VITAMIN A INTERVENTION PROJECT: INTERNATIONAL EYE FOUNDATION. April 1989

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1 MID-TERM EVALUATION VITAMIN A INTERVENTION PROJECT: GUATEMALA INTERNATIONAL EYE FOUNDATION April 199 BEST AVAILABLE COPY

2 MID-TERM EVALUATION VITAMIN A INTERVENTION PROJECT: GUATEMALA INTERNATIONAL EYE FOUNDATION April 199 M. G. Herrera, M.D., Consultant Faculty Lecturer Department of Nutrition Harvard University School of Public Health

3 TABLE OF CONTENTS Introduction... 1 Background... 2 Description of Comite Nacional Prociegos y Sordomudos (CNPCS)... 2 The Project: Objectives. Goals. Design... 4 Phase One (Six Months)... 5 Phase Two (Twenty-four Months)... 6 Progress Report 1. Formulation and Production of Nutriatol Nutriatol Acceptance and Biological Impact Studies Nutriatol Distribution Issues and Recommendat ions 1. Accomplishments and Problems Questions to be Answered Supervision Safe Use of Pesticides Final Evaluation The Project - A New CNPCS Initiative Organization and Management Vitamin A Content of Nutriatol Bibliography Appendices I. Studies on Comparative Acceptability of Nutriatol & Incaparina I1. Report on Plasma Retinol Levels in Healthy Children After Eight-Day Course of Nutriatol I11. Preliminary Report: Comparison of Nutriatol and Incaparina Effects on Plasma Vitamin A Levels Among Children Suffering From Diarrhea IV. Report on Baseline Sampling of Children for Initial Vitamin A Status V. Guidelines for Use of Visual Aids in Vitamin A Education Program VI. Data Collection Forms (Nutriatol Distribution. Household Survey. etc.) VII. MIS Information Needs Summary VIII. Database Management Programs Developed by the Project IX. EPA Manual Concerning Safe Use of Phospides

4 April 19, 199 TO: FROM : International Eye Foundation M. G. Herrera M. D., Consultant SUBJECT: Mid-Term Evaluation, Vitamin A Intervention Project, Guatemala (Grant No ). In keeping with letter of agreement dated January 19, 199, I visited Guatemala from February 19 to February 26 to assist in the mid term evaluation of the above named project. IEF provided me with background material and documentation concerning the project design, methods and progress to date. In Guatemala I worked closely with Dr. Gustavo Hernandez Polanco, Project Director, Dr. Noel Solomons, Director of CESSIAM, and with Ms. Cynthia Rivera, Assistant Project Coordinator; project staff was fully cooperative. Meetings were held with the data management consultant from Universidad Francisco Marroquin. A field visit was carried out to Alta Verapaz where promoters, teachers and school children were interviewed and distribution of Nutriatol witnessed. A draft of the report was discussed with Dr. Solomons and Dr. Hernandez on a subsequent trip to Guatemala. The report is organized as follows: A brief description of the organization and activities of the executing agency is presented first followed by a summary of the project's objectives, specific aims and design. A chronologic progress report follows underscoring accomplishments, problems encountered and plans for

5 the next phase. At the end there is a summary of the main issues and recommendations. 2 Backqround The International Eye Foundation (IEF) in Bethesda in collaboration with the National Committee for the Blind and Deaf in Guatemala (CNPCS) are carrying out a project to reduce prevalence of Vitamin A deficiency. The project entails development of a Vitamin A-rich refeeding mixture for children convalescing from diarrhea and testing of an innovative service delivery method whereby pre-school children are reached through their school-aged siblings. Teachers in rural schools are used to multiply effectiveness of rural health promoters; teachers identify preschool siblings of their pupils, organize gatherings of adult caregivers for nutritional and health education, and distribute supplements. The project is of special significance because it explores the feasibility of using the rural school as focal point for developing primary health care. Careful process evaluation is expected to yield useful general guidelines for future rural health and education projects. The Comite Nacional Procieqos y Sordomudos (CNPCS) CNPCS is a non governmental organization with a distinguished

6 3 track record in the provision of services to the blind and the deaf in Guatemala. CNPCS serves persons who cannot afford private care; all prospective beneficiaries are screened by a well run social service department. Services are financed by donations and the proceeds of a private lottery sanctioned by the government. CNPCS has three divisions: Medical, Education and Rehabilitation. The Medical Division (CNPCS-DM), directed by Dr. Gustavo Hernandez Polanco, runs several hospitals and clinics, schools and training centers. In the capital and in several provinces, it employs 670 persons, and it is recognized as one of Latin America's leading institutions in this field of endeavor. CNPCS-DM provides ophthalmology and otology services free to persons without resources, others are charged modest fees in keeping with their ability to pay. The Medical Division also offers an accredited residency training program leading to the postgraduate degree of Master in Ophthalmology conferred by the Universidad Francisco Marroquin. This well-known academic program (Institute de Ciencias de la Vision) is headed by Dr. Fernando Beltranena, one of Guatemala's leading ophthalmologists. CNPCS-DM also has an active research program (CESSIAM) headed by Dr. Noel Solomons formerly on the Massachusetts Institute of Technology's faculty. In addition, CNPCS-DM runs a blindness prevention program that provides training in ophthalmology to primary health care personnel including recent

7 4 medical graduates beginning rural service and health promoters. Also under this program surveys are conducted periodically to update epidemiological information concerning blindness and visual impairment in Guatemala. CNPCS-DM is recognized as a World Health Organization collaborating center for the prevention of blindness. The Special Education Division operates schools for the blind and for the deaf and a unit to provide early stimulation to young children with various forms of sensory impairment. The Rehabilitation Division operates sheltered, rural workshops, a training center to prepare blind persons for farm-based jobs and programs to foster self care and independent living for both young and elderly blind persons. The Project The goals of the project are to reduce childhood morbidity and mortality and protect preschool children from Vitamin A deficiency in a rural area of the province of Alta Verapaz. Specifically, the project aims to: 1. Develop and test a Vitamin A-rich convalescent refeeding mixture (Nutriatol) for use by children recovering from diarrhea. 2. Distribute Nutriatol to 12,000 preschool children at risk of

8 Vitamin A deficiency in the Province of Alta Verapaz. 3. Develop and implement a nutrition and health education program to instruct mothers on the management of diarrhea and the utilization of Nutriatol during convalescence. 4. Evaluate the acceptability of Nutriatol and its effectiveness to ameliorate Vitamin A deficiency. 5. Field test an innovative outreach method whereby health promoters utilize the rural school system to locate and deliver services to preschool children. Initiated in June of 197, the project was planned as follows: Phase One - Six Months 1. Formulation and production of Nutriatol. Assay of Vitamin A content of the commercial mixture by an independent laboratory and determination of shelf life. 2. Testing the effect of Nutriatol administration on serum levels of normal subjects and its acceptability to mothers and children. 3. Planning the field trial and making necessary contacts in

9 Alta Verapaz communities with local leaders and representatives of the health and education sectors Purchasing a vehicle and other equipment. 5. Selection of two bilingual persons to be trained as health promoters/primary eye care technicians. 6. Design of the project data management system (MIS) utilizing appropriate consultants. Phase Two - Twenty-Four Months 1. Appointment of project assistant coordinator to assume day- to-day management of project logistics, field supervision, data processing and analysis. 2. Training of health promoters/primary eye care technicians at Rodolfo Robles Hospital in Guatemala City and in Alta Verapaz. 3. Development of educational materials to be used in the field. 4. After a general meeting with teachers of forty-eight schools previously selected, the promoters visit each school to explain the project in detail to the teachers and distribute the forms where they are to record the names of all students

10 7 with siblings under the age of five. The latter are the target group of Nutriatol distribution, while the older siblings become the agents to communicate with the mothers and distribute the supplement. At the time of this first visit by the promoters, a date is set for a meeting to which all eligible mothers are invited to participate. 5. During a second round of visits to the schools, the promoters explain the purpose of the project to the school children and their mothers underscoring the importance of oral rehydration therapy and the administration of one packet of Nutriatol a day for eight days to preschool children recovering from diarrhea or other infectious diseases. At this time, baseline information on the agents and their siblings is collected. A supply of Nutriatol is left with the teachers at the schools. Mothers are instructed to return the empty packets via their school children in order to obtain further supplies. 6. At least twice more during the first year of the project (191, the promoters were to visit the schools to replenish supplies of Nutriatol. At those times, the promoters collect information concerning the number of packets distributed to each recipient, as well as any changes in the target group composition (new children, dropouts, etc.). The final round of visits was to take place in September of 19.

11 7. In the afternoons and during school vacation in October and November, home visits to a subsample of beneficiaries were planned in order to ascertain the utilization of Nutriatol as well as to investigate attitudes and practices concerning the management of diarrhea and feeding of preschool children. Proqress Report(Tab1e 1) 1. Formulation and Production of Nutriatol The project was initiated during the second semester of 197. CNPCS-DM/CESSIAM in consultation with the commercial firm Alimentos S.A. opted to utilize INCAPARINA, a well known low cost weaning food as the vehicle to deliver Vitamin-A to target children. The reasons for this decision were as follows: Incaparina when cooked resembles autochthonous thin cereal porridge ( At01 and is reasonably well accepted in rural Guatemala. Incaparina originally designed by scientists at the Institute of Nutrition of Central America and Panama contains various cereals in the necessary proportions to provide protein of high biological value at reasonable cost. It is manufactured commercially by Alimentos S.A. and therefore developing a new product was unnecessary thus saving time and money. CESSIAM studies have shown that Incaparina is frequently fed to children recovering from diarrhea and/or febrile illness and was therefore likely to be accepted. The Vitamin A

12 7.. :m TABLE 1!, " RESUMEN DE ACTIVIDADES DEL PROYECTO DE INTERVENCION DE \'ITAVINA "A" - PERIODO 19 EL~EYC list I C U S ~ iser - Estudio Iipactc Eiolooico y Ayptabi!idad - Las sosiates eoü:a:iv! sr liovaron a cabo ourante tooo e: lnstalacion at 12 coipntaoori no5 ct accstr - ~eleccioo dr arras para distribucion - 7.:. Sr:. dr Caitan y P.I.C. harrn supervision de sesiones - Sc coipro el vcbiculo ecc:;:!ra: cr boi.cb! irotp!obar trr~seisio~ clara dt: Convenio escrito Proiotorts/lospital. ittslt: - Se contrato P. 1. C. - inicia rn febrrro - LP! r:!kbipio: t~~a;ar 3 r! horas diarias el h'otriatol 2 ser ai iia siouiente FEbEERO 1911: Entrc~aiiento~de Pioiotoies dr S.O.P. - Sr deterio c~ot?iicacios ot cusano5 de paloiilla cn el Proiracto oeraate 1; lia. iobecz Ir aocstc... F,GZP IS p;cur!r! cx!!í;ocs er e! Lat. ~t Il!itntos S. A. - Tisita APKOFAH y ASBCSA IAsoc. 6t Servicios - t.?l\ a?! r.:<cr:ir ct!rrk,air rc! rr~r:~iir~acitr Assnte: Cuia para Cosnoitarios 6r Salod 1.!1\ ct1 r!oíbrtr Cr:iri.ac: r?- :!lect[ i?;+?"pi:abricz el~borar dc Chiialteúangol - 50 CFP::;!~ ;!:!oq:; ~fur;;a: 12:; icb~: 5~iec:ion del hut. uuias iisualrs. - A1iirn:os!. L. itrrzrnór ucñ i:iiciric! ~ o ~ ~ u ü l - Contrztacion artista pzra rlaborar auias visuales - P.A.C. ri'itc boeeqas dt Ii.liieotos S. L. lasñntn verifica1 -?.S. Sra. do lasoues contacta supervisores ac Educ. ctndicioors aosiateccion drl area ae aliarenarientol pzis hacci piezeotacion Ptl Prouraia en Coban - LE Or~versi~at i. L. lona resp~~sai~ilidad arl nesariollc Se ot~tirnen ~iacas y srouro drl vehicolr brl Proaraia UlS conuricacinn con Nestor Carcia cl - p. A. C. Pejo ar trabaja1 para rl Pio~iaia 16-S-ltl - I! sli6es oe vistzs ~ano:anicas (IECUATI lbñ1l 191I Se contrato nucva P.A.C. - Cr.tpíi t ins:ilacion parrilla del vehicilo sep~~eu~re 19E - st p:ntzt loqos cn las pieitas dr v~hicolo - so llerün cabc la: visitas rscolares Cons:iuccioo aita or pacientes externo' Hospital dt Caicha - 7, e y 9 at septi~iore Ivisita Sr. Ianceyl 15 dr abril: Srsirn de Harstros - asistrncia del I5\ - Se aplica encc~sta a Proiotoics lñsunto: ietroali~ontacion - huev~~ con:a:tn con escntla dt aite sobie 12~01 destiptnadal - Sr escooicion 47 Escuelas y 1 Ctotrn dr Salod - Vzri?: visitas i Data Pro Isayoiia do it!ras nrc. eiuste OC:!I!;L!9tt paia facilidad y eractituc - ;ieecc::~?el?anun! t,[!~st!~iciones dt Ceneraior Elec. - Iire. A. Iasoucr viaja a Coban y Carctta - asunto estudio - Prch!rrar pzre ieccitrtar lar ic:izr 115\ de escuelas ya aceptabilidad dtl Wotriatol en Alta Verapai rti~adasl - ~.j..c. r~;iií? scacrvi:iot dt Visir?: a Raoares CAYO a. Er, iovis:a PL Iticti fiui61 Ic;~proi~aci~ñl - ~ d y o H. liria docutento itsponsabilidad dcl vehicilo b. st ~ncostr~ ro~rtracion auia cniuriitario el c. Se cbseivo la talta de :ransporte a las aldeas - Corpra dt 513 sacos d. No hay acceso al Centro de Salod y el bospital - Se solicita crnso ninos prt-csco1;rts del arta e. Eo triste st?a;rcion oe viviendc y coridz dt personas - se ron:rita atro aitista.para otsarrcllar ayudas visuales y - ~iatvos intentos conractai bati Pro f. Lz ~ivit~;; re:.ri:tt en cr sc!c' rearto para cuargar - Arie;lo lento dr tiansportr Kutriatal, de Guatemala a Coban preparar sl;stntes, siendo el I~SLID ta'bien Jütí kipliacionts totograficas J 1 juegos slioes e ayodas visuales h'ffliu!ee 156f - 7 y á de junio heiatologia PAll - St rc~itcí? para ~:rir [tocando del 6 al 26 oc bayo) - Prc;r.leies r,écifiestar descontento coii labor dt etpaqnt - I~3:tip o? ií;arics : y 10\1 - st i:.r!irj:l; le nuevi fo:~z ot Visita a Hogares z 052! prtt 6f? p:o~rasa Uli lali~tntarion dt - 3L,III bolsas plasticas prqarnas (paprtts dt 1 onidedrsl eatcr '5 iricii t1 F de nov!trbrel.. - inrio de lutriatol a Carcba, 14 y 15-L-CL llls y 11P sacos1 a. s?oe:;caf b. Reaistro de datos cie - Se inicia labor de r~baoue rl aotrtes y :on'ucidores. l~au~uracion Hospital de Carcha - Frii'tritucion dt hutriatol dirtcte a Hooaies ddraitt - C0~prl at 125 boisas plasticas taeano oficio [sets Forias). uisitis sr hicitror: dsiinte rl te: de oovienbrt, te:tisando, - pro~o:~res son iustiuidos rn ianejo ayudas visuales y tl Qia 24 entrrci at ouia del ratriial raucativo : - Vet!culc So:cki t!aiao $üiesala por Edyn Hartine2 (par; ' - Eiaroiacion del lti. calendario dc info;iacion/distiibocion?:!rziectr tú Fv6:f:zIi curarte el trs de dicitcbit, basta - Irpresio~ at 11,)MP fcrias MIS O rtinicio dr lahrrer dtl Grnorair en enero Eiatoracion de recibo de forias HIS a firtai pcr iarstros - S: sti~:cio:.ar~r. 21 r!rutlai ziicionalrs a las CUF a~isten ct ;::!rlio ot!tll cl::?~: JULIO bol 11 a! tliitíiit 21 Y Lf oicittt!~ se tifararot BPPP - S"litucirn de 3 escuelas por asooto dt ubicarion p;ccc:r: Cc l;.:ria!c: ct E unidades c/u 111 dias e kocarrido dt inioreacion individual z ratstios sobre el p5;ztte: t; r.r:! iantjo dt la. iorias HlS, y al iisio titipo acordar citas -?!i SZCPZ EL ~Y!:~z:c!!tt:on trarsportados a Crrcbñ el par; srsion educativa (durante todo el iesl dia!i ir: 6:vltiBrt,, - Fjsita dr suprrvision sobie la cciunicacion positiva drl - I.r-'*r; c: ~t:irnal tr.. e! Ct~tro dt Salce 6r Ls9;oir ie~sñir eoucatiia, coiprension de iantlo df feria! po:.-.-:.c! : t!!:::!::;~:. S:.li::ntf![ z:;i;i?: iüerc:.. rzt:tros y itvisian del sistera de traoalc oe ~IFIG:FI~S : : i ::::::s. St solicita:::.!ii.;;:jt;a:..... ' <... r :?scltzdr ne~ativo dt co~unicacion ccr Eata Prr,:.,... e.... cis:i;:r:ici ct!!:l.,;;'.',. ' '. l. ' BES 7 AVAILA BU. COPY

13 content of NUTRIATOL was set at 3000 RE per 100 grams of uncooked powder approximately twice the Vitamin A content of Incaparina 9 (Table 2)'. Twenty grams of the enriched mixture and fifteen grams of sugar are then packaged in suitably labeled envelopes. Feeding the content of one envelope per day provides 2.4 times the Vitamin- A WHO/RDA for children <3 years and 2.1 times the RDA for children 4-6 :years of age. Alimentos S.A. undertook the production and packaging of Nutriatol and samples were sent for analysis to the laboratories of Haoffman La Roche in Basel, Switzerland. Vitamin A content was found to be within the expected range. Shelf life of Vitamin A in Nutriatol was also found satisfactory. Problems have been encountered in the storage of Nutriatol both at project headquarters in Alta Verapaz and at the rural schools. Infestation with moths ( Palomilla was discovered in a small 0.5% proportion of packets at the former location while rodents caused considerable damage to supplies at a few rural schools. Alimentos S.A. was consulted and they recommended the monthly use of phosphine gas at the warehouse. This has been done and the infestation problem is under control, but safety precautions in the use of the pesticide are not adequate. The rodent problem (vide infra) has been The proportion of recommended intake was calculated using WHO allowances which are lower than the U.S. RDA (Food and Nutrition Board, National Academy of Sciences, Recommended Dietary Allobrances, 190). If the latter are used, one Nutriatol packet provides 1.5 times the RDA for children <3 years of age and 1.3 times the RDA for children 4-6 years of age.

14 TABLE 2 Appendix A: Breakdovn of NUTRIATOL vs. INCAPARINA The specifications for the basic product (an INCAYARINA-like atol) and for the vitamin A-rich analogue (NUTRIATOL) are shown belov. INCAPARINA is a commercially-successful product made of locally-available basic ingredients (corn flour, cotton seed flour). A brief survey of urban mothers, folloved up after release of their respective children from the rehyudration unit of a general hospital after treatment for acute diarhea, showed that virtually a11 fed some INCAPARINA as part of the convalescent refeeding regimen (Lopez, H. L.; Holina, S.: unpubl.ished results, CeSSIAH). Nutrie!nt Content: per 100 g of povder vitamin A Niacin Thiamin (Bl) Riboflavin iron calcium phosphorus Lysine 4500 IU (1364 RE) mg 1.70 mg 1.01 mg rng rng 6.00 tug mg 9990 IU (3000 RE) rng 1.70 mg 1.01 mg rng rng 6.00 rng mg The amount of povder to be used for a serving is 20 grams. Thus each serving of INCAPARINA supplies 273 RE of dietary vitamin A activity and each serving of NUTRIATOL vill supply 600 RE vhich represents 2.4 times the requirement of vitamin A for r 0-3 year old child and twice the requirement for a 4-6 year old according to the recommendations of FAO/WHO.

15 addressed by using metal containers whenever possible. (The school I visited had such containers but they lacked covers) Nutriatol Acceptability and Bioloqical Impact Studies 2.1 Acceptability of Nutriatol The acceptability of Nutriatol and Incaparina was assessed among children recovering from diarrhea both in Guatemala City and in Alta Verapaz. Children age 6 to 72 months were given Nutriatol or Incaparina and instructed in their use at the time of discharge from ambulatory treatment facilities. Home visits conducted five days later revealed that consumption of both supplements was satisfactory (about 75% of prescribed amount). No significant differences were detected in the acceptability of Nutriatol and Incaparina in either geographic setting (Appendix I). Field staff reported that the sweet taste of the mixture appealed to beneficiaries since poor rural households frequently lack sugar to sweeten Incaparina. 2.2 Effect of Feedinq Nutriatol on Retinol Serum Levels Plasma retinol levels were determined in 3 healthy preschool children before and after receiving 1 packet of Nutriatol/day for days. No significant differences were observed in either mean retinol blood levels, a finding that is not surprising since the

16 subjects presumably had adequate Vitamin A reserves (See Appendix 11) Comparison of Nutriatol and Incaparina Effects on Plasma Vitamin A Levels Amonq Children Recovering from Diarrhea Sixty-nine children who attended the pediatric outpatient department of the General Hospital in Guatemala City because of diarrhea were enrolled in the study. They were assigned to either Nutriatol or Incaparina (1 packet/day Nutriatol or 20 grams Incaparina/day for days) treatment groups after a blood sample was obtained for plasma retinol determination. Only 34 children were brought back for follow-up examination two weeks later, and of these, 27 remained after excluding those who had not taken the supplements as instructed and those whose mothers refused to allow the taking of a second blood sample. Out of these 27, eleven matched pairs will be compared. Serum Vitamin A assay results are still pending. (Appendix 111). The interpretation of studies such as this one, which depend on sampling of blood to assess the effects of treatment, will be difficult given the high dropout rate which may bias the results. 2.4 Baseline Vitamin A Status of Preschool Children in the Project Target Area Preschool children attending two preschool nurseries of the

17 government's preschool education program (PAIN) in the Project area were selected for monitoring vitamin A status prior to Nutriatol distribution. The same children are to be studied two more times: one year and 2 years after initiating Nutriatol distribution. At these two sites, there are no 'agents' ; Nutriatol is given directly to the mothers by the teachers who instruct them on how to utilize the supplement and how to replenish their supplies. Blood samples were obtained in June 19 at the nurseries in the districts of 'Las Casas' and 'La Nueva Esperanza.' A total of 190 children were tested. The blood was centrifuged on site and the plasma packed in dry ice for shipment first to Guatemala City and then to the U.S. Department of Agriculture to laboratories in Boston (Appendix IV). 12 The results of the baseline plasma retinol level assays are summarized in Figure 1. The median retinol level was 19 with 55 percent of the cases falling below 20 micrograms/100 milliliters, i.e. in the 'at risk' category. Five percent of the children were frankly deficient: below 10 micrograms/100 milliliters. These results suggest that Vitamin A deficiency is a significant public health problem in the study area. Although the sample is not necessarily representative of preschool children reached via the school system, it is likely that they too are at risk of Vitamin A depletion. Comparison of the socioeconomic and household characteristics of the 'PAIN' and school-based samples will shed light on this issue. Unfortunately, collaboration of 'PAIN'

18 FIGURE L 50 EETI NOL ( ug/dl) Thks figure shows the Histogram Distribution of Plasma Retinol levels (As analyzed by Dr. Carmen Castaiieda in the Nutritional Evaluation Laboratory of the U.S.D.A. Human Nutrition Research Center on Agdng, a collaborative Center) for 1 preschool children from Kekchi households for two centers of the program of integrated attention to the preschool, child (P.A.1.N) collected by a team of investigators from Cessiam four point eight per cent of the children had retinol levels below 10 ugldl, considered "deficientlat -riskw; 54.% had levels from 10 to 19 ugldl, cpnsidered "low" the combined prevalence o subnormal, plasma retinol was 60%

19 13 nursery school teachers and the mothers of their pupils has been less than satisfactory. The problems appear to stem from insufficient time on the part of promoters to maintain communication with teachers and the lack of adequate incentives to sustain teachers' collaboration. This may be a problem also in the case of the primary school teachers who are key elements in the system to distribute Nutriatol and impart health and nutrition education. 3. Nutriatol Distribution 3.1 Fourth Quarter 197 During the last quarter of 197, the project director and CNPCS-DM staff made the necessary contacts with local health, education and civil authorities to explain the project and enlist their collaboration. Local candidates for the positions of health promoters were identified and arrangements were made for their training early in First Quarter 19 During the first quarter of 19 the health promoters were trained with the collaboration of CESSIAM staff, first in Guatemala City at CNPCS-DM headquarters and subsequently in Alta Verapaz. The Assistant Project Coordinator was appointed and the first steps

20 14 were taken to produce educational materials. School District supervisors were contacted and a list of rural schools in the project areas was compiled. Forty-eight were selected for participation in the project during the first year on the basis of staff interest and geographic accessibility. Two nursery schools and a health center were also selected. 3.3 Second Quarter 19 The baseline blood samples for the Nutriatol impact study were obtained at the nursery schools, Esperanza and Las Casas. Visits by the promoters to individual schools were scheduled. Problems related to staffing, development of educational materials, information management and transportation and storage of Nutriatol delayed the beginning of the education sessions and distribution of the supplement. The Assistant Project Coordinator resigned in March. She was replaced by Ms. Cynthia Rivera, a trained psychologist with excellent management skills who is fluent in English and Spanish. However, she is based in Guatemala City and makes only short fortnightly visits to supervise the promoters in the field. There were two abortive and time-consuming attempts to obtain appropriate visual materials for the educational sessions from commissioned artists. The new APC finally secured collaboration

21 15 from the director of the arts department of a local university who produced the posters; the promoters were instructed in their use and given the corresponding guidelines (Appendix V). On April 29 a general meeting with school teachers in the project area was held to explain project goals and procedures. Attendance was only 25% probably because of difficulties with transportation or problems in informing all those expected to attend. Transportation and storage of Nutriatol to project headquarters in Alta Verapaz was delayed until mid June, 19. The product then had to be packaged in units containing Nutriatol packets each, enough for one treatment. 3.4 Third Quarter 19 In July, the first round of visits to the schools was undertaken to individually enlist teachers' cooperation and instruct them in the utilization of data forms. The date was set for the meeting with mothers eligible for ~utriatol' distribution, i.e. those with preschool children. NUTRIATOL was delivered to some schools. The second round of school visits to meet with teachers and

22 16 mothers began in mid-august. One half of eligible mothers attended, a significant proportion considering the rains and difficult terrain. The APC and one of the CPCS-DM social headquarter's workers who is fluent in kekchi supervised several of the education sessions and concluded that the posters and presentations were effective. At the time of this second visit, damage by rodents to Nutriatol supplies was reported in the schools. Metal containers were made available and teachers were asked to accelerate distribution of Nutriatol (an packet kit for each preschool sibling was given to each child with siblings in that age range.) 3.5 Fourth Quarter 19 The third round of school visits, initiated September 20th, was impossible to complete as planned since almost half of the schools closed for vacation much earlier than expected i.e. November. Promoters sought teachers at their homes in order to collect the data forms concerning Nutriatol distribution. In some instances, the supplement had been distributed to target children as planned and further supplies provided to school children for their siblings when they returned empty packets. In some instances instead of storing left over supplies teachers decided on their own to distribute the supplement directly to families with preschoolers in the community. Other teachers kept unused supplies at the schools.

23 According to the January 199 monthly report, 1,369 kits were distributed in July, 3,344 in August, 1,179 in October and another 473 during home visits conducted in November. It proved impossible for the promoters to carry out home visits at the time they were visiting the schools since they used the afternoons for paperwork and to repackage the packets into treatment units. Development of the MIS was delayed by organizational and technical difficulties. The consulting firm originally selected to assist in this task was replaced in August 19 because of their inability to deliver services as agreed. Project management with assistance from IEF consultants prepared data forms to monitor NUTRIATOL distribution to the schools and its subsequent delivery to beneficiaries. Forms were also prepared by the APC to keep track of warehouse transactions, monitor vehicle use and record household survey information collected. (Appendix VI). The collaboration of the Universidad Marroquin computer science department was obtained and an able programmer assigned to the task of preparing the necessary software to archive and manage data. Based on the information needs provided by project management (Appendix VII), elaborate custom data base management programs were written to file and retrieve information in the

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