; the colour and other characteristics of the supplements; undesirable side effects; and low compliance.
The following are some of the special concerns related to supplementation programmes:
School feeding programmes have both a nutritional objective - to improve the nutritional status of schoolchildren - and an educational objective - to encourage school enrolment and attendance and to improve scholastic performance and cognitive development.
School feeding programmes operate with different modalities, ranging from the distribution of a small morning snack to full hot-lunch programmes that provide a relatively large proportion of the daily calorie, protein and other nutrient requirements. In some countries, eligibility is universal and all children who attend school are entitled to participate in the school feeding programme. For example, the Brazilian Constitution of 1988 specifically states that participation in school feeding is a universal right of all school-age children. In other countries, geographic targeting of schools in specific, low-income areas is applied and/or administrative targeting establishes eligibility for a limited number of students, usually based on nutritional or educational performance information about individual students, in addition to information about household conditions (see the country cases in the Annex). Such programmes generally require teachers' and school personnel's effort and time in acquiring, preparing and distributing the food and planning the menus. Parents are often encouraged to participate in the development and implementation of school feeding programmes.
The positive impacts of school feeding programmes are not limited to improving nutritional status and education performance. They also sometimes serve as means of introducing sound and healthy food habits and basic food hygiene practices. Certain activities such as school gardening, nutrition education and food preservation practices are sometimes linked to the school feeding programme and help address common nutrition and health problems, as well as enhancing the overall programme impact.
The benefits of these programmes can be increased by using local knowledge
- particularly that of mothers - in developing locally acceptable recipes, methods of cooking and size of individual servings, and in identifying local foods that can be added to the donated one.
The following are some of the special concerns related to school feeding programmes:
In food-for-work programmes, food is given as full or part payment to unskilled or semi-skilled workers who are employed in public work schemes such as building roads, schools or drainage canals, forestation and land reclamation. In general, food-for-work programmes are self-targeting in nature since they target beneficiaries by means of selecting food rations with a market value low enough to induce only those unable to find more remunerative employment to participate. The principal aim of these programmes is to provide income in the form of food. Community-based targeting also occurs when certain households are assigned to the public works programme by community leaders. This form of targeting may also lead to work sharing, whereby a large number of households are assigned to participate, somewhat independently of relative need. (This is demonstrated in the Ethiopia case study in the Annex.) However, when there is a homogeneous degree of poverty in target areas, geographic targeting may be sufficient to ensure a low leakage rate.
Food-for-work programmes can be effective in reaching the poorest members of the community and in contributing to national development projects. There also tends to be less corruption with these than with programmes that provide cash. In food-deficit areas, when basic food commodities are provided through external food aid the local consumer prices of those commodities are kept low, so there are secondary benefits for the non-participating population. In food-surplus areas, basic food prices remain unchanged, or may rise slightly if foods for the programme are acquired from local producers.
Food-for-work programmes rarely include explicit nutritional goals among their objectives, because they are seen basically as an employment and income-generating scheme. It is assumed, however, that the nutritional status of the participants and their households will improve as a result of greater access to food, while the infrastructure that is constructed should contribute to reducing food and nutritional insecurity in the long term. However, employment in these programmes is temporary and insecure, and is often not sufficient to reduce permanently the food and nutritional insecurity of the participating population.
Labour-intensive projects with a food-for-work component generally win government support, yet the outcome of these projects can sometimes be poor and ineffective, primarily owing to the lack of technical support, tools, proper supervision and cash. Community participation and mobilization during the planning, implementation and infrastructure maintenance phases are essential for the success of these programmes.
The following are some of the special concerns related to food-for-work programmes:
Nutrition education is used by many countries to improve the nutritional well-being of target groups in a population. The general objective of these programmes is to enable the target population to make the best use of existing food resources and to become familiar with food-based dietary guidelines for good health and nutrition. The ultimate goal of nutrition education programmes is to bring about appropriate and meaningful changes in knowledge, attitudes and dietary practices that result in improved nutritional status among the target population. Closely related to this are consumers' rights to have full knowledge about the nutritional qualities of the foods they consume and to be protected from inaccurate commercial information with respect to those qualities. Consumers should have the knowledge, as well as the means, to make informed food choices and to denounce any false claims by the commercial food sector. Thus, consumers should be partners in consumer protection programmes.
The effectiveness of these programmes depends mainly on how well they are planned, implemented, monitored and evaluated. The social and cultural relevance of educational messages is critical, as are the methods by which the messages are delivered. Equally important is an adequately trained programme staff who are socially and culturally sensitive. The programme design must reflect a basic understanding of the social, economic and cultural determinants of current food, health and nutritional behaviour.
Education programmes also require the commitment of political leaders and policy-makers, especially in the planning and launching stages of a nutrition education programme that is part of a national food and nutrition policy and action plan. They require the support of social, economic and organizational policies and strategies, as well as the involvement of all relevant sectors and actors in related disciplines, from the local to the national level.
The effectiveness of nutrition education programmes can be substantially increased by applying social marketing methodologies. Social marketing approaches contribute to establishing a programme that is based on an assessment of specific consumer needs and desires, rather than applying the same technology or solution universally. This contributes to better-designed and more effective programmes.
The following are some of the special concerns related to nutrition education and consumer awareness programmes: