Fortification of salt with iodine is the single most effective intervention for prevention and control of iodine deficiency disorders (IDD) which still affect large proportions of the population in developing countries. When properly implemented, universal salt iodination has shown to reduce IDD to levels of no public health significance. Salt iodination programs have been initiated throughout the past decades in most IDD endemic countries. Unfortunately, a number of common constraints of legislative, enforcement, salt production, quality control, population demand and other nature have affected program sustainability and precluded full realization of the great potential of salt iodination to control IDD.
Identification of such constraints by means of a comprehensive situation analysis of the policy and legislative environment, status of the salt industry and program performance is critical for decision-making on initiating new programs and strengthening those already existing, with the purpose of securing sustainable universal salt iodination. The International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the Program Against Micronutrient Malnutrition (PAMMI) of Emory University, with technical and financial support from USAID/OMNI, developed and field-tested a comprehensive Iodized Salt Program Assessment Tool (ISPAT) and Manual that will no doubt be extensively used in developing countries for analysis of the existing situation and as a basis for planing actions to strengthen salt iodination programs.
Summary
The process and tool fall in the program implementation monitoring and impact evaluation categories of the conceptual framework. By following a standardized process and instrument, the assessment is carried out using information obtained through documents and records reviews, and through structured interviews with various stakeholders, including government officials, industry representatives, policy makers, IDD experts, educators, students, consumers, and others. Information is obtained at the national, district, and local levels through a series of especially designed questionnaires and data collection checklists. This is followed by an analysis of program's status and prognosis for sustainability and, as appropriate, recommendations for strengthening program implementation.
Name: Iodized Salt Program Assessment Tool (ISPAT).
Origin: Developed by the International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the Program Against Micronutrient Malnutrition (PAMM) of Emory University, with technical and financial support from USAID/OMNI.
Ownership: ICCIDD, PAMM, and USAID/OMNI.
Basic Description: The process and tool are designed to be used by a team composed of members from the national program and technical support agencies, together with external experts, to assess an array of program elements to evaluate program effectiveness and sustainability. It gathers and analyzes information on the product (salt), the process (policy, advocacy, program implementation, monitoring), and the progress made (coverage, impact) in achieving program goals.
Country Applications: Field-tested in Malawi. To be used extensively elsewhere.
Languages: Developed originally in English, to be translated into other languages.
Technical Scope: The process and tool allow government and industry planners to carry out a comprehensive situation analysis of the salt iodination program, by systematically collecting and analyzing information on salt production and the salt i ndustry, the program implementation process (salt iodination), and the progress made in achieving the expected coverage and impact.
Purpose: Summative, program monitoring and evaluation.
Type of Methods: Both quantitative and qualitative information to be gathered at the central, district and local levels responsible for program design, implementation, monitoring and evaluation.
Design: The process and instrument are used to assess the strengths and weaknesses of the program in order to allow corrections that will result in full achievement and sustainability of programmatic goals. The assessment is based on interviews with key policy makers, program planners, managers and implementation staff, as well as documents review, field observations and, eventually, primary data collection or secondary data analysis involving IDD indicators, e.g. goiter prevalence and/or urinary iodine excretion in school aged children.
Frequency of Administration: Periodically as program implementation progresses and, more specifically, when the program has been implemented long enough with sufficient coverage and quality to expect a measurable impact.
Key Users of Information
Primary Users: Government policy, planning and program decision makers, program implementers, and the salt industry.
Secondary Users: NGOs/PVOs, consumer protection groups, USAID's missions, Cooperating Agencies (CAs), and other international donors (WHO, UNICEF).
Objectives and Scope of Tool
Objective:Program assessment, evaluation, and recommendations for strengthening, as well as advocacy with key officials from government, industry, cooperating agencies and NGOs, for reinvigoration of commitment and focus on IDD and emphasis on sustainability.
Scope: The process and tool encompass collection and analysis of key information on the product (raw salt), the program implementation process (policy and advocacy) and the progress (program coverage and impact). The process involves:
Information checklists are included for central and field assessments, including KAP surveys of health personnel, retail store owners/managers and consumers, as well as sampling techniques for school children and retail stores, and dummy tables for analysis of KAP data. The tool is intended for use, with appropriate adaptations, in practically all developing countries implementing salt iodination programs.
Key Monitoring Needs and Evaluation Questions Tool Seeks to Address
The following questions are to be answered:
What progress has been made in measuring and achieving established goals for expanding coverage and quality of salt iodination, and impact on IDD status of the population.
Key Indicators
Research Design
The review is mostly cross-sectional, with information collected through interviews, review of documents/records, and observation visits. To facilitate the review process, the multi-sectoral IDD program is broken down into three main components, each of which is evaluated to provide, in the end, an integrated picture of the entire program:
The product: raw salt - production/procurement, processing; iodination; packaging and labeling; internal quality assurance; product marketing.
The process: policy and advocacy the regulatory environment (legislation, regulations, enforcement); program monitoring, including external quality assurance; laboratory capacity; information, education and communication (IEC), including educational curriculum; management and program administration.
The progress: program coverage household and retail iodized salt coverage; prevalence biologic impact as measured by total goiter rates and urinary iodine excretion.
Implementation
The full review should take approximately two to four weeks, depending on the country and program size and complexity. Alternatively, the manual can help guide a more targeted assessment of particular program elements over a shorter period of time. In a field test of the process and instrument in Malawi, a small country that imports almost all of its salt, the assessment team was composed of one external consultant from the United States, another external consultant from West Africa, and two program staff consultants. Budget items include communications, international travel and domestic travel to and from field sites, field visits and per diem costs, document reproduction costs, supplies, incidental costs, international and local consultants salary and per diem, and local consultancy salary.
The individual in charge of local coordination reviews the instrument, picks the team members in a way that ensures inter-sectoral collaboration and participation, gathers the background documents to the extent possible, and arranges the field visits and interviews. Prior to beginning the interview process, a briefing is held with key representatives of ministries, industry, cooperating agencies, NGOs, and other individuals critical to the salt iodination program. The instrument is distributed to all team members prior to beginning the assessment process so that each member can become intimately familiar with the tool and the process. Following the central information review process, the team collects information in the field, at the district and local levels. They collect data during field visits by reviewing documents and interviewing individuals such as food inspection and enforcement officers, industry representatives, health personnel, teachers, school children, consumers, and others. Additionally, the team visits production sites, markets, and schools and observes processes and activities to gather additional information.
Analysis
Data analysis is relatively simple, including the quantitative data, and is greatly facilitated by specific directions and dummy tables provided in the ISPAT manual.
Reporting
The final report is important as a means of communicating the findings and recommendations to interested groups. It includes a short executive summary and clear and concise summary recommendations at the beginning of the report. The remaining of the report contains background information and elaboration of the findings and recommendations: a country profile, a summary of progress with respect to the product, a summary of progress with respect to the process, and a summary of improvement in iodized salt coverage and IDD prevalence. The report, or at least the executive summary, is distributed at the debriefing meeting at the conclusion of the process.
Dissemination of Results
The report is widely distributed to donors, implementers, and others as determined by the program manager. The results are disseminated to interested partners as part of advocacy efforts, to keep them updated of the existing situation regarding salt production, the IDD elimination program and the progress achieved, as well as, eventually, as a documentary basis for ICCIDD's statements on country progress towards meeting IDD eradication goals.
Manuals and Guidelines
The manual is divided into four sections: Introduction, Section I: Product, Section II: Process, and Section III: Progress. For each of these, suggestions are made for the methods to use, the types of documents to review, and the individuals and groups to interview. Each section provides suggestions for collecting information at the central level and during field visits. Checklists are provided for guidance on information to collect and also to serve as records of the evaluation. Reporting templates are useful in tabulating key information. Sample questionnaires, requiring adaptation to the national context, are included for guiding focus group discussions and for more representative KAP surveys. Sampling methods are suggested and referenced in the event an independent survey is needed.
References
Iodized Salt Program Assessment Tool. Partnership for Tracking Country Progress in Universal Salt Iodination Programs towards the Sustainable Elimination of Iodine Deficiency Disorders by and beyond the Year 2000. A manual for program managers.
The International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the Program Against Micronutrient Malnutrition (PAMM), in collaboration with USAID/OMNI, the Micronutrient Initiative (MI0, UNICEF, WHO. Draft, January 1998.
Indicators for assessing Iodine Deficiency Disorders (IDD) and their control through salt iodination. Published by WHO/UNICEF/ICCIDD. WHO/NUT/94.6, 1994.
Monitoring Universal Salt Iodination Programs. Joint UNICEF-PAMM-MI-ICCIDD-WHO Publication, 1995.
Other
At present, there is no other prototype instrument available for monitoring and evaluation of salt iodination programs. ISPAT is likely to be extensively used worldwide.