The concept of a focused ethnographic study (FES) emerged as a new methodology to answer specific sets of questions that are required by agencies, policymakers, programme planners or by project implementation teams in order to make decisions about future actions with respect to social, public health or nutrition interventions, and for public-private partnership activities. This paper describes the FES on complementary feeding that was commissioned by the Global Alliance for Improved Nutrition and highlights findings from studies conducted in three very different country contexts (Ghana, South Africa and Afghanistan) burdened by high levels of malnutrition in older infants and young children (IYC). The findings are analysed from the perspective of decision-making for future interventions. In Ghana, a primary finding was that in urban areas the fortified, but not instant cereal, which was being proposed, would not be an appropriate intervention, given the complex balancing of time, costs and health concerns of caregivers. In both urban and rural South Africa, home fortification products such as micronutrient powders and small quantity, lipid-based nutrient supplements (LNS) are potentially feasible interventions, and would require thoughtful behaviour change communication programmes to support their adoption. Among the important results for future decision-making for interventions in Afghanistan are the findings that there is little cultural recognition of the concept of special foods for infants, and that within households food procurement for IYC are in the hands of men, whereas food preparation and feeding are women's responsibilities.

Adding micronutrient powders (MNP) to complementary foods at the point of preparation (home fortification) can improve micronutrient status of young children. Ensuring sustained access to MNPs at scale, however, remains challenging in many countries. The Global Alliance for Improved Nutrition (GAIN) partnered with the National Institute of Nutrition (NIN) in Vietnam to pioneer the distribution of a locally-produced MNP, provided for sale through the public health system with counseling on optimal infant and young child feeding practices by trained health workers. Different packaging options were available to adapt to caregivers’ disposable income. During the six-month pilot, 1.5 million sachets were sold through 337 health centers across four provinces, targeting children 6–59 months of age. Sales were routinely monitored, and a cross-sectional survey in 32 communes for caregivers (n = 962) and health staff (n = 120) assessed MNP coverage and compliance, five months after the start of distribution. A total of 404 caregivers among the 962 caregivers surveyed (i.e., 42%) had visited the health center in the past year. Among them, 290 caregivers had heard about the product and a total of 217caregivers had given the MNP to their child at least once, representing a conversion rate from product awareness to product trial of 74.8%. The effective coverage (i.e., consumption of ≥3 sachets/child/week) was 11.5% among the total surveyed caregivers and reached 27.3% amongst caregivers who visited health centers in the previous month. The MNP purchase trends showed that the number of sachets bought by caregivers was positively correlated with the wealth index. The pilot showed that providing MNPs for sale in packs of various quantities, combined with infant and young child feeding (IYCF) counseling at the health center, is effective for groups accessing the health system.

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As a highly bioavailable iron compound, sodium iron (iii) ethylenediaminetetraacetate (NaFeEDTA) has been recommended as a food additive for fortification. The amount of a food additive that can be ingested daily over a lifetime without appreciable health risk is termed the acceptable daily intake (ADI). The ADI for NaFeEDTA is based on body weight. For complementary foods and food supplements for infants and young children in low-income countries, where prevalence of underweight is high yet nutrient needs are also high, it is not clear which doses might be appropriate. The objective is to calculate the dosage of NaFeEDTA for fortifying complementary foods assuming different population prevalences of underweight. Mathematical models were used to simulate the dosage of NaFeEDTA for 6-to 8-month-old infants under different prevalences of underweight ranging from 5% to 40%. In order to keep NaFeEDTA intake below the ADI for ethylenediaminetetraacetate (EDTA) recommended by the Joint Food and Agriculture Organization (FAO)/World Health Organization (WHO) Expert Committee on Food Additives for 95% of 6-to 8-month-old infants, the daily iron dose from NaFeEDTA in fortified complementary foods should be set between 2.2 mg and 1.8 mg in countries with a prevalence of underweight among 6-to 8-month-old infants between 5% and 40%, respectively. If 2 mg of iron is given to all 6-to 8-month-old infants, the percentage exceeding the ADI for EDTA would be <10% for populations with <30% of children who are underweight, which is the case for many countries. In conclusion, 2 mg of iron from NaFeEDTA could be used for fortifying one daily serving of complementary food to ensure EDTA levels are below the ADI for infants 6-8 months of age. An additional source of iron (such as ferrous sulfate) should be included to increase the iron dose to desired fortification levels.

Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d’Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage (message: awareness of the product; contact: use of the product ≥1 time; and effective: regular use aligned with program-specific goals), as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap.