Module 2 - Programs

Slide 1

This module looks at program characteristics. It uses two categories of programs for examples: Micronutrient intervention programs and oral rehydration therapy (ORT).

Slide 2

Programs are made up of activities designed to accomplish specific goals. Agencies conduct programs. They are not programs. For example, UNICEF is an agency that conducts programs to improve the health and welfare of children (target audience). Specifically, they have programs to reduce anemia in pregnant women (because they "carry" children), infants, and children. One of the program activities would be distribution of iron supplements to pregnant women, another would be development of a weaning food that contains iron, still another might be development of a school snack for children that is fortified with iron. In some cases the terms "activities" and "programs" are used to mean the same thing.

Slide 3

Supplementation programs focus on delivering nutrients in medicine forms, such as pills, capsules, or injections. Supplements are delivered to each individual separately, since each must make a conscious effort to take the supplement.

Fortification programs add nutrients to foods. Fortified foods deliver nutrients to larger target audiences. Since the nutrients are in the foods, the only individual effort is for the person who purchases and prepares the household's food to purchase the fortified food.

Dietary diversity programs help target populations to grow and use foods that will improve their nutrient intakes.

Food assistance delivers food or resources to purchase food directly to households or individuals. Food assistance programs may be emergency programs after earthquakes, etc. or they can be long-term programs.

Slide 4

There are many different programs worldwide to help people meet their vitamin A needs. These are just a few examples.

Slide 5

There are many different programs worldwide to help people meet their iron needs. These are just a few examples.

Slide 6

There are relatively few programs designed worldwide to meet iodine needs. However, these programs have been very successful, which is why the original models have been copied so many times. Fortification of salt and soy sauce with iodine have greatly reduced iodine deficiency disorders.

Slide 7

Supplement programs are effective when they reach the targeted individuals. Most supplementation programs operate out of clinics or through trained individuals who explain how to take the supplements. These programs are usually inexpensive and have little infrastructure required. An example of a supplement program is distribution of iron supplements to pregnant women (US and international).

As in taking any medication, supplement programs rely on individual actions. Problems include individuals taking too many doses at a time (thinking more is better or making up for forgotten doses) or not taking the full dose (forgetting to take doses or sharing with others, for example). Additionally, sometimes the target audiences do not trust pills or injections and do not participate in the programs.

Slide 8

In the first stages, the fortification programs must decide which nutrients to add to the food and the amount of the nutrient to be added. The appropriate food vehicle(s) must be considered. Usually these are inexpensive, staple foods consumed by most of the target population. The nutrient must be bioavailable and stable in the food. The amounts must be enough to meet nutrient needs and not enough to cause toxic effects. An example of a fortification program is iodized salt (US and international).

Infrastructure is required to produce the foods, monitor the foods for the nutrients added, and to make the foods accessible to the target population.

In most cases, where fortification of foods is a national or regional effort, fortified food products are not substantially more expensive than alternative foods. However, for poorer populations, even a small difference makes it unlikely that they will purchase the more expensive food. Some countries subsidize fortification programs for this reason.

Slide 9

Dietary diversity programs are in place in many countries. These programs meet many different needs - from farmer to consumer education.

Subsistence crops are those that people grow for themselves. Cash crops are those that people grow to sell. For farmers the decision of what to grow can be very difficult - food for family and community or food to sell.

Improving agricultural methods is difficult, too. What works on large commercial farms in the US may not work on smaller farms in developing countries. Consider the inputs for the larger farms - large equipment, energy resources, water resources, specialized chemicals. These inputs are unlikely to be available in developing countries and are too expensive for farmers working small plots of land. Instead, farmers are typically taught methods that require less water and that preserve soil.

Food processing can allow food to be available year-round instead of just at harvest time. Effective food processing requires appropriate storage. In some countries over half of the food produced for human consumption is consumed by insects and rodents instead of people.

Slide 10

Food assistance can provide just-in-time food for people in need. Sometimes these are emergency needs - after earthquakes, floods, etc. Sometimes these needs can be long-term, such as meeting the needs of regions after several years of drought or conflict.

The goal of many international programs is to use money to help countries develop so that they can meet their own long-term needs. This reduces long-term dependency. One way that this has been done is through food-for-work and food-for-education programs. These programs provide food (and other resources) to people who are working to develop local infrastructure (such as a dam, school, hospital, etc.) or who are in school. These programs can help communities to become less dependent upon outside aid. These programs are not perfect, though. Problems include reaching only healthy individuals who are able to participate, maintaining the infrastructure once it is developed, and providing meaningful training and education.

Slide 11

Water is used for drinking, preparation of food, cleaning, agriculture, and other purposes.

There are many waterborne diseases. Dirty water and inadequate sanitation are directly linked to the illnesses that are the leading causes of infant mortality in the developing world (and a fertile breeding ground for malaria-carrying mosquitoes and cholera).

Water sanitation and disinfection requires filtration to remove particulate matter and disinfection to inactivate pathogens in the water (including bacteria and parasites). This is difficult to do without rather extensive infrastructure, especially when water is scarce. It generally requires that waste water be treated or that water be "captured" from deep systems that are not contaminated.

• The 1980s were declared the International Drinking Water Supply and Sanitation Decade.
  • 1.5 billion more people now have an adequate and safe water supply
  • 750 million gained access to sanitation
  • about 1 billion people in developing countries still lack access to clean water
  • about 2 billion people still lack adequate sanitation service

ORT--Perhaps the greatest life-saving breakthrough in human history can be credited to a simple packet of salt and sugar that costs about seven cents, known throughout the world as ORT.

Diarrhea is one of the biggest causes of infant mortality in developing countries, leading to more than 3 million deaths of children under 5 each year. ORT prevents these deaths. UNICEF estimates that use of ORT has saved over 1 million lives/year in the developing world.

Slide 12

This pie chart shows deaths from infectious disease worldwide. Of these deaths, about 1/6 are water-related. [The two other largest causes are maternal, perinatal, and nutrition-related problems (severe undernutrition and vitamin A deficiency that contribute to lowered immunity) and HIV/AIDS.]

Slide 13

There are many diseases caused by contaminated water.

Pathogens contaminate water and cause disease when the contaminated water is consumed. Most of these diseases result in severe, life-threatening diarrhea. The parasitic diseases frequently cause anemias by competing for nutrients with the person they infect (or by causing some internal bleeding).
Bacterial - campylobacteriosis, cholera, typhoid
Parasite-caused - Guinea worm infection, ascariasis, leptospirosis, onchocerciasis, schistosomiasis
Viral - hepatitis

Mosquitoes lay eggs in standing water. Mosquitoes carry many diseases, including malaria, dengue hemorrhagic fever, (and West Nile virus).

Heavy metals, such as lead, mercury, and cadmium can cause harm when they are consumed at high levels. These metals frequently contaminate water (and foods, such as fish), when contaminated runoff from mining or manufacturing enter the drinking water supply or the food-production (fishing water) supply.

Slide 14

Water can be sanitized by heat treatment or chemical treatment.

The traditional heat treatment is boiling, which requires quite a bit of fuel. The newer treatment puts water into standardized plastic bottles which are exposed to direct sunlight. This program is called SODIS (SOlar DISinfection). Their website is at http://www.sodis.ch/. [As a local note, The Coca Cola Company is supplying bottles and delivering them to target populations free of charge.]

Chemical treatment of water is largely through cholorination. To be effective, water must be filtered and treated with appropriate amounts of chorine.

Slide 15

In the US, diarrhea is usually considered an inconvenience. Worldwide, it can be life-threatening. In developing countries children typically exhibit diarrhea 2-6 times per year. Approximately 2.2 million children under age 5 die from diarrheal diseases each year. Worldwide five percent of children die from diarrheal disease before age 5.

In addition to being life-threatening itself, diarrhea can impair nutritional status by reducing absorption of essential nutrients. Diarrhea also weakens individuals and makes them more susceptible to other acute infections.

Slide 16

Oral rehydration therapy (ORT) is a home-focused therapy for children who have diarrhea. Because children can lose water very quickly and hospitals are not usually close to homes, this remedy was designed for home use. It requires minimal training to use. It is easy to distribute and hold until needed because it does not "go bad."

ORS is a packet of salt and sugar that increases water absorption. Years ago we learned in cholera epidemics that giving water alone did not increase water absorption, but giving water with small amounts of salt and sugar did increase water absorption. This packet results from that observation (as do many sports drinks recommended for endurance events). The packet must be mixed with sanitary water because sugar and salt will not destroy pathogens.

ORT uses ORS plus continued feeding throughout the diarrheal episode and higher levels of feeding for a week after the diarrhea ceases (to improve nutrient absorption).

Slide 17

UNICEF and WHO estimate that ORT saves approximately 1 million lives each year. However, this is only about 1/3 of those who potentially be saved.

ORT use in households has increased greatly since the mid-1980s. There is some confusion over the newer (1993) ORT definition that includes continued feeding instead of concentrating solely on giving fluids. However, some form of ORS/ORT is used by about 75% of families worldwide. Use appears to increase when social mobilization and education programs are active and decrease when those programs are not active.

Slide 18

Programs work toward achieving measurable goals, although program outcomes are frequently difficult to measure since many things are happening at the same time. Since several programs/activities may be operating at the same time, it is difficult to separate out the effects of a single program.

Programs are organized around activities and evaluation of those activities. Sometimes, especially at the beginning of a program, participation in the program is the only measure available. A mature program should have participation data and outcome data.

Programs usually target specific populations. Those populations may be small, such as agricultural workers aged 8-12 or new mothers aged 12-18. The target population may be large, such as individuals in Sub-Saharan Africa.

Data on populations, program participation, and program outcomes are important because a program that is successful in one instance may serve as a model for other programs. Success is more likely when a program that is successful in one instance is re-applied under similar circumstances and conditions. Also, data may help to show why a program is unsuccessful in one area; it may be successful in another area.

Slide 19