Tools to improve planning, implementation, monitoring, and evaluation of complementary feeding programmes

Abstract

Adequate nutrient intake is a prerequisite for achieving good nutrition status. Suboptimal complementary feeding practices are a main risk factor for stunting. The need for systematic and user‐friendly tools to guide the planning, implementation, monitoring, and evaluation of dietary interventions for children aged 6–23 months has been recognized. This paper describes five tools, namely, ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap, and Monitoring Results for Equity System that can be used in different combinations to improve situation analysis, planning, implementation, monitoring, or evaluation approaches for complementary feeding in a particular context. ProPAN helps with development of strategies and activities designed to change the behaviours of the target population. Optifood provides guidance for developing food‐based recommendations. The Cost of the Diet can provide insight on economic barriers to accessing a nutritious and balanced diet. The Fill the Nutrient Gap facilitates formulation of context‐specific policies and programmatic approaches to improve nutrient intake, through a multistakeholder process that uses insights from linear programming and secondary data. The Monitoring Results for Equity System helps with analysis of gaps, constraints, and determinants of complementary feeding interventions and adoption of recommended practices especially in the most vulnerable and deprived populations. These tools, and support for their use, are readily available and can be used either alone and/or complementarily throughout the programme cycle to improve infant and young child‐feeding programmes at subnational and national levels.

1. INTRODUCTION

The new Sustainable Development Goals, the World Health Assembly's Nutrition Target, and the Scaling up Nutrition Movement, which have stunting reduction as a major goal, have focused attention on the need for more effective programmes to improve infant and young child feeding (IYCF; Baker, Sanghvi, Hajeebhoy, Martin, & Lapping, 2013; United Nations Standing Committee on Nutrition, (UNSCN), 2014. Stunting often begins very early in life, typically in utero, and generally continues until 2 years of age. A large part of the decline in length‐for‐age Z score occurs during the complementary feeding period that is age 6–23 months (Dewey & Huffman, 2009; Victora, de Onis, Hallal, Blössner, & Shrimpton, 2010). Poor complementary feeding that fails to meet the nutrient requirements of the child has been identified as a risk factor directly associated with stunting (Bhutta et al., 2013).

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) issued a Global Strategy for IYCF in 2003 to guide actions to develop comprehensive complementary feeding programmes (WHO/UNICEF, 2003). Few field‐tested, large, multicomponent IYCF programmes existed. Although there are some examples of successful complementary feeding programmes to promote healthy growth and prevent stunting (Dewey & Adu Afarwuah, 2008), to date, there are only a few examples of successful large‐scale programmes to improve IYCF and nutrition in the first 2 years of life (Baker, Sanghvi, Hajeebhoy, & Abrha, 2013; Lutter et al., 2013; Piwoz, Baker, & Frongillo, 2013).

Programmes to improve nutrition rarely follow systematic processes of planning, implementing, monitoring, and evaluation to enhance their effectiveness in the long term (Lutter et al., 2013). Moreover, adequate nutrient intake is a prerequisite for achieving good nutrition status. Breast‐fed infants and young children need high nutrient‐dense complementary foods (particularly for iron and zinc), especially at 6–12 months, (Dewey 2013). Having specific IYCF recommendations and identifying and addressing constraints or bottlenecks to accessing and consuming nutrient‐dense foods are essential to make improvements.

Interventions to improve complementary feeding practices and/or the nutritional quality of complementary foods must take into consideration the contextual as well as proximal determinants of stunting (Stewart, Iannotti, Dewey, Michaelsen, & Onyango, 2013). Tools to assess the IYCF situation have been available; however, until recently, these did not include a systematic, quantitative assessment of the nutrient content of the prevailing diet and ways to improve it based on locally available natural as well as processed and fortified foods, and factors that affect their availability and accessibility, such as purchasing power (Daelmans, et al. 2013). There has been a need for user‐friendly tools to guide the assessment, prioritization, planning, implementation, monitoring, and evaluation of dietary interventions for children aged 6–23 months (Daelmans et al. 2013; WHO 2008).

This paper describes tools that are increasingly being used for complementary feeding programming, particularly ProPAN, Optifood, Fill the Nutrient Gap (FNG), Cost of the Diet (CotD), and the Monitoring Results for Equity System (MoRES), including their strengths and limitations, and discusses how they can be used in different combinations to improve situation analysis, planning, implementation, monitoring, or evaluation of context‐specific approaches to improving complementary feeding. The data and information provided in this paper is based on literature reviews and secondary data provided by institutions involved in development and/or use of the tools. Table 1 gives a brief summary of each tool, and Table 2 lists their strengths and weaknesses.

Table 1.

Summary and description of the tools

ProPAN	Optifood	CotD	FNG	MoRES
(a) Concept/Structure
Consists of four modules: assessment, testing recipes and recommendations, developing intervention plans, and monitoring and evaluation.	Linear programming to identify “problem nutrient” (inadequacy in current diets) and generate optimal diets that suits the habitual eating practices	Linear programme to calculate a combination of locally available foods that would need to be bought to meet specifications for energy, macronutrients, and micronutrients for any given individual or household, at lowest possible cost.	A framework for improved situation analysis that incorporates secondary data and information collected by other tools to gain a better understanding of the nutrition situation. It also uses linear programming tools, in particular CotD, to model possible interventions to improve access to nutritious diets.	The seven‐step process for MoRES follows a theory of change framework, which starts with analysis of the prevalence, location, and burden of a particular deprivation—e.g., child stunting—and its reduction as the impact of interest. The seven‐step process follows a pathway through understanding the equity profile of the deprivation, the main context‐specific immediate, underlying and structural causes; selecting and implementing effective interventions; to identification and causal analysis of the bottlenecks in the delivery and outcomes of the interventions and finally identification and application of solutions to the bottlenecks.
(b) Objectives
Identifying problems related to IYCF, that is, breastfeeding and complementary feeding, within a specific target population. Defining the context in which these problems occur, including barriers to and facilitators of improved or “ideal” practices. Formulating, testing, and selecting behaviour‐change recommendations and nutritional recipes; developing the interventions to promote them. Designing a monitoring and evaluation system to measure progress toward intervention goals. ProPAN materials include a multimodule field manual with detailed instructions on how to collect, analyze, and integrate the quantitative and qualitative data required to design and evaluate interventions. Identifying locally available foods that provide the greatest amount of energy and nutrients at the lowest cost.	Identify problem nutrients (nutrient inadequacy in the population) Identify optimal diets, which are realistic (fit in habitual diets) Testing alternative food‐based interventions	Identify which individuals and households are able to locally access the foods required to meet their specifications for energy, protein, fat, and micronutrients. Calculate the lowest combination of foods that are required to meet the energy, protein, fat, and micronutrient specifications for a household. Determine what proportion of the population could afford a diet that meets these specifications. Allow “what if” models to be created by adjusting parameters to examine the effect of theoretical interventions on cost	Identify context‐specific policy and programmes that are rooted in a sound situation analysis Gain consensus among key stakeholders within the country about the barriers to adequate nutrient intake and collectively identify possible solutions.	To provide systematic framework to assess the main determinants of effective coverage or optimal practices for selected interventions, and thus to help identify problem areas relating to six main determinants of the supply, demand, and quality of services, which need to be acted upon, as well as the underlying causes of these bottlenecks.
(c) Complexitya
Medium	High	Medium	Medium	High
(d) Outputs
Module I (assessment): suboptimal IYCF practices (those that fall short of ideal practices) and the generation of a list of recommendations that could be promoted to improve them. Module II (testing recipes and recommendations): final recommendations and recipes (feasible and acceptable) Module III (developing the intervention plan): set of strategies and activities designed to change the behaviours of the target population Module IV (designing a monitoring and evaluation system): the design of a system for monitoring and evaluating the intervention including plans specifying how to assess inputs and outputs (monitoring) and outcomes and impact (evaluation)	The software works in four phases: Phase I (Module I) formulates, via a goal programming model, a first draft set of FBRs corresponding to the target's actual dietary practices, nutritionally favourable, and affordable. Phase II (Module II) takes the first draft FBRs via linear programming to assess whether they can achieve the desired nutrient goals. “Problem nutrients” (inadequate or low) in the habitual diets or feedings are identified. Phase III (Module III) identifies nutrient‐dense food(s) that can be incorporated to improve the first draft FBRs. Phase IV uses various combinations of nutrient‐dense foods or with other intervention (e.g., food fortification), using Module II (run multiple times) to produce new sets of FBRs, which are further selected for evaluation in community trials. In all models, constraints on diet energy content, food pattern ranges, food portion sizes, diet cost, food groupings, or food combinations (linkages) can be used to ensure realistic optimized diets	Primarily, a tool to understand the problems of achieving economic access to food for a household. Policy, programmatic interventions proposed by wealth group.	A situation analysis of the barriers to adequate nutrient intake within the country. Identification of policy and programmatic strategies to improve nutrient intake that are well adapted to the context. Multistakeholder consensus over the key barriers to nutrient intake and the optimal strategies to improve this situation, using existing targeting strategies and distribution platforms from different sectors.	Theory of change framework for complementary feeding including determinants of poor complementary feeding practices and list of prioritized interventions. Map of most‐deprived populations. Bottlenecks analysis of six determinants of supply, demand, and effective coverage; can be displayed as a bottleneck graph. Causality analysis of the bottlenecks, including in the enabling environment domains of social norms and sociocultural practices, financial access and budget allocations or execution, policy, and governance or management.
(e) Data requirements
Caregiver survey: breastfeeding and complementary feeding practices; context in which feeding occurs (e.g., family sociodemographic characteristics, housing conditions, reach of main communication channels, consumption of micronutrient supplements, and use of health services). 24‐hr dietary recall and anthropometry: dietary intake and complementary feeding practices; child's weight, height, and mid‐upper arm circumference. Market survey: accessibility as a potential reason for limited consumption of foods, locally available foods that provide the greatest amount of energy and nutrients for the least cost (nutrient/cost ratio); seasonality and availability of specific foods and the foods most frequently consumed by children 6–23 months. Opportunistic observations: current complementary feeding practices; reasons for current practices and the potential for change; and facilitators of and barriers to the ideal practice of responsive feeding. Semistructured interviews: current breastfeeding and complementary feeding practices; reasons for current practices and the potential for change; and facilitators of and barriers to each ideal practice for breastfeeding and complementary feeding	List of foods consumed by the target population For each food: minimum number of portion, average‐sized daily portion (g/day), maximum weekly portion (g/week), cost per gram, food group category, and energy and nutrient content. Market survey or secondary sources for food price data.	Market surveys or secondary food price data where geographical overlap, collected recently and detailed enough to include all foods available to the household. Interviews and focus group discussions to determine food habits. Background data on sources of “free” foods (e.g., own production). Definition of wealth, income, and expenditure data (required to measure affordability).	Secondary data related to a) malnutrition characteristics; b) availability of nutritious foods on the local market (foods that can make a substantial contribution to intake of a variety of nutrients); c) access to nutritious foods by households; d) nutrient intake of target groups; e) local practices related to food and nutrient intake; f) enabling environment–national policies, programmes and regulatory frameworks; and g) the inputs required for linear programming: income data and market price data.	National household surveys with complementary feeding practices, disaggregated by geographic area, residence, economic quintiles, sex, and other dimensions. Socioeconomic, food security, social protection, sociocultural, programmatic, and other data to assess determinants of poor complementary feeding practices. Process indicators on the supply of products such as MNPs, for example, stockouts; skilled and trained human resource availability; and geographic distribution of health facilities providing complementary feeding counselling and MNPs; coverage of counselling and MNPs.

^aFrom the point of view of the user, that is, how complex is the application of the tool in terms of the number of steps and/or efforts required, that is, easy, medium, and high.

Note. CotD = Cost of the Diet; FBRs = food‐based recommendations; FNG = Fill the Nutrient Gap; IYCF = infant and young child feeding; MNP = micronutrient powder; MoRES = Monitoring Results for Equity System.

Table 2.

Strengths and limitations of the tools

Tool	Strengths	Limitations	References
ProPAN	Comprehensive, available modules and software, flexible use and adaptability into the local context, adaptability into the cultural, political and economic context of the areas where it is implemented.	Resource intensive especially module I (assessment). The software is limited to descriptive statistical analyses. For the module II, the limitation is the short time period in which the recommendations are tested, and in practice, participants are expected to follow the recommendations for a few months or even longer.	PAHO & UNICEF, 2013; Daelmans et al., 2013; Kinabo et al., 2013
Optifood	Identify specific “problem nutrients” and FBR is based on habitual diets. Other interventions, for example, fortified foods or MNP can be simulated to complement FBRs (where necessary) for the problem nutrients	The analysis is conceptually complex. The results are also sensitive to errors in the RNIs and completeness of food composition data.	Daelmans et al., 2013, Ferguson et al., 2006
Cost of the Diet (CotD)	Systematic, quantitative results based on local foods. Adaptable, allows user to generate models to estimate the potential impact of changing most underlying parameters on the cost, composition, quality, and affordability of a diet.	Not designed to be used to plan a diet, does not analyze the nutrient content of foods in a given diet	Deptford & Hall (unpublished)
Fill the Nutrient Gap (FNG)	Comprehensive, brings together information from all of the tools to better understand a country's nutrition situation. It is also a process that facilitates policy dialogue between multiple stakeholders. It primarily uses secondary data so is relatively low cost. It can help uncover data sources within a country and identify if further data collection is required	Its scope is limited by the type and the quality of data that are available, and the breadth of topics depends on the level of engagement of stakeholders from different sectors. It focuses primarily on the nutrient intake side of the undernutrition causal framework.	WFP, 2016a; WFP, 2016b; WFP, 2016c.
Monitoring Results for Equity System (MoRES)	The bottleneck analysis process and tool are integral to sound, evidence‐based programming. There is evidence of effectiveness from related health interventions, and MoRES has been reported to increase ownership of data and its use for improved management and programming at the local level, and specifically for IYCF. MoRES gives greater priority and value to generation and the use of intervention (process) information.	The application of MoRES to complementary feeding or nutrition is relatively recent, and there is a lack of documented results currently available in the literature—for example, programme improvement, increased coverage of interventions, or attributable changes in complementary feeding practices. Another limitation for the use of the tool for IYCF is lack of available routine data for the full set of determinants, which then requires time consuming and expensive primary data collection. In addition, it is emphasized that the bottleneck analysis process must be accompanied by dissemination of best programme practices. It will only have desired results to improve systems, programmes, and coverage if orientation and capacity development on the most current evidence and programmatic practice is undertaken and key paradigm shifts take place.	Dickson et al. 2014; Christie and McPherson 2014; LSTM, 2012a; UNICEF, 2012a; LSTM, 2012b; UNICEF, 2013, Chopra et al. 2012.

Note. FBR = food‐based recommendation; MNP = micronutrient powder; RNIs = recommended nutrient intakes.

Key messages.

• Suboptimal complementary feeding practices have been identified as one of the risk factors associated with stunting. There has been a need for systematic and user‐friendly tools to guide the assessment, prioritization, planning, and evaluation of complementary feeding strategies and programmes.

• ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap, and Monitoring for Results for Equity System can be used in different combinations, to improve approaches to situational analysis, planning, implementation, monitoring, or evaluation to improve complementary feeding in a way that fits the particular context.

• These tools can be used alone and/or in combination to provide guidance for developing complementary feeding recommendations, prioritizing interventions and developing key messages and communication strategies to advocate for improving complementary feeding programmes and policies.

1.1. Pro PAN (Process for the Promotion of Child Feeding)

ProPAN, developed in 2004 and updated (ProPAN 2.0) in 2013, is a tool to develop, implement, and evaluate interventions and programmes to improve infant and young child diet and feeding (PAHO & UNICEF, 2013). The tool guides users through a step‐by‐step process for identifying problems related to IYCF: defining the context in which the problems occur, including barriers to and facilitators of improved or “ideal” practices (PAHO & WHO, 2003; WHO, 2005); formulating, testing, and selecting behaviour‐change recommendations and recipes for nutritious diets; developing interventions to promote them primarily among caregivers; and designing a monitoring and evaluation plan to measure progress towards achieving intervention goals. The analysis and recommendations for daily nutrient and energy intakes and nutrient and energy densities is based on the assumption of an average or medium breast milk intake (PAHO & UNICEF, 2013). ProPAN includes a detailed field manual that consists of four modules ( Daelmans et al. 2013; PAHO & UNICEF 2013):

• Module I (assessment) uses quantitative and qualitative research methods to identify diet and feeding problems.

• Module II (testing recommendations and recipes) provides detailed guidance on how to test the acceptability and feasibility of the potential recommendations (behaviour and recipe) identified in Module I.

• Module III (developing intervention plan) helps users devise an intervention plan based on the final recommendations selected and tested in Module II.

• Module IV (designing monitoring and evaluation) to identify appropriate indicators to monitor the intervention's implementation process and impact.

The main products of each module are outlined in Table 1. The tool is equipped with an Epi Info™‐based software programme and user's guide for data entry and analysis of quantitative data and also includes an analytical tool for identifying key nutrients gaps and locally available foods that provide the greatest amount of energy and nutrients.

1.2. Application of Pro PAN

The tool was used initially in Latin America and is now also used in Asia and Africa, including recently in Botswana, Kenya, and Tanzania (Daelmans, et al. 2013; Kinabo et al. 2013). These three countries applied the method to assess IYCF practices (Module I) and to create and test recipes and potential recommendations (Module II) aimed at changing behaviour by caregivers and health workers. New recipes were developed by modifying traditional recipes to improve their nutritional quality and using commonly used local ingredients, through the active participation of caregivers (Kinabo et al. 2013; PAHO & UNICEF 2013). An international consultant was hired to train fieldworkers in the three countries for the data collection for Module I and to facilitate the testing of recipes and recommendations.

In Tanzania, ProPAN was used to guide the development of an IYCF strategy for Zanzibar. This was the first systematic evidence‐based approach in Zanzibar to develop complementary feeding recipes that have the potential to improve the nutritional status of children through introduction of nutrient‐rich recipes using locally available foods. The caregivers were provided with correct feeding knowledge and shown cooking practices for nutritious meals. The recipes were acceptable, feasible, and caregivers used them; however, the long‐term effects on the nutritional status of children have not yet been assessed (Kinabo et al., 2013). In Botswana, the information gathered in Modules I and II has been used to develop district multisectoral nutrition action plans (Module III) to improve the nutritional status of children under 5 years old in Ghanzi district.

The effective implementation of the ProPAN tool requires participation and engagement of stakeholders at all levels (ministries, institutions, communities, and households). The feedback cycles that are part of implementing ProPAN are very important for understanding the situation, motivation, and community engagement (Kinabo et al., 2013). In Botswana, the strong community engagement during the process of developing recommendations strengthened the understanding of issues, ownership of solutions and helped identification of potential platforms for effective communication on child feeding. The lessons from Botswana and Tanzania showed that ProPAN was able to provide a systematic evidence‐based method to develop interventions and strategies that can address complementary feeding problems through optimizing food choices and feeding practices. The implementation of ProPAN has strengthened capacity of key stakeholders to strengthen IYCF programming (Kinabo et al., 2013). In Tanzania, the tool has been integrated into the current Sokoine University of Agriculture nutrition training curriculum.

1.3. Strengths and limitations

The strengths of ProPAN include its adaptability into the cultural, political, and economic context of the areas where it is implemented. Although ProPAN is designed for use as one comprehensive set of modules, it can also be applied partially, where users select and apply only the modules or parts of modules needed to complement existing information on IYCF and to meet programming needs as was done in Bolivia, Ecuador (Lutter et al. 2008; Pachón & Reynoso 2002), Botswana, Kenya, and Tanzania (Kinabo et al., 2013).

Some of the limitations are that it is resource intensive, that is, the assessment module is relatively time consuming and can be resource intensive (Daelmans et al., 2013; Kinabo et al., 2013). The software is limited to performing descriptive statistical analyses. Therefore, it is advisable to adapt the assessment tool to the local context and to use advanced statistical software for further analyses. For Module II, testing recommendations and recipes, the limitation is the short time period in which the recommendations are tested, usually between 1 to 2 weeks, although in practice, participants are expected to follow the recommendations for a few months or even longer (Table 2; PAHO & UNICEF 2013). The testing is used for program design. Monitoring of continued use of optimal behaviours and uptake of new behaviours will be required during program implementation.

1.4. Optifood

Optifood uses linear programming analysis to create food‐based recommendations (FBRs) for specific populations, including children during the complementary feeding period (Daelmans et al., 2013). Conceptually, it is a multifactorial approach based on linear programming analysis, which simultaneously takes into account multiple factors, including diet, nutrient content, cost, and cultural eating pattern (Ferguson et al., 2006). It is recognized that designing realistic food‐based complementary feeding recommendations that are nutritionally adequate using a combination of local foods is not always feasible, especially for infants living in rural areas of developing countries. Thus, Optifood uses a goal‐programming concept, namely, modelling diets based on habitual dietary practices in an attempt to achieve the recommended nutrient intakes (RNIs). The optimal results will provide FBRs that are realistic according to the dietary habits and local food supply and access, but may not necessarily meet the nutrient goals. In such cases, other alternative interventions (such as food fortification or supplementation) can be added and recalculated in the Optifood software to offer final recommended interventions. For example, Optifood was used to generate FBRs on complementary feeding, taking into account habitual diet and food patterns for children aged 6–23 months who are still being breast‐fed in Indonesia, Kenya, and Myanmar.

Optifood programme consists of four modules (Daelmans et al., 2013):

• Phase I: An optimized diet is selected, using goal programming (Model #1), by entering the data on dietary intakes from 24‐hr recall and/or food frequency questionnaires for 7‐day period to generate the first draft of FBRs based on the current dietary habits and practices.

• Phase II: Reviewing the draft FBRs using linear programming (Model #2) to assess whether they reach the recommended intakes (e.g., RNI) of all nutrients of interest. In this step, “problem nutrients” can be identified and needs for modification of the draft FBRs identified.

• Phase III: Using Model #3 to select nutrient dense‐foods, which can potentially fill the nutrient gaps identified for the first draft FBRs.

• Phase IV: Incorporating the nutrient‐dense foods identified in Phase III in the first draft FBRs, recalculating and selecting the best revised FBRs that can meet the RNIs. If nutrient gaps remain, repeat the process with other nutrient‐dense foods or complements.

  Overall, Models 1 and 3 are done once, whereas Model 2 is used multiple times to select the best FBRs. In all models, constraints on energy content, food pattern, portion sizes, and diet cost (based on market price of foods and expenditure capped at costs currently paid by 75% of the population; Daelmans et al. 2013; Ferguson et al. 2006). For breast‐fed infants, average estimated breast milk intakes are used for the respective age range (Dewey & Brown, 2003).

  The tool calculates 7‐day diets that have an energy content equal to the average energy requirement of the target population. It also calculates amounts of protein, fat carbohydrate, and 11 micronutrients, namely, iron, zinc, calcium, six B‐vitamins, vitamin C, and vitamin A. A complete food composition table (FCT) that includes the amounts of these macro and micronutrients in commonly eaten foods is needed. Data on food composition from reliable sources can be entered if the available FCT data is incomplete. It is important to note that the current food composition data have some limitation including variability in the composition and coverage of local foods in developing countries. The RNIs for the specific population as specified by the WHO and the Food and Agriculture Organization of the United Nations (FAO) are used as nutrient goals. The details of Optifood operation are described elsewhere (Daelmans et al. 2013; Ferguson et al. 2006) and summarized in Table 1.

1.5. Application of Optifood

Optifood has been applied in five Southeast Asian countries (Cambodia, Indonesia, Laos, Thailand, and Vietnam) as a component of the SMILING project (Berger et al., 2013) and other countries in Asia, Africa, and Latin America to generate FBRs (Daelmans et al., 2013). The main objectives of the application of Optifood in that context were as follows: to determine whether FBRs could be designed that would ensure adequate nutrient intake for most children in each population, using locally available foods; to identify which nutrient recommendations were most difficult to achieve (problem nutrients) using locally available foods; and to evaluate additional interventions for 6–23 months children and women of reproductive age.

Where locally available foods could not completely meet nutritional requirements, fortified foods or multiple micronutrient powders (MNPs) were assessed to determine whether they could close the gaps in nutrient adequacy. Use of MNPs together with FBRs decreased the number of MNP sachets that would be needed in comparison to the MNP not being accompanied by improved FBRs. The cost of diets based on various FBRs can also be estimated. Based on these results, interventions for complementary feeding of breastfed children aged 6–23 months are expected to be included in the IYCF national policy or plan of action in respective countries (Berger et al., 2013). In summary, Optifood was used to formulate FBRs and to guide decisions on interventions, such as whether to use local foods alone or include additional interventions (such as fortified food and MNP).

1.6. Strengths and limitations

The main strength of Optifood is that FBRs are based on habitual diets and other interventions (e.g., fortified foods or MNP) are added if local foods cannot provide the nutrients the specific population needs. Some limitations on the use of Optifood include the complexity of the analysis, and requirement of the fixed cut‐point approach to estimate the percentage of individuals at risk of inadequate intake. The results are also sensitive to errors in the RNIs and FCTs. Moreover, the Optifood analysis is based on dietary data; thus, Optifood can only predict the risk of inadequate intake, but not confirm nutrient deficiencies (Table 2).

1.7. The CotD

Save the Children developed the innovative CotD method and bespoke software to help understand the impact of poverty on the ability of individuals and households to acquire foods that can meet their recommended intakes for energy, protein, fat, and micronutrients. It was developed in response to reports that even when nutritious foods are available, cost is a major barrier to accessing a nutritious and balanced diet. Subsequent studies have confirmed that cost limits access to nutritious food ( Baldi et al. 2013; Barosh, Friel, Engelhardt, & Chan, 2014; Jones & Charlton 2015; Geniez, Mathiassen, de Pee, Grede, & Rose, 2014; Newell, Williams, & Watt, 2014).

The principle of the CotD method was conceived in 2005. The first version of the software used the linear solver in Microsoft Excel to identify the lowest cost combination of locally available foods that would meet recommended intakes for energy, macronutrients, and micronutrients for any given individual or household. The second version of the software was launched recently. It is based on the same principles but was rewritten in Delphi XE4© and applies an open source mixed integer linear solver called lp_solve (Berkelaar, Eikland, & Notebaert, 2004) to do the calculations. The methods, mathematics, and parameters applied in the calculations are described in detail in a manual (Deptford & Hall, 2014).

The CotD software incorporates five databases that contain the underlying parameters used by the linear solver:

• the energy and nutrient composition of 3,580 food items extracted from five food tables;

• the energy, protein, and micronutrient intake recommendations of 237 individuals of all ages, sex, physiological state, and activity level (WHO/FAO 2001, WHO/FAO 2004, WHO/FAO 2007);

• a range of predefined groups of individuals in typical households of 4–10 individuals;

• typical portion sizes of foods; and

• currency conversion factors.

These parameters are applied in calculations with the following data that need to be added by the user: the cost per 100 g of locally available foods, calculated from primary data collected during a market survey or secondary data such as the national living standard survey depending on age and geographical area of the data and when detailed enough; limits to the number of times that a food can be eaten in a week based on three meals a day; and limits to the total weight of food that can be consumed in a meal by individuals of different ages (Deptford & Hall, 2014).

The least expensive combination of local foods is calculated for four standard diets: the energy only diet, which meets specifications for energy only; the macronutrients diet, which meets specifications for energy and macronutrients; the nutritious diet, which meets specifications for energy, macronutrients, and micronutrients with no limits on the amounts of individual foods per meal; and the food habits nutritious diet, which meets specifications for energy, macronutrients, and micronutrients with limits on the amounts per meal and frequency per week that are based on typical local dietary habits. This last diet, the food habits nutritious diet, is the most realistic in terms of diversity and amounts of foods. If data are available on income or expenditure from a Household Economy Analysis (Boudreau, 2008) or from other sources, the affordability of each of the four diets can be estimated, expressed as proportion of households that would be able to meet the nutrient needs of the members. The specifications for recommended intake of energy, protein, and for 13 micronutrients can be adjusted for any percentile of RNIs specified by FAO and WHO. For “standard” use, the percentiles are set at 50 for energy, 95 for protein, and 97.5 for micronutrients (FAO/WHO/UNU 2005, WHO/FAO 2004, WHO/FAO 2007). These high values minimize the risk of deficiency but drive up the cost of meeting nutrient intake recommendations.

1.8. Application of CotD

The CotD method and software has been used for the purposes of both advocacy and programme design. SC_UK used the CotD in 2009 to illustrate how a global food price crisis had increased the cost of a nutritious diet for vulnerable households in Bangladesh (Save the Children 2009); in 2013 to do an assessment in Myanmar to guide the amount of money given to beneficiaries in a cash‐for‐work programme and to mothers participating in a maternity cash transfer programme (Deptford, Hall, Schofield, & Self, 2013a); and, also in 2013, results were used in Bangladesh to identify the most nutritious foods that could be grown in a homestead garden (Deptford, Hall, Schofield, & Self, 2013b). Other agencies, such as the World Food Programme (WFP), are also increasingly using the tool ( Baldi et al. 2013; Frega et al. 2012; Geniez et al. 2014).

1.9. Strengths and limitations

The CotD enables a practitioner to estimate the cost of meeting specifications for energy and nutrients using the current market prices of foods and to create “what if” models by adjusting parameters to examine the effect of theoretical interventions, for example, adding micronutrient supplements to the diet, providing free or subsidized foods, buying foods in bulk rather than small daily amounts, adding new or improved varieties of food, reducing portion sizes to increase dietary diversity, and so on. The software offers a tool to guide thinking on what drives the cost of meeting recommendations for energy and nutrients and to stimulate debate about foods, nutrient sufficiency, and nutrition security.

A limitation of CotD is that it is primarily a tool to understand the economic barriers to nutritious diets at the individual and household level. It was not designed to be used to plan a diet, does not analyze the nutrient content of foods in a given diet, does not account for nutrient losses during cooking or take intra household distribution of foods into account. Some specific local foods may not be available in the software, and iodine, vitamin D, essential fatty acids, and essential amino acids are not included in the food composition and nutrient intake recommendation data and therefore not part of the analysis.

1.10. FNG tool

With technical input from the University of California Davis, the International Food Policy Research Institute, Epicentre/Harvard, Mahidol University, and UNICEF, the WFP developed a framework for a nutrition situation analysis and decision‐making tool that focuses on meeting nutrient intake recommendations, called FNG. A nutrition situation analysis is conducted to increase the understanding of the likely magnitude and main causes of the nutrient gap (when nutrient intakes do not meet recommended levels) in a given area and among particular target groups, such as children aged 6–23 months or pregnant and lactating women, and propose solutions. FNG facilitates situation analysis based on secondary data at the country level, including information provided by other tools such ProPAN, Optifood, and CotD, datasets such as Demographic and Health Surveys, national surveys of standards of living, market access data as well as focused ethnographic surveys on complementary feeding. The information is consolidated into the following categories:

• malnutrition characteristics;

• availability of nutritious foods on the local market (particularly those that can make a substantial contribution to intake of a variety of nutrients);

• access to nutritious foods by households;

• nutrient intake of target groups;

• local practices related to food and nutrient intake;

• enabling policy environment by identifying existing entry points within national policy, programming, and regulatory frameworks to address the barriers to achieving an adequate nutrient intake, such as increasing availability and/or access to nutrient‐dense foods for specific target groups; and

• cost optimization by calculating affordability of minimum cost nutritious diets and modelling different options to improve affordability (using CotD and, if available, Optifood).

  The information compilation, primary data collection (when needed) and linear programming analysis using CotD, involves key stakeholders at the country level. It is essential to involve stakeholders from different sectors from the beginning, as it is widely acknowledged that good nutrition can only be achieved by harnessing the expertise of a range of sectors, starting with the identification of useful data sources. The joint engagement of stakeholders from multiple sectors also increases their understanding of the interrelated causes of malnutrition and access to nutrients in particular and the roles that each sector can play to combat it.

  FNG helps to identify a package of different policy and programmatic interventions towards meeting nutrient requirements of vulnerable groups that are well adapted to the context. The package can include policy advocacy, public‐private partnerships, and behaviour change communication recommendations, in addition to identifying foods of adequate nutrient density, targeting and transfer modalities for providing access to such foods and potential entry points for provision of these interventions.

1.11. Early lessons from pilots in El Salvador, Ghana, and Madagascar

FNG was pilot‐tested in El Salvador, Ghana, and Madagascar between Oct 2015 and Oct 2016, and the operationalization of the framework varies by country. One example of the differences in the process relates to stakeholder engagement. In one context, large meetings were pursued from the very start, although in another small meetings were held to discuss initial analyses. These approaches were selected by the country teams to fit existing multistakeholder collaboration and dynamics. In El Salvador, the tool is being used to help redesign the government's social protection programming (WFP, 2016a). In Ghana, the government is refining national nutrition planning and has been a key stakeholder from the inception of the FNG process (WFP, 2016b). In Madagascar, the results from the FNG are being used to inform the design of their new national nutrition policy and plan for 2016–2020. Similar to Ghana, the government of Madagascar has been a key stakeholder from the very start of the process (WFP, 2016c). Gradual rollout of the tool is currently ongoing, including in Guatemala and Tanzania.

1.12. Strengths and limitations

As demonstrated in the pilot testing, the process of stakeholder engagement and collaboration can uncover data in places and on topics where it was thought there was no information. Frequently, national stakeholders (such as nongovernmental organizations and local academia) have conducted small‐scale studies or assessments that are not widely known but that can provide important information to gain a better understanding of the nutrition and food access or consumption situation. A strength of FNG is that it leverages stakeholder engagement to access secondary data and information that is already available and does not require primary data collection. This process can reveal significant data gaps and lead to joint prioritization of additional primary data collection. Pilot testing indicates that the tool can bring together essential information and support a process of analysis and interpretation that generates multistakeholder understanding and consensus around the barriers to nutrient intake and enables effective policy and programmatic decision making to reduce the nutrient gap among vulnerable groups in diverse situations and contexts.

The scope of FNG is limited by the type and the quality of available data. The breadth of topics depends on the level of engagement of stakeholders from different sectors in data compilation and analysis or interpretation. Furthermore, FNG is not prescriptive, so it requires strong capacity to effectively analyze and interpret the results, and for stakeholders to come to a consensus in their interpretation of key issues and possible approaches to addressing them that could be realized by building on existing strategies, platforms, and programmes. Due to the specific skill set and familiarity with the topic that is required for the FNG stakeholder engagement process and data analysis and interpretation, WFP, with involvement of partners, is currently building a team that can facilitate the process at the country level. The focus of FNG is limited primarily to the nutrient gap and its underlying and basic causes, including food preparation and storage, access to nutritious foods, poverty, and so on, because adequate nutrient intake is a prerequisite for preventing undernutrition. The other direct causes of undernutrition, that is, disease and inflammation, and its underlying causes of water, hygiene, sanitation, and preventive and curative health care services can be taken into consideration in the interpretation phase depending on what is already known.

1.13. MoRES

MoRES was initially developed to operationalize UNICEF's refocus on equity. MoRES is defined as “a conceptual framework for effective planning, programming, implementation, monitoring and managing for results to achieve desired outcomes for the most disadvantaged children.” It is based on the rationale that an equity‐focused system is needed to resolve critical analytical, targeting, monitoring, and decision‐making bottlenecks in programme design and implementation. MoRES was introduced in 2012 across 27 countries and a global mainstreaming phase followed in 2013. The process has its origins in the health systems bottleneck analysis using the Tanahashi framework (Tanahashi, 1978). UNICEF adapted it in both scope and design, and the most recent iteration is in use across a broad range of sectors and programmes, particularly health (Dickson et al., 2014). MoRES is not a tool specific to nutrition or complementary feeding programmes, but its use is highly relevant to improving the context‐specific design, quality, and coverage of these programmes through following a seven‐step process.

MoRES follows a theory of change framework, which starts with an analysis of the prevalence, location, and burden of a particular deprivation—child stunting, for example—and its reduction as the impact of interest. The MoRES process includes the following seven steps: (1) understanding the equity profile of the deprivation (i.e., analysis of stunting patterns by economic quintile, residence, geography, gender, and ethnicity); (2) identifying the main context‐specific immediate, underlying, and structural causes of the inequity; (3) selecting and implementing effective interventions; (4) identifying bottlenecks in the delivery and outcomes of the interventions; (5) conducting a causal analysis of the bottlenecks; (6) identifying and applying solutions to the bottlenecks; and (7) monitoring and reporting on impacts and reduction in bottlenecks. A bottleneck analysis is a systematic way to assess the main determinants of effective coverage or optimal practices for selected interventions.

Steps 4 and 5 of the seven‐step process involve the assessment of bottlenecks in the six determinants of an “enabling environment” (policies, governance, budgets, financial barriers of households, social norms, and sociocultural practices) and the analysis of their causes to tailor the solutions. Steps 6 and 7 involve the design of solutions and strategies, and monitoring of progress in their implementation and quantitative assessment of the reduction of bottlenecks and improvements in effective coverage. Solving bottlenecks will often involve a feedback loop to higher levels for policy or budget issues which cannot be solved at the local level.

The bottleneck analysis process is applied to specific interventions. In terms of complementary feeding, an example could be counselling on IYCF practices and home fortification delivered through health facilities. Table 3 provides an example of six indicators to quantitatively assess the determinants of this intervention. Data is obtained from existing information systems, surveys, or records; but particularly for IYCF, a full set of information for all six indicators may not be available and primary data collection may be required. The data is often displayed in a so‐called “bottleneck graph” such as Figure 1, an example of complementary feeding counselling from Malawi.

Table 3.

Possible indicators to assess bottlenecks: the seven‐step Monitoring Results for Equity System (MoRES) process applied to complementary feeding interventions in health services

Determinant		Possible indicator (countries tailor to their needs)
Commodities	Availability of essential commodities or inputs	Proportion of health workers with adequate materials on complementary feeding counselling and communication and/or home fortification product (MNP or lipid‐based nutrition supplement or other).
Human resources	Availability of adequately trained human resources	Proportion of health workers trained on complementary feeding counselling, home fortification, and communication in the past 5 years.
Geographical access	Geographic access to services or facilities	Proportion of the population with access within 1 hr/5 km of a facility or outreach service with an active health worker trained on complementary feeding and home fortification.
Utilization	Initial use of services	Proportion of children 6–23 months who received any home fortification product during the reporting period (such as 1 year).
Continuity	Continuous use of services or knowledge	Proportion of mothers or caregivers of children 6–23 months who had at least one counselling session on complementary feeding from a health worker and received any home fortification product.
Quality	Effective coverage	Proportion of mothers or caregivers of children 6–23 months who received at least two counselling sessions and the full targeted amount of home fortification product.

Note. MNP = micronutrient powder.

Figure 1.

Example of a bottleneck graph on complementary feeding counselling from Neno district, Malawi*. *Supplies: proportion of health facilities with complementary feeding counselling tools; human resources: proportion of health workers trained on CF counselling; geographic access: proportion of caregivers living within 1 hr of health workers with CF counselling; initial use: proportion of caregivers who received CF counselling; continued use: proportion of caregivers who can correctly state how a child 6–23 months should be fed; and effective coverage: proportion of children 6–23 m who received minimal acceptable diet

1.14. Application of MoRES

Bottleneck analysis has been applied by UNICEF, government counterparts, and partners in nutrition programmes including but not limited to complementary feeding, in a range of settings in some 30 countries in Africa, Asia, and Latin America. A formative evaluation of MoRES documented successes and challenges of its application in UNICEF, with seven in‐depth case studies in countries such as the Democratic Republic of the Congo, Nepal, Bangladesh, and Indonesia where the application also included nutrition (Christie & McPherson, 2014).

The district‐focused analysis that took place in Malawi from 2013 onwards is one of the most in‐depth and comprehensive examples for nutrition (UNICEF, 2012b). The process included analysis of complementary feeding counselling as one of 12 priority nutrition interventions in selected districts and used lot quality assurance sampling for health facility and community worker surveys to collect data for the six country‐specific indicators of supply, demand, and effective coverage (LSTM, 2012a). Qualitative analyses using key informant interviews and focus group discussions were conducted to explore the underlying causes of the identified bottlenecks. The district health authorities and district partners conducted the analysis and used the results to identify solutions and actions to incorporate in their district plans. The stakeholders were very cognizant of avoiding a “business as usual” set of actions for their plans, for example, “train health workers” or “print Information, Education and Communication (IEC) materials.”

Generic tools for bottleneck analysis are available and include the following: guidance on selecting indicators and conducting the analysis (LSTM, 2012b); a summary of strategies and solutions to address bottlenecks in health and nutrition (Chopra et al., 2012; UNICEF, 2013); an excel tool to compile the full set of results of a bottleneck analysis process (Chopra et al., 2012); questionnaires and tools for rapid small‐scale surveys, community worker, and health facility surveys (LSTM, 2012a); and tools for qualitative assessments (UNICEF, 2012a).

1.15. Strengths and limitations

The MoRES bottleneck analysis is integral to sound, evidence‐based programming. There is evidence of effectiveness from its application to health interventions, and the process has been reported to increase ownership of data and its use for improved management and programming at local level. Specifically for IYCF, MoRES gives greater priority and value to generating and using intervention (process) information.

Within the context of nutrition, the lack of documented results including programme improvement, increased coverage of interventions, or attributable changes in complementary feeding practices is currently a limitation. Improving complementary feeding practices requires multiple interventions across several sectors, and so far, the bottleneck analysis process has mainly been applied to health facilities and community‐based IYCF counselling. The use of the tool for IYCF may be limited by the lack of available routine data for the full set of determinants, making primary data collection a necessity. In addition, the bottleneck analysis process must be accompanied by dissemination of best programme practices. It will only have desired results to improve systems, programmes, and coverage if orientation and capacity development on the most current evidence and programmatic practice is undertaken and key paradigm shifts take place.

2. DISCUSSION

Interventions to improve IYCF need to follow a systematic process of assessment, planning, implementation, and evaluation to ensure effectiveness over the long term. Too often, however, actions are started based on a trigger event, such as the release of funds for a particular issue or setting (Lutter et al., 2013). Epidemiological and community‐based assessments are needed to adequately understand the nutrition situation (Issel, 2009), which is a particularly important first step for improving complementary feeding where understanding contextual factors is vital to success (Lutter et al., 2013).

The tools described in this paper each support one or more steps in the process of planning, implementation, monitoring, and evaluation of improving complementary feeding, such that nutrient intake recommendations can be better met (Table 4). Although some users may consider the tools to be relatively complex, the availability of software and/or operational manuals with detailed instructions on how to collect, analyze, and integrate the quantitative and qualitative data are proving useful to facilitate their use. All tools can be used for complementary feeding programmes; however, MoRES and FNG can also be used for nutrition programmes for other target groups. Each tool has its key focuses and occupies a different and complementary space.

• ProPAN focuses on improving practices of breastfeeding and complementary feeding in a given context, by identifying problems, assessing barriers to and facilitators of improved feeding practices and as such is primarily focused on improving utilization of locally available options and improving on existing services such as primary health care and community‐based services.

• Optifood is focused on identifying nutrients gaps and designing optimal food‐based complementary feeding recommendations to improve nutrient intake of specific vulnerable groups based on what is available to and affordable by the average household in the specific context. As such, it provides insights into what locally available options offer and whether optimizing choice can reach adequacy. In case it does not, modelling can be used to see if other solutions such as MNP or fortified food can fill the gaps.

• CotD serves to highlight the affordability constraint of meeting nutrient intake recommendations, and to model different options for overcoming these. This is especially for advocacy purposes and enables identification of possible ways to increase nutrient access (e.g., what if eggs became cheaper, dark green leafy vegetables were produced at low cost, and subsidized fortified complementary foods were introduced).

• FNG assesses the constraints to achieving adequate nutrient intake by analysing aspects across food system (availability, access to markets, fortification of complementary foods and staples, etc), health system (supplementation and nutrition education), social protection system (improving affordability and preferential access to specific nutritious foods), and through its multistakeholder involvement process raises awareness among different sectors of context specific options that can be prioritized for action, including in national policies and strategies, whether for social protection, nutrition, and/or development of local food industry capacity. In other words, its aim is to improve the contributions from different sectors to improving nutrient intake, in particular among the most vulnerable groups.

• MoRES aims at achieving equity in nutrition (and other) programmes. Focusing on those with the highest burdens of undernutrition, the MoRES tool is used to assess bottlenecks to access to and uptake of nutrition interventions and adoption of practices. The analysing of major bottlenecks leads to identification of strategies to address the programme constraints such as lack of supplies, limited geographical and financial access, inadequate availability and capacity of human resources, and low compliance with the services and sociocultural practices and norms, which inhibit adoption of recommended nutrition practices (Figure 1).

Table 4.

Programmatic application of various complementary feeding tools

	Application in programme cycle
Tool	Planning	Implementation	Monitoring and evaluation
ProPAN	The tools have been mostly useful for planning purpose. This includes development of strategy, development and design interventions.	Module III helps designing strategies and activities.	The Module IV of ProPAN provides guidance on (a) designing appropriate indicators to monitor the intervention implementation process and impact and (b) select an appropriate evaluation design.
Optifood	The tool has been useful for selecting appropriate food‐based interventions, developing food‐based dietary guidelines.	Key FBRs form key messages for nutrition education and counselling, specific nutrition interventions
Cost of the Diet (CotD)	The tool has been mostly used for planning purposes. This includes the design of nutrition, food security, livelihoods, and social protection programmes; to inform and influence nutrition and food security‐related policy; and to inform advocacy processes and debates.	The CotD can provide background inputs on economic barriers to accessing a nutritious and balanced diet.	The tool can be used to model or monitor the effect of external shocks such as global food price increases.
Fill the Nutrient Gap (FNG)	This tool is primarily to identify strategies that can be applied at policy and programme level across different systems (e.g., health, food, and social protection) and sectors to improve nutrient intake.	FNG enables a sound situation analysis based on compiling and reviewing secondary data among multisector stakeholders, which allows to design context‐specific policy and programmatic strategies	The tool focuses on the design of policy and programmes, which should subsequently be evaluated for changes made to policies and programs and ultimately their combined impact on availability and access to nutritious foods and nutrient intake by the most vulnerable
Monitoring Results for Equity System (MoRES)	The MoRES process helps base complementary feeding strategies and interventions on analysis of context‐specific determinants and a sound theory of change and identify the most vulnerable and deprived populations. The process can then be used to assess the implementation status of interventions and strategies, and the solutions to the specific bottlenecks that were identified can be incorporated into annual and longer term planning cycles.	The tool contributes the analysis of gaps and constraints in implementation and the identification of tailored solutions.	The MoRES tool is specifically designed for monitoring, usually on an annual basis, the chain of determinants of supply, demand, and effective coverage that lead to intermediate results. A causality analysis of the determinants of coverage allows adjustment of programme strategies to solve the bottlenecks and their causes.

2.1. Programme planning

A systematic, evidence‐based collaborative approach can facilitate the design of comprehensive IYCF programmes (Baker, Sanghvi, Hajeebhoy, Martin, et al. 2013). Situation analysis and formative research have long been recognized as essential to developing appropriate, responsive interventions; nevertheless, they are often neglected (Lutter et al., 2013). In the planning stage of a specific programme, a logic model together with programme goals and objectives should be developed and it should remain dynamic and integral to programme evaluation (Bryce et al., 2005; Lutter et al., 2013).

ProPAN, CotD, and FNG tools can be used to guide situation assessments, and information from one tool can be integrated into or used by another. ProPAN and Optifood can be used alone but gain strength when combined with identification of the lowest cost FBRs and the need to include additional strategies such as fortified foods (Daelmans et al., 2013). For example, in Botswana, Kenya, and Tanzania, ProPAN was used to collect critical data to run Optifood (existing feeding practices, available foods, feeding frequency, servings, and prices). In Peru, the ProPAN assessment facilitated the Optifood assessment of current IYCF practices and ways to optimize them in the specific context (Daelmans et al., 2013).

FNG uses secondary data and key stakeholder consultations to identify strategies for both policy and programming at the level of the enabling environment, such as, regulatory framework, policies for nutrition, agriculture, and social protection. FNG helps in programme planning by demonstrating the need to target different groups based on geography (including urban, rural, and distance to markets) and socioeconomic status (by linking to social safety nets where feasible and so on). CotD analysis is an important part of the FNG, and Optifood can also provide important information. In El Salvador, Madagascar, and Ghana, CotD was used to model possible food‐based interventions for improving affordability of a nutritious diet. Optifood analysis results that were available for two areas in Ghana were used to complement the results of the CotD and gain deeper insight into the problem nutrients for children aged 6–23 months. MoRES can use information from ProPAN, Optifood, CotD, and FNG for bottleneck analyses of complementary feeding programmes and adoption of recommended practices.

ProPAN, Optifood, CotD, FNG, and MoRES have been helpful in informing evidence‐based decisions related to complementary feeding. They can play an important role in development of a national IYCF policy with clear recommendations for adequate IYCF practices and development of a comprehensive IYCF strategy with prioritized interventions. Including the design of key messages, development of a communication strategy and provision of information to support the policy changes necessary to create an environment that enables improved feeding practices. The MoRES process helps in the development of complementary feeding strategies and interventions based on analysis of context‐specific determinants and a sound theory of change, and identifying the most vulnerable and deprived populations.

2.2. Programme implementation

Improving complementary feeding requires rethinking traditional implementation strategies, ensuring better coordination across sectors, linkages to delivery platforms, tailoring to context, and improved programming (de Pee et al. 2016; Lutter et al., 2013). Progress in implementing large‐scale complementary feeding programmes has been limited, and the main reasons include lack of strategies and resources to support them, incomplete understanding of economic and cultural barriers, and incorrect assumptions about determinants of poor feeding practices, such as a priori assuming that food insecurity or poverty is the main or only underlying cause of poor complementary feeding (Piwoz et al., 2013).

The tools described in this paper can be used to improve design and implementation of complementary feeding programmes (Table 1). For example, CotD can provide background inputs on economic barriers to accessing a nutritious and balanced diet. The FNG tool enables a sound situation analysis for the design of context‐specific policy and programmatic strategies. ProPAN provides input to the development of strategies and activities designed to change the behaviours of the target population. Optifood provides specific FBRs, which form key messages for counselling and nutrition education or communication. Finally, MoRES can help in the analysis of gaps, constraints, and causes and can ensure focus on addressing priority bottlenecks of recommended practices. This analysis can then be used to develop solutions to the specific identified bottlenecks, which is incorporated into annual and longer term programme planning cycles.

2.3. Programme monitoring and evaluation

Strong monitoring systems are key to assessing progress towards programme objectives and providing data for decision making. The process and impact evaluations of complementary feeding programmes should be initiated early in the programme planning and implementation stages (Lutter et al., 2013). The evidence base for effectiveness in complementary feeding programming lags behind in part because of the complexity of interventions, but also because few interventions are designed in such a way as to enable the evaluation to attribute impact to it (De Pee & Grais 2017; Lutter et al., 2013).

The ProPAN, CotD, FNG, and MoRES tools can be used for both monitoring and evaluation. The ProPAN Module IV (Table 4) provides guidance on how to assess inputs and outputs, evaluate outcomes and impact, design appropriate indicators to monitor the intervention process and impact, and select an appropriate evaluation design (Levinson et al., 2000; PAHO & UNICEF, 2013). The FNG tool focuses on the design of policies and programmes, which should subsequently be evaluated for impact on the availability and access to nutritious foods and nutrient intake of the most vulnerable. The MoRES framework includes systematic monitoring, usually on an annual basis, of the determinants that lead to intermediate IYCF results. It has been used to emphasize the importance of a coordinated and evidence‐based approach by different social services to address the most substantial barriers faced by those living in extreme poverty (UNICEF, 2012a).

The tools described in this paper complement each other and have been used in various countries. The complexity of the tools varies (Table 1) but investment in capacity development for their use in countries promises to strengthen programmes to improve IYCF practices, which is a prerequisite for preventing stunting.

SOURCE OF FUNDING

No outside funding was received for this paper.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

CONTRIBUTIONS

J.U. drafted the outline and coordinated inputs from all coauthors. All coauthors conceptualized the content of the review and contributed to the initial draft. They also critically reviewed the submitted manuscript and responded to reviewers' comments. J.U. and S.D.P. did the final preparation of the manuscript.

DISCLAIMER

J.U. and C.R. are staff members of the United Nations Children's Fund (UNICEF). The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions, policy, or views of the UNICEF.

Untoro J, Childs R, Bose I, et al. Tools to improve planning, implementation, monitoring, and evaluation of complementary feeding programmes. Matern Child Nutr. 2017;13(S2):e12438 10.1111/mcn.12438