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1 Process evaluation of vitamin a supplementation of 6-59 months old children in Cameroon

Cameroon Academy of Sciences

Academie des Sciences du Cameroun

PROCESS EVALUATION OF VITAMIN A SUPPLEMENTATION OF 6-59 MONTHS

OLD CHILDREN IN CAMEROON


PROCESS EVALUATION OF VITAMIN A SUPPLEMENTATION

OF 6-59 MONTHS OLD CHILDREN IN CAMEROON

Produced by an expert committee of the Cameroon Academy of Sciences

Committee members (authors)

Carl M.F. Mbofung, B.Sc., PhD, FCAS (Chair), Professor of Food and Nutritional Biochemistry, College of Technology& Registrar, University of Bamenda, Cameroon.

Agatha N.K. Tanya, B.Sc., M.S., PhD, Associate Professor of Food Science, Nutrition and Dietetics, Head of Department of Food Science and Nutrition & Deputy Director of the College of Technology, University of Bamenda, Cameroon.

Daniel Sibetcheu, M.Sc., MPH, Public Health Nutritionist, Executive Director of OFSAD, Yaoundé, Former Director of Health Promotion, Ministry of Public Health, Yaoundé, Cameroon

Ndam Mama, B. Sc., M. Sc., Applied Economist, Senior Lecturer, Head of Department of Marketing, Higher Institute of Commerce and Management, University of Bamenda, Cameroon

Study Staff of the Cameroon Academy of Sciences

David A. Mbah, PhD, FCAS, Executive Secretary

Vincent N. Tanya, PhD, FCAS, FTWAS, Programme Officer

Thaddeus A. Ego, Administrative/Finance Assistant

October 2014


Published by

The Cameroon Academy of Sciences P.O. Box 1457 Yaoundé, Cameroon

Telephone/Fax:+237 222 239741 E-mail: [email protected]

Website: www.casciences.com

NOTICE

The project that is the subject of this study was supported by grant agreement n°IOM-5855-05-002 between the United States National Academy of Sciences and the Cameroon Academy of Sciences with support from the Bill and Melinda Gates Foundation.

International Standard Book Number 9956-26-38-x

Additional copies of this publication are available from the Cameroon Academy of Sciences, P.O. Box 1457 Yaoundé, Cameroon or http:www.casciences.com

Citation : CAS (2014). Process evaluation of vitamin A supplementation of 6–59 month old children in Cameroon. Cameroon Academy of Sciences, Yaoundé, Cameroon.

All rights reserved

© The Cameroon Academy of Sciences


Table of Contents

Acronyms .......................................................................................................................................... 5

Cameroon Academy of Sciences ........................................................................................................ 6

Acknowledgements ........................................................................................................................... 7

Preface .............................................................................................................................................. 8

Executive summary ........................................................................................................................... 9

Résumé analytique .......................................................................................................................... 14

Introduction ..................................................................................................................................... 20

Overview of the vitamin A supplementation programme in Cameroon ............................................. 28

Methodology ................................................................................................................................... 31

Results and Discussions ................................................................................................................... 36

Conclusions and recommendations .................................................................................................. 54

References....................................................................................................................................... 56

Annexes .......................................................................................................................................... 58

Questionnaires .......................................................................................................................... 58

Biographical sketch of the authors ............................................................................................ 62


Acronyms

ASADI African Science Academy Development Initiative

CAS Cameroon Academy of Sciences

CIDA Canadian International Development Agency

DHS Demographic Health Survey

MICS Multiple Indicator Cluster Survey

EPI Expanded Programme for Immunization

FCAS Fellow of the Cameroon Academy of Sciences

FTWAS Fellow of the Third World Academy of Science

GIVS Global Immunization Vision and Strategy

HKI Helen Keller International

IAP Inter Academy Panel on International Issues

IAMP Inter Academy Medical Panel

MCHNAW Maternal and Child Health and Nutrition Action Week

MDG Millennium Development Goal

MOH Ministry of Public Health

NASAC Network of African Science Academies

PECS Post Event Coverage Survey

SASNIM Semaine d’Action de Santé et de Nutrition Infantile et Maternelle

TWAS Third World Academy of Science (i.e. The Academy of Sciences for the Developing World)

UNICEF United Nations International Children Education Fund

USAID United States Agency for International Development

USNAS United States National Academy of Sciences

VAC Vitamin A Capsule

VAD Vitamin A Deficiency

VAS Vitamin A Supplementation

WHO World Health Organisation


Cameroon Academy of Sciences

The Cameroon Academy of Sciences (CAS) was formally recognized by declaration N° Reg. 00701/RDA/J06/BAPP of 29 May 1991 by the Cameroon Government in accordance with law N° 90/053 of 19 December 1990, regulating freedom of association. It is a non‐profit society of distinguished scholars engaged in promoting excellence and relevance in science and technology and providing advice to the government of Cameroon and other partners.

The vision of the Cameroon Academy of Sciences is to be the prime mover of science and technology, making scientific knowledge available to decision and policy makers with a view to influence investment priorities in science and technology, and promoting the use of science and innovation in the economic, social and cultural development of Cameroon. Consequently, the Academy produces robust forum and committee advisory documents as well as reports on priority problems that are delivered to policy and decision makers and the public. The independence, highly qualified membership, multidisciplinary composition and rigorous procedures for objective and unbiased analysis enable the Academy to effectively deliver credible advice.

In carrying out its work, the Academy collaborates with the various ministries of the Government of Cameroon, the United States National Academy of Sciences (USNAS), the Academy of Sciences for the Developing World (TWAS), Royal Society (UK), the Network of African Science Academies (NASAC), Inter Academy Panel on International Issues (IAP), Inter Academy Medical Panel (IAMP) and other international and national organizations. EXECUTIVE COMMITTEE OF CAS

President Prof. Samuel Domngang 1st Vice President Prof. Sammy Beban Chumbow Executive Secretary Dr. David Akuro Mbah Assistant Executive Secretary Prof. Manguelle‐Dicom E. Treasurer/Programme Officer Dr. Vincent N. Tanya

DEANS OF CAS COLLEGES

College of Biological Sciences Prof. Daniel N. Lantum College of Mathematics and Physical Sciences Prof. Samuel Domngang College of Social Sciences Prof. Sammy Beban Chumbow

JOURNAL OF THE CAMEROON ACADEMY OF SCIENCES (JCAS)

Editor‐in‐Chief Prof. Vincent P. K. Titanji KEY STAFF

David Akuro Mbah, PhD Executive Secretary E. Manguelle‐Dicom, PhD Assistant Executive Secretary Vincent N. Tanya, PhD Treasurer/Programme Officer Thaddeus A. Ego Administrative/Financial Assistant

CONTACT INFORMATION

Cameroon Academy of Sciences P.O. BOX 1457 Yaoundé, Cameroon Telephone: +237 222 239741 Fax: +237 222239741 Email: [email protected] Website: www.casciences.com


Acknowledgements

The funding for this work was facilitated by the USNAS within the frame work of the African Science Academy Development Initiative (ASADI) which is financed by the Bill and Melinda Gates Foundation. We thank the Foundation and all the officials (Dr Patrick Kelley, Ms Patricia Cuff and Mr Jim Banihashemi) at USNAS who made the collaboration with CAS possible. We are grateful to Professor Samuel Domngang, the President of CAS for giving us the opportunity to carry out this study.

We recognise Professor Wali Muna, the Chair of the CAS Public Health Forum and the members of the Forum for selecting this important public health topic for study and for providing useful inputs that improved the quality of the document.

Our work for CAS was facilitated by the excellent collaboration we had with Dr David A. Mbah (CAS Executive Secretary), Dr Vincent N. Tanya (Programme Officer) and Mr Thaddeus A. Ego (CAS Administrative/Finance Assistant). Additionally, Dr Tanya acted as the Editor and CAS-branded the document. We are grateful to them.

In undertaking this assignment, we received considerable assistance from 14 data collectors in the field, the Regional Delegates of Public Health of the Far North, North West, Centre, Littoral and South Regions and Non-Governmental Organizations such as HKI and UNICEF. We are indebted to all of them.

The review process of this report was overseen by Dr David A. Mbah. We thank Ms Patricia Cuff, MS, MPH, Senior Programme Officer, Institute of Medicine, US National Academies and Julius Oben, PhD, Professor of Nutritional Biochemistry, Faculty of Science, University of Yaoundé 1 for their role in reviewing this work. However the responsibility for the final content and quality of this report is totally that of the Expert Committee and CAS.


Preface

As part of its present strategic plan, the Cameroon Academy of Sciences (CAS) organises workshops and seminars and carries out research and consensus studies in order to provide information for evidence-based actions by various stakeholders.

It has so far organised several seminars, workshops and training sessions either alone or in collaboration with other partners. In its meeting of 21 April 2011, the Academy’s Forum on Public Health decided to carry out consensus studies as well. From among several themes that were short-listed during the meeting, it was decided that consensus studies should be carried out on “recent advances in onchocerciasis research and implications for control” and on the “content and quality of nutrition in national public health programmes”. Accordingly, CAS in recognition of its advocacy role in giving visibility to Cameroonian research efforts and that of its partners and other scientists convened two expert panels to carry out these assignments. In the present study, the panel was set up to bring together the data on vitamin A supplementation of children aged 6-59 months, analyse it and present sound advice and reasoning for reorientation of the current supplementation strategy in Cameroon.

In view of all of the above, it is hoped that the report herein presented will provoke dialogue among stakeholders and draw public attention to this very important issue.


Executive summary

Objective

The Cameroon Academy of Sciences (CAS) convened an expert panel to carry out a formative evaluation of the nutrition-based strategies adopted by Cameroon to fight against vitamin A deficiency (VAD) in an effort to determine whether the government and multi-national organizations with specific programmes to decrease VAD in children are effectively executing the national strategies adopted to combat vitamin A deficiency. The outcome of this effort is this peer-reviewed report containing evidence-based advice from CAS to the Cameroon government and other stakeholders on how to improve the execution, the effectiveness and/or efficiency of the strategies adopted for vitamin A supplementation in the fight against VAD in children less than 5 years old. It is hoped that the report herein presented will contribute to the reduction of the morbidity and mortality rates as envisaged by the Millennium Development Goals.

Methodology

The study evaluation was limited to children aged 6 to 59 months and focused on the evaluation of the adequacy of the inputs, the activities and the outputs associated with the process of execution of the strategies. Quantitative and qualitative data were collected from primary and secondary sources. The study used a process evaluation methodology. In the course of the work, the study panel had several open and closed working sessions. During the open sessions, experts and/or workers in different sectors of government and the public involved with the nutrition/health programmes were contacted to provide needed inputs through focused discussions and/or interviews. Documented information (published or unpublished) as well as a pretested questionnaire were also used. Generally the study followed a cross sectional design model. Both quantitative and qualitative data were collected. Information was collected at selected points of the evaluation with particular attention to process indicators partially adapted from Bloem et al. (2002).A stratified random sampling procedure was used in selecting study sites. Regions for the study were randomly selected, taking into consideration factors such as the principal language of communication (French or English), ecology of the area (Sahel, Western Plateau, Forest), urban centres and epidemiology based on data on vitamin A deficiency. In this respect the Far North, North West and South Regions as well as two urban settings, Douala in the Littoral Region and Yaoundé in the Centre Region were selected.

Findings

The data collected and analysed showed the existence of a number of International Organizations (HKI, USAID, UNICEF, WHO, CIDA) and other donors collaborating with the Cameroon Ministry


of Public Health in various activities concerning the vitamin A supplementation (VAS) programme whose major objective is to contribute to the reduction of infant mortality by attending a uniform VAS rate of 80% of children aged between 6 and 59 months. The contributory programmes in this direction include immunization, vaccination and deworming campaigns as well as the distribution of mosquito nets. It has been observed that the multitude of these programmes has helped to increase the coverage rate of VAS in several parts of the country.

Initial programme design : The efficient execution of a programme depends on its design which takes into consideration such important items as funding, logistics, communication strategies, the quality and numbers of personnel needed at different levels, capacity building, cost of vitamin A capsules, distribution of the capsules and monitoring and evaluation. Unfortunately, no initial VAS programme design had been made. Consequently, no clear logical framework (exhibiting inputs, activities, output, the outcome and the impact) which should have been used as a basis for monitoring eventual progress was in existence. There was however a policy on VAS implementation but which was not widely understood and followed by health workers involved with Programme. The absence of such an initial programme design and its effect on the implementation was evidenced by the numerous problems faced during the introduction of the Programme in the late nineties in the ten regions of the country.

Personnel : Most of the personnel involved in the VAS programme at the different levels of the health set up are employees of the Ministry of Public Health originally trained for other services. As a consequence, they need to be regularly retrained to build up their capacity. Information from group discussions at the Regional, Divisional and District levels revealed that, these workers are not sufficient in quantity and quality and many complain of low salaries. Except for a few appointed officials of the Ministry of Public Health charged with the coordination of nutrition programmes at the national and regional levels in some cases, no staff was employed to work solely for the VAS programme. Interviews with some personnel showed that there is a growing tendency for trained nurses and midwifes to abandon their government paid jobs and go abroad or in the private sector. Duties so abandoned by the trained staff are often taken over for long periods, by junior incompetent staff. This was reported to be having an effect on the implementation of VAS and other health programmes in some health areas of the Far North and South Regions.

Funding : It was evident from the study that the VAS programme in Cameroon is heavily dependent on the financial and material collaboration of donor organizations. Government funding of VAS is indirect and limited and takes care of the salaries of the health workers, communication, coordination and supervision of public health programmes, organization of meetings and some workshops as well as the facilitation of the integration of VAS into other public health programmes. The acquisition and transportation of VAS to the regions for distribution is taken care of by the International organizations.

Transportation : Materials for use in the VAS programme are systematically transported to the Regions alongside vaccines by UNICEF. These are subsequently redistributed to the Divisions and then to the Districts and are made available prior to each public health campaign. Although the


strategy of using trained community volunteers has been observed to improve on the coverage rate of VAS in some areas, there were complaints of lack of transportation of personnel within some health districts. This handicap has a direct negative effect on VAS in these areas. These complaints were mostly in areas recorded as ‘low coverage’ areas in the North West and in the Littoral and South Regions.

Supervision and monitoring of VAS and personnel : This is important for the generation of information that can be used to improve the programme or for advocacy for resources for the sustainability of the programme. This has not been given its due importance at different stages of the execution of the programme. The common reports of shortages in quality and quantity of Vitamin A capsules reported in most health centres are not unrelated to this short coming. It is a proven fact that a continuous supervision of junior or less qualified health personnel coupled with orientated in-service capacity building training programmes can and does improve on the execution of health programmes.

VAC storage and management of supplies : Most health workers were found to be properly informed of the necessity to keep VAC away from direct sunlight and to be conscious of the expiry date of supplies in store. A lot of the material was brought in during specific health campaigns and leftovers were to be used alongside routine supplies. However, there were cases where leftover campaign supplies were left untouched waiting for the next campaign to the detriment of satisfying the current routine VAS of the target group.

Capacity building for supplementation : The study showed that the introduction of VAS in the Cameroon public health sector faced many problems related to lack of the training of the personnel. This led to the organization of the first ever National training workshop on Vitamin A in Obala from the 26 to the 27 of February 1998. Subsequently the training workshops were conducted through a cascade system at the Regional, District and Health Centre levels. The incorporation of VAS into other public health programmes would have required that the grouped training period be longer. Unfortunately, this has not been taken into consideration in some recent training programmes.

Knowledge and Awareness of VAD : One of the determining factors that can spur a parent to take his/her child for VAS is his/her knowledge of the consequences of VAD. Evaluation of the knowledge and awareness of VAD showed that a little less than one in four (23.3%) of parents were knowledgeable on VAD as a health problem in children. This observation varied significantly from one region to the other with the Far North Region (known to have the highest prevalence of VAD) having the lowest (10.0%) and the North West the highest (41.9%) percentage of parents who were knowledgeable and aware of the VAD. Significant differences were also observed between urban and rural settings in this respect. Another important influencing factor of variability in the knowledge and awareness of VAD was the level of education of parents.

Information and awareness of VAS : Information and awareness of VAS programme is known to be an important determinant of the level of its coverage. Current strategies for the improvement of the awareness of VAS alongside other health programmes was found to include advocacy, interpersonal communication (IPC), social mobilization and the use of media (Radio and Television) and to have


different levels of efficacy depending on the region of the country. Thus, while an 80% level of VAS coverage could be attained by concentrating on the use of IPC and TV strategies, IPC alone was sufficient to produce the same results in the North West and South Regions. On the other hand, Social Mobilisation and Radio was found to be the most effective strategy in the Far North Region. These results reveal that the use of communication strategy for the improvement of VAS coverage should not be based on a ‘one size fits all’ approach.

VAS output : Available records consulted indicate that VAS coverage rates in the country have fallen with time from 100% coverage rate in 2001 to 83% in 2008. In the course of the present evaluation, an overall national coverage rate of 88.6% was observed. At the regional level the highest coverage rate (94.9%) was observed in the Far North Region while the lowest (74.2%) was found in the South Region. It has been widely acknowledged that a consistent high (>80%) VAS coverage rate leads to a decrease in the VAD level and consequently in morbidity and mortality rates. However, the situation in Cameroon seems to be paradoxical. Indeed, the findings in the course of this study reveal that the VAS coverage rate in Cameroon is averagely 80%, but unfortunately, this high rate does not have any significant effect on the drop in VAD level as well as on the morbidity and mortality rates.

The analysis of the data from this study data provides evidence for the existence of two, hitherto, unknown factors likely to be contributing to the existence of the above paradox. These are what we call the ‘‘Dropout syndrome’’ and the ‘‘Sham vaccination phenomenon’’. The “Dropout syndrome” characterises a situation whereby the effective cumulative relative frequency rate of VAS as envisaged by the protocol requirement decreases with time during the period of 6 to 59 months. The cumulative VAS frequency rate is high during the 6-9 months period of life and tends to decline thereafter with increase in age. The decline was found to be inversely related to earlier reports of the prevalence of diarrhoea and stuntedness which confirm the existence of the syndrome.

The second possible determinant factor to ‘‘the paradox of the coexistence of high VAS and VAD rates’’ is that of ‘‘Sham Vaccination phenomenon’’ as revealed by various interviews of some parents. This phenomenon describes the situation whereby some health workers systematically record houses during a vaccination campaign exercise without actually having vaccinated the children in these homes. In this case, the integration of VAS in a vaccination campaign is bound to equally be negatively affected.

Recommendations

1. As a result of the fact that Government funding of VAS is indirect and limited, the VAS programme depends largely on the financial and material support of donor organisations which is not sustainable. Actions to improve this situation should include:

Carrying out a cost analysis of the implementation of VAS taking into consideration the changing roles of partner organisations;

Developing and sustaining relationships with international organisations participating in VAS to achieve the optimal VAS coverage;


Having the political will to commit important and sufficient resources (human, financial and material) at the national, regional and district levels for the achievement of the ultimate goals of reducing by half child morbidity and mortality at an extended dateline of 2020.

2. The VAS programme started without an initial design which takes into consideration such important items like funding and logistics. In order to have a clear logical framework which should provide information for monitoring and evaluation, it is desirable that the VAS programme be :

Designed in close consultation with all partners and taking into consideration the heterogeneous nature of the target groups in terms of culture, education and the communication media;

Result-oriented and evaluable;

As much as possible specific to the target groups so as to avoid the consequences of applying the “one size fits all” approach.

3. The study showed that the VAS was bedevilled with many capacity building and communication difficulties. Efforts to reduce these should target:

Developing effective information sharing among the stakeholders through meetings, workshops and seminars;

Improving the communication gap between the target groups and various stakeholders involved in the VAS programme implementation through:

o Production and publication of posters adapted to each region or culture;

o The use of region specific communication strategies;

Educating the target population about the dangers of the VAD and on the VAS programme at different levels, (regions, Divisions, Sub-divisions and community);

Regular and effective training and retraining of the stakeholders for a better understanding of the activity (i.e., the supplementation process).

4. Consultation among all the VAS stakeholders must be carried out to come out with appropriate actions for solving the triple critical problems facing the VAS programme in Cameroon, namely: “The paradox of the coexistence of high VAS Coverage and VAD Rates”, “The Dropout Syndrome” and “The Sham Vaccination Phenomenon”. The new observation of a ‘dropout syndrome’ in the VAS programme between the period of 9-59 months of life of children as well as that of the existence of a “Sham vaccination phenomenon” compels a total review of the strategy for VAS of under five year old children in Cameroon with a particular attention for those older than nine months. On the other hand, the possible link between VAD and the ‘Dropout syndrome’, as well as between it and the “Sham vaccination phenomenon” needs to be closely examined.


Résumé analytique

Objectif

L'Académie des Sciences du Cameroun (ASC) a réuni un groupe d'experts dans le but de procéder à une formation évaluative des stratégies relatives à la nutrition adoptées par le Cameroun pour lutter contre la carence en vitamine A (CVA). Il s’agissait de vérifier si le gouvernement et les Organisations Internationales ayant de programmes spécifiques de réduction de CVA chez les enfants exécutent effectivement les stratégies nationales mises au point à cet effet. Le résultat de cette initiative est présenté dans un rapport révisé par les pairs et contenant les avis éclairés de l'ASC à l'attention du gouvernement camerounais et des autres parties prenantes sur l’approche à adopter en vue de l’amélioration de l'exécution, de la mise en œuvre effective et/ou efficace des stratégies adoptées pour la supplémentation en vitamine A dans la lutte contre la CVA chez les enfants de moins de 5 ans. L’on espère que le présent rapport contribuera à la réduction des taux de morbidité et de mortalité conformément aux Objectifs du Millénaire pour le Développement.

Méthodologie

L’évaluation s’est limitée aux enfants de 6 à 59 mois et portait essentiellement sur l'appréciation de l'adéquation des ressources, des activités et des rendements associés au processus d'exécution de ces stratégies. Des données quantitatives et qualitatives ont été collectées auprès des sources principales et secondaires. L'étude a été réalisée en utilisant une méthodologie d'évaluation des processus. Au cours des travaux, le groupe d’experts a tenu plusieurs sessions de travail publiques et restreintes. Au cours des sessions publiques, les experts et/ou les acteurs de différents secteurs du gouvernement et du public impliqués dans les programmes de nutrition/santé ont été contactés pour fournir les données nécessaires à travers des débats ciblés et/ou des entretiens. Des informations documentées (publiées ou non) ainsi que des questionnaires pré testés ont également été utilisés. En général, l'étude s’est inspirée du mode d’analyse croisée. Des données aussi bien quantitatives que qualitatives ont été collectées. Les informations ont été collectées à certains moments de l'évaluation avec une attention particulière aux indicateurs de procédé partiellement adaptés de Bloem et al. (2002). Les sites d'étude ont été sélectionnées selon un mode d'échantillonnage aléatoire stratifié. Les régions d'étude ont été sélectionnées de manière aléatoire tout en tenant compte de facteurs tels que la principale langue de communication (français ou anglais), l'écologie de la région, (Sahel, Hauts plateaux, Forêt), les centres urbains et l'épidémiologie basée sur les données de carence en vitamine A. A cet effet, les régions de l'Extrême-Nord, du Nord-Ouest et du Sud ainsi que deux villes, Douala dans la Région du Littoral et Yaoundé dans la Région du Centre ont été choisies.


Résultats

Les données collectées et analysées ont mis en relief la présence d'un certain nombre d'organisations internationales (HKI, USAID, UNICEF, OMS, ACDI) et d'autres bailleurs de fonds qui œuvrent en collaboration avec le Ministère camerounais de la Santé Publique dans différentes activités relatives au programme de supplémentation en vitamine A (SVA) dont le but principal est de contribuer à la réduction du taux de mortalité infantile en atteignant un taux uniforme de SVA de 80% chez les enfants âgés de 6 à 59 mois. Les programmes associés à la SVA comprennent les campagnes de vaccination et d'administration de vermifuges, ainsi que de distribution des moustiquaires. Il a été noté que la multiplicité de ces programmes a contribué à l’accroissement du taux de couverture de la SVA dans plusieurs parties du pays.

Conception initiale du programme

L'exécution efficace d'un programme dépend de sa conception qui tient compte d'éléments importants comme le financement, la logistique, les stratégies de communication, la qualité et l'effectif du personnel nécessaire à chaque niveau, le renforcement des capacités, le coût des capsules de vitamine A, la distribution de ces capsules ainsi que le suivi et l'évaluation. Malheureusement, aucun programme initial de SVA n’avait été élaboré. Par conséquent, il n’existait aucun cadre logique explicite (présentant les ressources, les activités, le rendement, le résultat et l'impact) qui aurait pu être utilisé comme base de suivi d'une éventuelle évolution. Il existait néanmoins une politique sur la mise en œuvre de la SVA mais qui, malheureusement, n’était pas comprise par tous ni respectée par les professionnels de la santé impliqués dans ce Programme. L'absence de ce programme initial structuré et ses effets sur la mise en œuvre explique les nombreux problèmes rencontrés pendant l'introduction du programme à la fin des années quatre-vingt-dix dans les dix régions du pays.

Personnel

La plupart du personnel impliqué dans le programme SVA à différents niveaux du système sanitaire est constitué du personnel du Ministère de la Santé Publique ayant reçu une formation pour d'autres services. Par conséquent, ils ont régulièrement besoin de recyclage afin de renforcer leurs capacités. Les informations recueillies à l’issue d’échanges effectués aux niveaux régional, départemental et du district ont montré que ce personnel est insuffisant en quantité et qualité, et se plaint de recevoir des salaires dérisoires. A l'exception de quelques responsables du Ministère de la Santé Publique nommés et chargés de coordonner les programmes de nutrition aux niveaux national et régional dans certains cas, aucun membre du personnel n'a été recruté pour travailler uniquement dans le cadre du Programme de SVA. Les échanges avec certains membres du personnel ont révélé qu’un nombre de plus en plus croissant d’infirmier(ière)s et de sages-femmes formés abandonne leur emploi rémunéré dans la fonction publique pour aller travailler à l'étranger ou dans le secteur privé. Les postes de travail ainsi abandonnés par le personnel formé sont généralement occupés, longtemps après le départ de ceux-ci, par un personnel jeune et incompétent. Selon des rapports, cette situation entraîne des effets néfastes sur la mise en œuvre de la SVA et d'autres programmes de santé dans certaines localités des régions de l'Extrême-Nord et du Sud.


Financement

L’étude montre clairement que le programme de SVA au Cameroun dépend énormément de la participation financière et matérielle de bailleurs de fonds. Le financement du gouvernement en matière de SVA est indirect et limité. Il concerne surtout le paiement des salaires des employés, la communication, la coordination et la supervision des programmes de santé publique, l'organisation des réunions et de certains ateliers, ainsi que la facilitation de l'intégration de la SVA dans d'autres programmes de santé publique. L'acquisition et l’acheminement des intrants de SVA vers les régions pour distribution sont pris en charge par les organisations internationales.

Transport

Les matériels utilisés dans le cadre du programme de SVA sont systématiquement transportés par l'UNICEF vers les régions en même temps que les vaccins. Ils sont redistribués, par la suite, dans les départements puis les districts, et rendus disponibles avant chaque campagne de santé publique. S’il est vrai que la mise à contribution des volontaires communautaires formés a permis d'améliorer le taux de couverture de la SVA dans certaines localités, des plaintes concernant le manque de moyen de transport du personnel au sein de certains districts de santé ont été formulées. Ce manquement a un effet négatif direct sur la SVA dans ces localités. Ces plaintes ont été le plus enregistrées dans des localités dites "de faible couverture" dans les Régions du Nord-Ouest, du Littoral et du Sud.

Supervision et suivi de la SVA et du personnel

Cet aspect du programme, qui est crucial pour la production d'informations pouvant être utilisées dans le sens de l'amélioration du programme ou pour les activités de plaidoyer pour l’obtention des ressources afin d'assurer la pérennité du programme, n'a pas reçu attention qu’il mérite aux différentes étapes de l'exécution du programme. Les rapports faisant état de pénurie, en terme qualitatif et quantitatif des capsules de Vitamine A, au niveau de la plupart des centres de santé ne sont pas sans rapport avec cette lacune. Il est prouvé que la supervision continue du personnel de santé inexpérimenté ou peu qualifié, couplée à un programme de renforcement interne de capacités peut contribuer à l’amélioration de l’exécution de certains programmes de santé.

Conservation de CVA et gestion des approvisionnements

Il a été relevé que la plupart des professionnels de santé était bien informée de la nécessité de garder les CVA à l'abri de la lumière du soleil, et de vérifier la date de péremption des produits entreposés. Une bonne partie du matériel était fournie pendant les campagnes spécifiques de santé, et les restes devaient être utilisés pendant les campagnes d’administration de routine. Cependant, dans certains cas, les restes de produits de campagnes n'ont pas été utilisés dans l’attente de la prochaine campagne, au détriment de la satisfaction des besoins en SVA courants du groupe cible.


Renforcement des capacités en matière de supplémentation

Cette étude a montré que l'introduction de la SVA dans le secteur de la santé publique au Cameroun a rencontré plusieurs problèmes relatifs au manque de formation du personnel. Cette constatation a entrainé l'organisation du tout premier atelier national de formation sur la Vitamine A à Obala du 26 au 27 février 1998. Par la suite, une série d’ateliers de formation a été organisée en cascade aux niveaux des régions, des districts et des centres de santé. L'inclusion de la SVA dans d'autres programmes de santé publique aurait nécessité que la période de formation groupée soit plus longue. Malheureusement, ce paramètre n'a pas été pris en compte dans certains programmes récents de formations.

Connaissance et sensibilisation sur la CVA

L'un des facteurs déterminants pouvant encourager un parent à faire administrer à son enfant un SVA repose sur les connaissances dont il ou elle dispose quant aux conséquences néfastes de la CVA. Une évaluation des connaissances et de la sensibilisation relatives à la CVA a montré qu'un peu moins d'un quart (23,3%) de parents sont bien informés des CVA comme problème de santé chez les enfants. Cette observation varie considérablement d'une région à une autre ; la Région de l'Extrême-Nord (connue pour avoir le taux de prévalence le plus élevé de CVA) a enregistré le taux le plus bas (10%) et le Nord-Ouest le taux le plus élevé (49,9%) de parents informés et conscients de la CVA. La même évaluation met en exergue des différences considérables entre les sites urbains et ruraux. Un autre facteur déterminant de variabilité dans les connaissances sur la CVA est le niveau d'éducation des parents.

Informations et sensibilisation sur la SVA

Les informations sur le programme de SVA et la sensibilisation y relative conditionnent le niveau de couverture du programme. Il a été relevé que les stratégies actuelles visant l'amélioration de la sensibilisation sur la SVA ainsi que sur d'autres programmes de santé incluent les plaidoyers, la communication interpersonnelle, la mobilisation sociale et l'utilisation des médias (Radio et Télévision). Il y a une variabilité dans l’efficacité des stratégies en fonction de la région du pays. Ainsi, tandis qu'une couverture à 80% de SVA pourrait être atteinte en se concentrant sur l'utilisation de la communication interpersonnelle (CIP) et les stratégies TV, la CIP à elle seule était suffisante pour produire les mêmes résultats dans les Régions du Nord-Ouest et du Sud. D'autre part, la mobilisation sociale et la sensibilisation par le biais de la radio se sont avéré les meilleures stratégies dans la Région de l'Extrême-Nord. Ces résultats révèlent que l'utilisation des stratégies de communication pour améliorer la couverture SVA ne doit pas se baser sur une approche uniformisée.

Rendement de la SVA

Les données disponibles consultées indiquent que le taux de couverture en SVA dans le pays a chuté avec le temps, passant d'un taux de couverture de 100% en 2001 à 83% en 2008. Au moment où la présente évaluation était effectuée, une couverture nationale générale de 88,6% a été observée. Au


niveau régional, le taux de couverture le plus élevé (94,9%) a été observé dans la région de l'Extrême-Nord tandis que la région la moins couverte (74,2%) était le Sud. L'on s'accorde généralement à considérer qu'une couverture en SVA constamment élevée (>80%) aboutit à une baisse du niveau de CVA et par conséquent à une baisse du taux de morbidité et de mortalité. Toutefois, la situation au Cameroun semble paradoxale. En effet, les résultats obtenus au cours de la présente étude révèlent que le taux moyen de couverture en SVA au Cameroun est de 80%. Toutefois, ce taux élevé n'a pas d'effet considérable sur la chute du niveau de CVA ainsi que sur le taux de morbidité et de mortalité.

L'analyse des données de cette étude fournit des preuves de l'existence de deux facteurs jusqu'ici inconnus susceptibles de contribuer à l'existence du paradoxe ci-dessus. Il s'agit là de ce que l’on pourrait appeler le «Syndrome d’abandon» et le «Phénomène de simulacre de vaccination ». Le «Syndrome d’abandon» marque une situation au cours de laquelle le taux de fréquence relative cumulée de la SVA, tel qu'envisagé par les exigences du protocole baisse avec le temps pendant la période allant de 6 à 59 mois. Ainsi, le taux de fréquence cumulée de la SVA est élevé au cours des 9 premiers mois de vie et a tendance à baisser plus tard lorsque l'enfant prend de l'âge. Il a été noté que la baisse était inversement liée à la prévalence de diarrhée et le retard de croissance confirmant ainsi l'existence du syndrome.

Le deuxième facteur déterminant éventuel du «paradoxe de la coexistence des taux élevés de SVA et de CVA» est celui du «Phénomène de simulacre de vaccination » révélé par différents échanges avec certains parents. Ce phénomène décrit la situation où certains professionnels de la santé enregistrent systématiquement les domiciles pendant une campagne de vaccination sans toutefois avoir vacciné les enfants y vivant. Dans ce cas, l'inclusion de la SVA dans une campagne de vaccination ne peut être vouée qu’à échec.

Recommandations

1. En raison du fait que le financement du gouvernement en matière de SVA est indirect et limité, le programme SVA dépend presque entièrement de l'appui financier et matériel des bailleurs de fonds qui ne saurait être durable. Les mesures à prendre en vue de l’amélioration de cette situation devraient inclure ;

La réalisation d'une analyse du coût de la mise en œuvre de la SVA, en tenant compte des nouveaux rôles des organisations partenaires;

Le développement et le renforcement des relations avec les organisations internationales participant au programme de SVA pour atteindre une couverture optimale en SVA;

La volonté politique de fournir des ressources importantes et suffisantes (humaines, financières et matérielles) aux niveaux national, régional et de district afin d'atteindre les objectifs finaux consistant à réduire de moitié le taux de morbidité et de mortalité infantile d'ici à 2020.

2. Le programme SVA a démarré sans conception initiale prenant en compte des éléments importants comme le financement et la logistique. Afin d'avoir un cadre logique bien défini pouvant fournir les


informations pour un suivi et une évaluation efficaces, il est souhaitable que le programme de SVA soit:

Conçu en étroite collaboration avec tous les partenaires en tenant compte de la nature hétérogène des groupes cibles en matière de culture, d'éducation et de média de communication;

Axé sur les résultats évaluables;

Autant que possible spécifique aux groupes cibles afin d'éviter les conséquences relatives à l'application de l'approche uniformisée.

3. Selon l’étude, la SVA a rencontré plusieurs difficultés relatives au renforcement des capacités et à la communication. Des efforts visant à limiter ces problèmes devraient avoir pour objectifs:

Développer le partage effectif des informations entre les acteurs à travers des réunions, des ateliers et des séminaires;

Améliorer le « fossé » communicationnel entre les groupes cibles et les différents acteurs impliqués dans la mise en œuvre du programme de SVA à travers:

o La production et la publication des posters adaptés à chaque région ou culture.

o L'utilisation de stratégies de communication propres à chaque région;

Eduquer la population cible sur les dangers de la CVA et sur les bienfaits du programme de SVA à différents niveaux (régions, départements, arrondissements et communautés);

Former et recycler régulièrement et effectivement les acteurs pour une meilleure compréhension de l'activité (c’est-à-dire le processus de supplémentation).

4. Tous les acteurs de la SVA doivent se concerter afin que des actions appropriées puissent être mises en œuvre pour résoudre les trois problèmes critiques que rencontre le programme de SVA au Cameroun, notamment: « La paradoxe de la coexistence des taux élevés de couverture de SVA et de taux de CVA », « Le Syndrome d’abandon » et le « Phénomène de Simulacre de Vaccination ». L’observation de ce «Syndrome d’abandon» dans le programme de SVA chez les enfants âgés de 6 à 59 mois, de même que du « phénomène de simulacre de vaccination », appelle à une révision totale de la stratégie de SVA chez les enfants de moins de cinq ans au Cameroun, avec une attention particulière accordée aux enfants âgés de plus de neuf mois. D'autre part, le lien possible entre la CVA et le «syndrome d’abandon» d’une part, et le «Phénomène de Simulacre de Vaccination» d’autre part, devra être soigneusement examiné.


Introduction

Malnutrition is a major public health problem. On a global level, it affects approximately one in every five adults in developing countries and accounts for about 50% of childhood mortality1. The prevalence of the chronic form of the condition during the first two years of life has been said to be an essential component indicator of a country’s level of overall human development. In this respect, there is a growing consensus that poor nutritional status during childhood can have long-lasting scarring consequences into adulthood. This is more so because its occurrence at this age tends to result in irreversible harm and higher rates of morbidity and mortality, impaired cognitive ability and school performance in children and eventually decreased productivity and lifetime earnings for adults.2, 3

In Cameroon, one of the major aspects of this problem which is of public health concern is that linked to micronutrient under nutrition. It affects mostly those within the vulnerable age groups –children under the age of five and pregnant and lactating women. At the national level, the prevalence rate patterns vary between urban and rural settings, as well as with agro-ecological zones, probably as a consequence of differences in food supply and availability.

One of the most scourging problems of micronutrient deficiency is that of vitamin A. It is a major contributing factor to high morbidity and mortality in children under the age of five. Vitamin A-deficient children face a 23% greater risk of dying from illnesses such as measles, diarrhoea or malaria. It is estimated that as many as 190 million children, especially in Africa and Southeast Asia, suffer from vitamin A deficiency (VAD)4.

In several countries where VAD is a public health problem, vitamin A supplementation (VAS) is recommended in infants and children 6–59 months of age as a public health intervention to reduce child morbidity and mortality4. VAS is associated with approximately 23% reduction in mortality in children5. In particular, it has been consistently found to reduce total and diarrhoea-specific mortality and severity of disease (diarrhoea and measles), in areas where VAD is a public health problem6. The following is the recommended dosing protocl for children under the age of five:

Table 1: Protocol of Vitamin A supplementation

Age Dose (IU) Frequency

0-5 months 50.000 Once for children who are not breast-fed

6-11 months 100.000 4-6 months

12-59 months 200.000 4-6 months

Source : National Vitamin A Supplementation protocol, Ministry of Public Health. 2011.


In general, the most effective delivery mechanism is a regular twice-yearly event striving to achieve +80% coverage rates among target groups. Food-based approaches, such as food fortification and consumption of foods rich in vitamin A, are more sustainable but have not yet ensured coverage levels similar to supplementation in most affected areas7.

VAS has been acknowledged as a low-cost high-impact means of improving vitamin A status in children4. In fact, it was ranked as one of the top development priorities during the 2008 Copenhagen Consensus. The World Health Organisation (WHO) and the United Nations International Children Emergency Fund (UNICEF) recommend VAS of children in areas where infant mortality rate is greater than 70 per 1,000. This rate is 132 per 1,000 in Cameroon as reported by the demographic health survey carried out in 20118.

In Cameroon, the prevalence of VAD is highest among the vulnerable groups especially children under the age of five and increases in level from the south to the North of the Country. It has been noted that food habits and availability also vary within these zones. In this context, it would be expected that the design and execution of any nutritional programme of public health importance aimed at combatting the problem should not be made up of a ‘one size fits all’ strategy and approach. To what extent this is the case with past and on-going programmes will constitute part of the knowledge gap to be bridged by the present study.

Given the paradigmatic shift in the past decade in our knowledge and understanding of the relationship between good nutrition and health, the implication of nutrition in public health programmes cannot be overemphasized. In fact, experiences in several countries indicate that the level of effectiveness of public health programmes is highly dependent on the nutritional component which in some cases requires the development of guidelines and improved skills and capacity of health workers involved with their implementation. The absence of a properly designed and executed nutritional component in some of these programmes is often due to the “professional tribalism” of the medical doctors who initiate and manage them. The contribution of such professional tribalism to the many factors that often affect nutritional component of public health programmes cannot be over emphasised.

These factors include :

The inadequacy of support and investment in nutrition actions by communities, government and donor agencies;

Poor integration within on-going health service of actions proven to positively impact on child and maternal health;

Poor quality of services to clients which limit the demand for and the continuity of the services;

The lack of an efficient and permanently available system to regularly and accurately monitor and evaluate services and data collection geared toward the improvement of maternal and child nutrition – especially before, during and after given interventions;

The slow pace of government development of human and institutional capacity to address these challenges.


Given the above, the design and execution of health programmes must, as a matter of strategy, include inter alia the following practices:

A quality assurance service at each step of the programme;

Integration of essential nutrition action into existing health delivery system;

Accurate measurement and use of information on nutrition and mortality;

Advocacy for action in nutrition at all levels9.

A review of the available statistics on the prevalence of malnutrition in Cameroon for the past three decades shows a disturbing scenario in which the incidence and prevalence of certain forms of malnutrition have either remained stagnant or have worsened in the course of this period. This has been the case with chronic malnutrition and above all that of what is commonly known as “hidden hunger” (micronutrient deficiencies). Worthy of note is the fact that this situation not only complicates but is equally complicated by the prevalence of diseases like malaria, HIV and tuberculosis leading to high death burden especially among children under the age of five.

Information from a nutrition survey carried out in Cameroon in 2000 by the Ministry of Public Health10showed a national prevalence rate of 38.8% for VAD. In addition, it was observed that the prevalence of the deficiency varied with agro-ecological zones with the severe cases occurring within the Sudano-Sahelian and guinea savannah zones which include the three northern regions of Adamawa, North and Far North. An earlier National Survey on micronutrient deficiencies and food consumption for fortified foods carried out in 200911 reported a national prevalence rate of 34.4% for VAD in children under the age of five years. The survey further reported that this prevalence rate is about twice (70.7%) higher in the case of children suffering from infectious diseases. For mothers aged 15-49 years, the prevalence rate stood at 21.4% and was almost three times (61.3%) higher for those who were suffering from one infection or the other.

In a recent national forum on nutrition and public health in Cameroon, organised by the Cameroon Academy of Sciences, it was emphasized that micronutrient deficiencies, including that of vitamin A, constitute a huge hidden scourge that causes severe damage and contributes extensively to infant-juvenile malnutrition, poor development, morbidity and mortality in Cameroon. Participants at the forum were unanimous in recommending that the fight against micronutrient deficiency diseases in Cameroon should be pursued with vigor12.

The importance of such a recommendation cannot be overemphasized given accumulating evidence from studies that clearly show the role of micronutrients in health. In this respect, the role of vitamin A in the fight against high morbidity and mortality in children under the age of five has been documented from past and very recent studies13-17. In these different publications, conclusive evidence shows that improving the vitamin A status of young children contributes to reducing their morbidity and mortality.


Statement of task

Fighting against VAD in children can contribute to the attainment of the fourth MDG of reducing by two-thirds child mortality between 1990 and 2015. Unfortunately, on the eve of the targeted date of 2015, Cameroon is far from attaining that stated goal of reducing infant morbidity and mortality as spelled out in the fourth Millennium Development Goal.

Given all of the above, the Cameroon Academy of Sciences (CAS) decided to convene an expert panel to carry out a formative evaluation of the nutrition-based strategies adopted by Cameroon to fight against vitamin A deficiency (VAD) in children aged from 6 to 59 months. This was in an effort to determine whether the government and multi-national organizations with specific programmes to decrease VAD in children, are effectively executing the national strategies adopted to combat vitamin A deficiency. The outcome of this assignment was to be a peer-reviewed report containing evidence-based advice from the CAS to the Cameroon government and other stakeholders on how to improve the execution, the effectiveness and/or efficiency of the strategies adopted for vitamin A supplementation in the fight against VAD in children less than 5 years old. It was hoped that the report to be presented would contribute to the reduction of the morbidity and mortality rates as envisaged by the Millennium Development Goals.

The strategies adopted by the Cameroon government that directly include this age group range are based on two main approaches:

i) Supplementation with Vitamin A capsules; and

ii) Use of the food-based approach.

With regards to the supplementation strategies, government planned the following:

1) Vitamin A supplementation of children aged between 6 and 59months during the vaccination campaigns twice a year, starting from 1998 with the regions most at risk (Adamawa, North and Far-North Regions) and then extending the exercise to the whole country from 2002;

2) Progressive introduction of vitamin A supplementation during the vaccination campaigns and ante natal care clinics; and

3) Systematic supplementation of vitamin A to children suffering from severe malnutrition, small pox and/or persistent diarrhoea.

Food-based strategies in favour of children under the age of five include:

1) Vitamin A supplementation to lactating mothers in order to increase thevitamin A content of breast milk;

2) Promotion of the consumption of foods rich in vitamin A or its precursor.

3) Protection and support of the practice of exclusive breast feeding during the first six months of life and its promotion up to the age of two years;

4) Development of pedagogic material for nutrition education;

5) Exploitation of potential local food industries for the fortification of foods with vitamin A.


The merits of these different approaches are well known. While vitamin A supplements can be used as a rapid and a cost effective and efficient tool for combating VAD, its sustainability is often dependent and delimited by several economic, material and social factors. On the other hand, the food-based approach which equally produces good results is not only complex to implement and to evaluate but takes time to mature and exert impact. However, unlike supplementation, this approach affects all members of the community. It is also safe, sustainable and cost effective against multiple nutrient deficiencies in addition to improving vitamin A status of the beneficiaries. It can be adapted to different cultural and dietary traditions. It builds partnerships among governments, consumer groups, the food industry and other organisations to achieve the shared goal of overcoming micronutrient malnutrition. Although this approach is thought to be expensive from the view point of donor organizations, its economic benefits to the country, communities and families who grow vitamin A rich foods are likely to outweigh the costs.

In view of the above, and considering that these approaches differ in their method of design and execution by government and collaborating organization, our intended formative evaluation of nutritional programmes aimed at combating VAD in Cameroon shall be carried out in two phases.

The first phase (the present study) concentrates on the vitamin A supplementation (VAS) strategies while the second phase shall concern all the strategies classified under the food-based approach. The reason for the two phase approach in the formative evaluation of the strategies is further explained by the need to use a different study design in each case for proper execution and eventual analysis and interpretation of results.

Objective

The study was thus aimed at carrying out a formative evaluation of the different strategies of VAS programme in Cameroon. Specifically, the study focused on the evaluation of the adequacy of the inputs, the activities and the outputs associated with the process of execution of the programme.

Evaluation questions

The following questions (in the form of a questionnaire for stakeholders) leading to key indicators for the evaluation of the programme were addressed to attain the stated objectives :

What was the initial programme design of the VAS programme?

Who were/are the stakeholders involved in the programme implementation?

Was/is the target population aware of VAD?

Did/does the target population know of the presence and the utility of the VAS programme?

Did/do the programme implementers receive sufficient training for the execution of the programme?

Are there any lapses in the knowledge of those involved in the implementation of the project with respect to its design and objective?


Is the programme being implemented on schedule?

Is there any congruency between the design of the Programme and its implementation?

Are there any misconceptions about the programme at given levels and environment of implementation?

What are the micro-environmental factors which have negatively or positively affected or are affecting the implementation of the programme (poverty, educational level, migration - for economic purposes like in the South connected with Equatorial Guinea, drought, flooding that led to displacement of villages and religious beliefs)?

What are the macro-environmental factors that have affected or are affecting the implementation of the programme?

What policy measures, should be taken to help improve and optimize the different strategies to fight against VAD in the Cameroonian context?

Theoretical framework

The present study was conceived in the context of the present shift in the debate on public health policy which is focused on evaluation findings. It is advocated that most publicly funded human service programmes should be evaluated in order to demonstrate their benefits. For this purpose, appropriate evaluation programmes must be designed with the aim of enhancing their effectiveness and efficiency.

The design of the study made use of the current knowledge on process evaluation which emphasises the 'theory of change' which is a ‘logic model’ for different forms of evaluation. It is generally used regardless of the type of evaluation (formative, process, summative). The theory of change model has five components, namely, inputs, activities, outputs, outcome and impacts. Some of them have been more complex including target groups and internal and external factors. The main components of the theory18 are explained thus:

- Inputs are resources that go into a project, programme, policy (funding, staffing, equipment, curriculum materials, etc.)

- Activities are what can be done; often stated with verbs such as market, provide, facilitate, and deliver.

- Outputs are what is produced (tangible products or services) as a result of the activities.

- Outcomes are why the activity was undertaken and might be the behavioural changes resulting from a project output. Outcomes can be increased, decreased, enhanced, improved or maintained.

- Impacts are long term changes that result from an accumulation of outcomes.

The theory of change can be depicted graphically to represent what has come to be known in some circles as the 'Logic model' which is shown in Figure 1.


RESULTS

Implementation

Figure 1. Theory of Change

Source : Adapted from Binnendijk (2000)

The theory of change (Fig 1) is an important topic for evaluation, be it during the ex-ante or the ex-post stage of the study. According to Morrasimas and Rist19,this is so because it clearly and logically depicts a sequence of the inputs into the projects/programmes, the activities the inputs will support, the outputs toward which the project/programme is budgeted(a single activity or a combination of activities) and the outcomes and expected impacts. It also identifies events or convictions that may affect the process and outcome, as well as the assumptions that the programme design is making with respect to cause and effect as well as those that are based on the policy, environmental context and the reviewed literature, - all which must be carefully considered as factors existing within a black box (Fig. 2). These black box factors can essentially be classified after Bloem et al.20 as micro and macro environmental factors. In this respect, micro environmental factors include but are not limited to:

Communication system;

Corruption on the programme implementation;

Attitude of the VAC suppliers (supplying on time);

Other organisational issues;

Civil-educational status of beneficiaries, etc.

Macro-environmental factors on the other hand include:

Impacts

Outcomes

Outputs

Activities

Inputs

IMPACT

EVALUATION

PROCESS EVALUATION


Economic (crisis during the implementation);

Socio-cultural (attitudes towards the programme);

Demographic: migration, increase in population;

Physical factors (drought, flood, etc.).

As such the theory is valuable to both evaluators and stake holders.

Moving from inputs to results

RESULTS

n

Figure 2. Enlarged logic model

In the light of the above theory of change20, we have adapted the conceptual framework (Figure 3) developed by UNICEF21 to explain the aetiology of VAD in order to situate the points for the different strategies applicable in the fight against it. In the Cameroonian context, this framework seemed to have been adopted by government and other stakeholders in the elaboration and execution of strategies aimed at combating Vitamin A deficiency.

Figure 3. Conceptual Frame Work

Inputs

Activities Outputs

Black Box (Micro and Macro Environmental Factors)

impact Outcome


Overview of the vitamin A supplementation programme in Cameroon

Introduction

Vitamin A deficiency is a major public health problem in Cameroon affecting mostly children under the age of five as well as pregnant and lactating women. In Cameroon, almost 40% of the population of children under five years old is threatened by the consequences of VAD, with rates exceeding 62% in the North region. VAD in children tends to favour high morbidity and mortality rates. Meanwhile research findings have shown that VAS can be an important strategy of combatting the deficiency and thereby reducing the mortality rates among children. In fact this strategy is being used by many countries (including Cameroon) in order to meet the fourth Millennium Development Goal which focuses on improving child survival with the specific target of reducing by two thirds the mortality rate among children less than five years of age by the year 2015. The VAS programme has been in Cameroon since the late nineties.

Background of VAS

Vitamin A is essential for the normal functioning of the visual system, maintenance of cell function for growth, epithelial integrity, red blood cell production, immunity and reproduction. As such, its deficiency tends to result in adverse health consequences such as xerophthalmia (dry eyes), increased susceptibility to infection, stunting and anaemia. From a public health standpoint, Vitamin A deficiency (VAD) is known to be a major contributor of mortality in children under five. Vitamin A-deficient children face a 23% greater risk of dying from illnesses such as measles, diarrhoea or malaria. It is estimated that as many as 190 million children, especially in Africa and Southeast Asia, suffer from VAD (WHO, 2009).

In Cameroon, VAD is a public health problem. Information from a nutrition survey carried out in Cameroon in 2000 by the Ministry of Public Health (DHS, 2000) shows that the prevalence of VAD among children below the age of 5, determined by the serum retinol levels was 38.8% and varied according to ecological zones as follows:

The Sahel zone - 50.6%; The Forest zone – 38.0%; Yaoundé/Douala - 37.5%; The Coastal zone - 35.1%; The High Plateau zone - 24.9%.

On a regional basis, the VAD varied from 62.7% (the highest) in the North to 24.4% (the lowest) in the North West. It was 34.0% in Yaoundé as against 40.1% in Douala. From an age specific perspective, almost 1 out of every 2 children (45%) of 2 years of age was found to suffer from VAD.


The survey on micronutrient deficiencies and food consumption for fortified foods carried out in 2009 (DHS, 2009) reported a national prevalence rate of 34.4% for VAD in children under the age of five years. The survey further reported that this prevalence rate is twice (70.7%). higher in the case of children suffering from infectious diseases. For mothers aged 15-49, the prevalence rate stood at 21.4% and was almost three times (61.3%) higher for those who were suffering from one infection or the other.

VAD is a preventable health condition. One of the most common methods of fighting VAD is through Vitamin A Supplementation (VAS). Studies carried out in several countries have established that VAS can significantly reduce the mortality rate among under-5 year olds. This method has been widely accepted and recommended as the most effective strategy of addressing the problem in affected areas (UNICEF, 2007). WHO and UNICEF recommend VAS of children in areas where infant mortality rate is greater than 70 per 1000. In 2011 a demographic health survey in Cameroon revealed a mortality rate of 132 per 1000 (DHS-MICS 2011).

Given the high prevalence of Vitamin A deficiency (VAD) with its attendant effect on child health and mortality of children in Cameroon, the strategy of VAS was envisaged as one of the methods of resolving the problem. In general, the history of VAS in Cameroon can be divided into three periods, namely:

i) Before 1998: prepositioning vitamin A capsules in regions;

ii) From 1998 to 2000: supplementation on the basis of indirect indicators;

iii) From 2000 National Survey on vitamin A Deficiency.

The period prior to 1998 was marked by the introduction of the distribution of vitamin A capsules (VAC) at regional levels. The first consignment of VAC each contained 200 000 IU of vitamin A and were made available for distribution, following a stipulated protocol, to children (6 - 59 months), women postpartum and sick children (measles, complications of acute respiratory infections, malnutrition and persistent diarrhoea) in the regions, health districts and health centres.

This process was however affected by several logistical problems. For example, a consignment of 24,500 vitamin A capsules (with an expiry date of July 1997) which arrived Douala on 7 July 1995 was only received in the South West on 26 September 1996, more than a year after. Other problems that characterized this early stage of VAS in Cameroon included:

The systematic lack of recorded data on VAS;

Inexperience of health workers in the use of the established protocol for VAS;

Poor monitoring and management of VAS activities at all levels (regional, district and health facility);

Poor mastering of the technic for administration of 200,000 IU capsules in target groups requiring 100 000 IU capsules;

The abusive use of VAC as a curative medicine; and

The slow rate of reporting on VAS from regions such as the Far North and North West.


The period between 1998 and 2000 marked yet another distinct period of VAS in the country. Given the series of problems observed in the VAS programme before this time, it became obvious that the availability of manpower trained in the art of VAS was necessary to guarantee an improvement in the execution of the programme. Thus, this period was marked by the beginning of capacity building by stakeholders aimed at improving the knowledge and practice of VAS among health workers. This need for capacity building was further spurred by an analysis of information on the extent of the problem of VAD in Cameroon at the time.

The analysis of the VAD situation made use of available data from local studies, indirect research information and the indicators identified by the International Vitamin A Consultative Group (IVACG) and UNICEF to define the accepted limit to consider a vitamin A supplementation.

With regards to data from local studies, observations made in 1992 in the Far North Region on children aged 2 to 5 years showed that 0.71% of the children suffer from xerophtalmia, 0.45% from Bitot spots while 21% had serum retinols levels below 0.70 µmoles/litre. In addition, the same study also reported a high level (55%) of inadequate daily consumption of vitamin A. In 1993, a similar study carried out in the South Region in the ecological forest zone of the country showed that 17.1% of children had serum retinol levels lower than 0.70 µmole/l). Another study conducted in the forest zone of the Centre Region reported a high (85%) prevalence rate of low serum retinol levels (less than 0.70µmole/l) among children living a zone with high of onchocercaisis prevalence.

In addition to the above research findings, the following indirect indicators were also taken into consideration to assess the degree of VAD in the country. These included:

- The high and increasing rate of infant-juvenile mortality which passed from 144/1,000 in 1991to 151/1,000 in 1998;

- The increase in cases of growth retardation among children aged 0-3 years which passed from 23% in 1991 to 29% in 1998;

- The increase in the number of cases of measles from 5,335 in 1995 to 10,731 in 1998;

- The poor coverage rate of vaccination against measles which stood at a low of 43.6% in 1998 with frequent epidemics.

The above analysis of the situation led to the organisation of the first ever training workshop at the national level in Obala from the 26 to 27 of February 1998 with participants coming from the different regions of the country. Those attending were to later serve as trainers at their respective places of work. They included physicians, nutritionists and senior health technicians. This training and the adoption of VAS as part of the activities to be carried out during routine vaccination of children was found to increase the coverage rate of VAS.

It is however important to note that while VAC was provided by UNICEF for the purposes of VAS, no additional financial means were added to vaccination campaigns to take care of the additional problems of transportation, handling, storage and administration of VAS alongside the routine vaccination programme.


The National Survey on vitamin A deficiency in Cameroon in 2000 showed the extent of the problem and confirmed that vitamin A deficiency is a public health problem in all regions of Cameroon (38.8% in under-5 year olds). Highlighting the seriousness of the problem across the country increased the interest of partners such as HKI, WHO, UNICEF and USAID in the fight against vitamin A deficiency. Integration with the Enlarged Programme of Immunization (EPI) activities and other health activities tended to improve the coverage rate of VAS over the national territory. According to UNICEF (2007), VAS coverage rates of at least 70% can lead to substantial reductions in mortality due to VAD.

Methodology

As indicated above, this study followed a process evaluation methodology. In the course of its execution, the study panel had several open and closed working sessions. During the open sessions, workers in different sectors of government and the public involved with the nutrition/health programme under review were contacted to provide needed inputs through focused discussions and/or interviews. Documented information (published or unpublished) as well as a pretested questionnaire were also used.

Study design

Generally the study followed a cross-sectional design model. Quantitative and qualitative data were collected from different stakeholders. To help answer the major research questions, data were collected at selected points of the evaluation with particular attention on the following process indicators partially adapted from Bloem et al.20.

Resources used in the programme

- Human resources: number of people employed; - Implementations (nurses, health assistant, sanitarians, etc); - Procurement and logistics of VAC delivery system: (provision and distribution plan of

Vitamin A Capsules; - Planned and actual frequency of distribution of supplements per ecological zone; - Target groups for supplementation.

Training workshops/sessions

- Types of training provided; - Number of training programmes; - Participants (types and level, numbers); - Formative research report and number of meetings; - Pre-testing report and number of meetings.

Time allocation or schedule (Time allocated as opposed to time required)

Maternal

- Knowledge of Vitamin A supplementation programme;


- Knowledge of the consequence of VAD; - Percentage participating in vitamin A supplementation programmes; - Willingness to purchase vitamin A supplements/fortified food; - Information on VAS of their children.

In addition, information was sought on mothers reporting that one of their children had received vitamin A supplements (to be compared with the initial objective or goal defined by the programme so as to know whether the programme has reached the target or group).

Micro environmental factors affecting the programme

- Communication system; - Corruption on the programme implementation; - Attitude of the VAC suppliers (supplying on time); - Other organisational issues; - Civil-educational status of beneficiaries, etc.

Macro-environmental factors affecting the programme

- Economic (crisis during the implementation); - Socio-cultural (attitudes towards the programme); - Demographic: migration, increase in population; - Physical factors (drought, flood, etc.).

Data collection

The extraction of data from the study population made use of the following instruments: questionnaires, interviews, focus group discussions and observations as well as documents obtained from different sources.

Type of data collected

The data was collected from different secondary and primary sources. A trained team of mid-level professionals and graduate students was recruited to collect the data under the supervision of the panel members. The secondary data (resources used in the programme, training workshop, time schedule etc.) as well as published documentation (print and electronic) was obtained from the following sources:

i. The Ministry of Public Health and collaborating NGOs

ii. United Nations Agencies (World Bank, WHO, UNICEF, etc.)

Relevant documents available at each of these sources were identified, listed and exploited to obtain relevant information. The primary data was collected from multiple sources including the stakeholders, main actors and beneficiaries. A structured, pretested and validated questionnaire jointly developed by researchers, was administrated to representative samples of the target group.


Sampling design

Criteria of choice of data collecting sites

At the national level, the persons to be interviewed came from the central services of the Ministry of Public Health, partners of the United Nations system and the civil society.

In selecting the study location, a stratified random sampling procedure was adopted. Regions for the study were randomly selected, taking into considerations factors such as the principal language of communication (French or English), ecology of the area (Sahel, Western Plateau, and Forest), urban centres and epidemiological data. In this respect, the Far North, North West and South Regions as well as two urban settings (Douala in the Littoral Region and Yaoundé in the Centre Region) were selected.

In each region and urban milieu, the choice of health district was based on information on the vitamin A supplementation coverage rate. Thus in each Region/Town, two health Districts (one documented as a high coverage rate - superior or equal to 80% and a second with a low coverage rate - inferior to 50 %°) were selected. Based on the same logic, two health areas (one with a high VAS rate and the second with a low VAS rate) were chosen in each health district. In each health area, 50 to 60 consenting mothers with children aged between 6 and 59 months were equally randomly selected for the administration of the questionnaires.

Selected health personnel in the chosen areas of the study were interviewed or invited to take part in group discussions as the case may be. Personnel were interviewed at the National, Regional and District levels.

Development of the data collection instrument

Observation check list;

Interviews guides for the National, Regional and District levels;

Focused group discussions at the District levels;

Questionnaire for the target group.

Observational Checklist : A check list was developed and used by the field staff for recording specific observations concerning timing, availability of materials and personnel and the administration of Vitamin A to children.

Interviews : Guidelines were developed and revised by the research team for in depth interviews of selected principal officers concerned with the VAS at the National, Regional and District levels as well as with those working with NGOs concerned with VAS (such as UNICEF and HKI). To facilitate the meetings for the interviews, the Cameroon Academy of Sciences provided the research teams with letters of introduction explaining the objective of the study. Information collected from the interview was recorded on specific forms designed for the purposes of the interviews. In all, a total of 20 interviews were conducted at the National, Regional and District levels.


For the different interviews, identified officials were contacted and the interview arranged at their convenience. This process was however, not without difficulties because in some cases it was never possible to contact the identified individuals either because they were not in the country at the time of the study or they were just too 'occupied' to attend to the request of the interviewers. The Interviews at the national level (in Yaoundé) were conducted by one of the main researchers in the group while those at the Regional and District levels were conducted by personnel recruited and trained for the purpose of data collection in the study.

Given the importance for quality assurance in data collection, field staffs were trained for three days on the collection of information from respondents during the interviews, group discussions as well as during the administration of the questionnaire to volunteers of the target populations. In addition, field staffs were supervised through visits on the field and also through the use of telephone calls.

Focus group discussions

Focus group discussions and observations were carried out with selected groups and individuals at the District level of implementation of the VAS programme. In this respect, an average of 10 members of the district health team including the head of the district health service, nurses, nutritionists and other health personnel were invited to a discussion lasting not more than one hour. The discussion was centred on their general appraisal of the VAS programme with emphasis on logistics, the actual execution of VAS, the results so far obtained and the problems encountered.

Questionnaire

The questionnaire developed for administration to the target group was tested at three levels before being used for the survey. First, it was verified in a closed meeting involving all members of the research team. During this meeting, corrections and adjustments were made in the use of unfamiliar words, wrong formulation of questions as well as the clarity of certain statements. Since the original questionnaire was in English, a close attention was also paid to the correctness of the translated French version. After this the questionnaire was presented to a trained team of thirty field workers made up of mostly postgraduate students recruited to administer the questionnaire to selected members of the target group in the different health districts randomly chosen for the study. The members of the team were asked to carefully read through the questionnaire and point out any issues of misconception and wording for further corrections. The questionnaire was then pretested using a group of randomly selected women attending a post natal clinic. The objective here was to identify and correct any problems that could arise due to wrong formulation of questions during the survey. The questionnaire administered sought among other things for general information on the respondents, their knowledge of VAD and VAS as well as their participation in VAS.

Recruitment of field workers

As part of the strategy to guarantee the quality of the data to be collected, field investigators recruited for the study were made up of young experienced university graduates with Master’s degree


qualifications in such diverse areas as applied nutrition, sociology, psychology and economics. In addition, candidates for recruitment had to show proof of good knowledge of the common language and basic culture of the local community in which he/she was going to work. Acquaintance with the administrative set up of the region was an added advantage.

Authorisation to carry out the study was sought and obtained from the Ministry of Public Health by the Cameroon Academy of Sciences.

Scope and limitation of the study

The study was carried out in three regions and two urban centres of the country randomly selected in the background of existing information on VAS and other nutrition programmes.

Limitations of the study bordered around the accuracy of the information gathered, the subjectivity of field works and interviewers and the varying degrees of accuracy of documented information consulted. The absence and/or unwillingness of some resource persons to release information and documentation were handicaps in the attainment of the objectives of the study. In addition, the high dependence on the target group accounts of the vitamin A supplementation status of their children as well as the lack of properly kept records along the health chain were also limiting factors for the evaluation exercise.

Quality assurance of data collection

Mid-level professionals as well as graduate students were recruited and trained for the collection of data at the different levels provided for in the design of the study. During the data collection phase, they were closely supervised in person and by telephone calls on a daily basis by designated members of the study panel.

Collation and analysis of information

Information obtained from interviews and group discussions was assembled in a given format for eventual exploitation by members of the research team. Following the administration of the survey questionnaires in the different selected health districts, the questionnaires were assembled in a given order in one place and examined for any errors of wrong or incomplete recording of the reports etc. Questionnaires that were grossly lacking in content of information due to negligence or other reasons were excluded from the lot. The questions were then coded, entered into an Excel Data base. The data so entered was double-checked for entry errors and transcribed into an SPSS data file for further checks through the use of range and internal consistency analysis before proceeding to statistical analysis. Graphical representation of information was made using Excel 2013 and Sigma plot softwares.


Results and Discussions

Initial programme design

The efficient execution of a programme such as VAS is highly dependent on its design. The design should take into consideration important items such as funding, logistics, communication strategies, the quality and numbers of personnel needed at different levels for the execution of the programme, capacity building in the course of the training, estimating and purchase of vitamin A capsules, VAC distribution process and mechanisms along the health chain right up to health centres and distribution of same to the target populations and monitoring and evaluation.

No information was available during the study on the initial design of the VAS programme implementation. This means that there was no clear logical framework (exhibiting inputs, activities, output and the outcome to be used as a basis as normally required) for monitoring eventual progress. There was however, a policy on VAS but which was not widely understood and followed by health workers involved with VAS.

The absence of such an initial programme design and its effect on implementation was evidenced by the catalogue of problems reported during a training workshop following the introduction of the VAS programme in the late nineties. The problems presented during the first ever workshop on VAS in Obala in 1998 included the following:

Lack of records on the actual distribution of Vitamin A;

Inadequate mastery of the protocol for VA administration by field staff;

Poor monitoring of the vitamin A distribution at the different levels of the health chain;

Poor understanding of the techniques of dividing 200,000IU capsules for children under

The age of 12 months;

Poor handling of logistics leading to delays in the transport and delivery of VAC

Consignments with the consequence that some VAC reached their destinations after

The expiry dates;

Reports of use of mega doses of Vitamin A as ordinary supplements;

Poor record keeping of VAS exercise in the Far North and North West Provinces;

Lack of knowledge on the importance of vitamin A in child health;

The sale of VAC meant for supplementation as medicine.

These problems reflect the initial lack of information and projections on the required inputs (in terms of logistics, funding, manpower needs for the programmes, human resources for the implementation,


equipment to be used by the staff in charge of the supplementation, etc) or the activities to be carried out (in terms of capacity building, monitoring of Programme, supplementation process, etc.).

Stakeholders in VAS programme

Information gathered from secondary sources, interviews and group discussions revealed the presence of a number of international organizations and donors involved in the running of the vitamin A supplementation Programme whose major objective is to contribute to the reduction of infant mortality by attaining a uniform VAS rate of 80% of children aged between 6 and 59 months. Other essential and critical contributory programmes in this direction include, immunization and deworming campaigns as well as the distribution of mosquito nets.

The programme receives technical, financial and logistic assistance and cooperation from organizations such as HKI, USAID, UNICEF, World Bank, etc. Government funding of VAS is indirect and limited and takes care of the salaries of the health workers, coordination and supervision of public health programmes, organization of meetings and some workshops as well as the facilitation of the integration of VAS into other public health programmes. The following are some of the specific roles of the donor organizations:

Helen Keller International (HKI) : Between 2003 and 2007, HKI worked in collaboration with other international partners to assist government to couple the VAS programme with public health programmes like local immunization days and routine immunization activities. HKI equally helps to include VAS as an activity during the biannual organization of the National Maternal and Child Health and Nutrition Action Weeks (MCHNAW). HKI assists the government and various communities in different aspects of VAS including the supply of some materials, training and capacity building.

United States Agency for International Development (USAID) : The USAID is the principal financial sponsor of the vitamin A supplementation programme.

United Nations International Children Emergency Fund (UNICEF) : It is the first international organization championing and facilitating VAS programmes. UNICEF has and is playing a leading role in the acquisition and distribution of VAC throughout the country.

World Health Organisation (WHO) : It is the principal partner concerned with the integration of VAS in public health programmes.

Canadian International Development Agency (CIDA)1: It also a provided funds for the procurement of vitamin A capsules for VAS.

1CIDA which was created in 1968 administered Canadian foreign aid programmes in developing countries. In March 2013, it was merged into the Department of Foreign Affairs which then became the Department of Foreign Affairs, Trade and Development.


As far back as the late 1990s, these organizations worked together to link VAS to public health vaccination programmes. The first consignment of VAC to Cameroon was supplied by UNICEF.

Ministry of Public Health : The running of the VAS programme is done through a cascade system involving five levels of organisation: The Ministry (National), regional, divisional, district and community health Centre levels. Each level is involved in the management of public health programmes as directed by the Minister.

The Table below summarises the expected responsibility of partners involved in the VAS programme

Table 2 . Summary of the roles of partners and government in the execution of VAS programme Partner Responsibilities

CIDA/UNICEF Purchase and supply of VAC. Technical assistance

USAID,WHO Provisions of funds, materials and technical support for the execution of the VAS programme

HKI,UNICEF, CIDA

Assistance in the planning and execution of VAS activities; Provision of funds; Lobbying at all levels for the cause of the programme; Conception of messages for communication of public health programmes; Training and supervision of health personnel; Capacity building of personnel; Facilitating the integration of VAS in other public health programmes.

Government (Ministry of

Public Health)

Submission of projects for funding by international organisations; Evaluation and submission of the needs for Vitamin A capsules and other materials for the VAS programme;

Training and payment of health personnel; Coordination of public health activities; Provision of funds for the different activities of the Ministry; Facilitation

of the integration of VAS into other Public Health programmes, etc.

Divisional and District Health

Centres

Education of target groups; Reception and distribution of Vitamin A Capsules; Monitoring of health activities; Compilation and analysis of health data; Administration of vitamin A.

Community Health Workers

Distribution of Vitamin A alongside other health materials; Monitoring health activities at the base;

Collection of information for the Health Centres etc.


Inputs

The findings concerning inputs into the programme concerned the following:

Personnel

Most of the personnel involved in the VAS programme at the different levels of the health system are employees of the Ministry of Public Health originally trained for services other than the implementation of the VAS programme. As a consequence, these needed to be regularly retrained to build up their capacity. Information from group discussions at the Regional, Divisional and District levels revealed that these health workers are not sufficient in quantity and quality and many complain of low salaries.

There is a growing tendency for the trained nurses and midwifes to abandon their government paid jobs and go in search for greener pastures abroad or in the private sector. This trend was reported to be having an effect on the implementation of VAS and other health programmes in some health areas of the Far North and South Regions.

Funding

Adequate funding is a very important input for the successful execution of any public health programme. It was observed that Government funding of VAS was indirect and limited and takes care only of the normal salaries of personnel as well as some needs for transportation and contribution to the running of health campaigns. In relative terms, the overall effort of government in this respect was found to be relatively low compared with the role of donor organisations such as HKI, UNICEF and WHO, whose support has been very critical for the current level of the activities of the VAS programme. UNICEF for example has been and is involved with the purchase and transport of VAC to the regions for distribution. The number and cost of vitamin A capsules sponsored by CIDA through UNICEF over the last four years are shown in Table 3.

Table 3 : Acquisition of Vitamin A Capsules over the last five years

Year POPULATION COST OF CAPSULES (USD)

Target Population 6–11months 12-59 months 100,000 200,000

2010 3238183 371921 2833410 6250 123880

2011 3238183 412037 2826146 6922 123559

2012 3463060 476537 3312491 8006 144822

2013 3673244 397033 3216317 6670 140617

2014 3975409 481430 3256521 8088 142375


In addition to the above, UNICEF as well as the other international donors contributed to the cost of logistics for VAS and health campaign programmes in the country including the supervision, production and distribution of communication materials as well as the training of the personnel.

In order to realize an appropriate funding budget for the VAS programme, cost analysis should take into consideration expenditures linked to such specific aspects of the programme like the purchase and delivery of vitamin A capsules, transportation, training, vehicle maintenance, communication, interpersonal and social mobilisation costs as well as expenditures related to personnel and other capital expenditure.

A consideration of the different elements of costing listed above show that the VAS programme in Cameroon is heavily dependent on the goodwill and collaboration of donor organisations. Government would need to revisit its funding policy in this programme so as to avoid the recurrent incidences of shortages of vitamin A capsules in health centres, inadequate personnel and means of mobility as was revealed during interviews and group discussions with health personnel in most of the areas covered by the present study.

Acquisition and transport of materials for VAS

The needs for the vitamin A capsules for distribution is calculated using census figures as shown in the Table below.

Table 4. Calculation of needs for vitamin A capsules Target groups % Population containing target group

Children aged 6-11 months 2% Children aged 11-59 months 14% Children aged 0-59 months 18 % Pregnant women 5% Lactating women 4% Women of Child bearing age 23%

Thus vitamin A capsules needs for children aged 6-11 months are calculated on the basis of 2% of the census figures for this group while the needs for children aged 11-59 months are estimated on the basis of a 14% of the target group.

Orders and supplies made using information from this formula on time would normally reduce or completely eradicate the frequent cases of shortages in quality and quantity of capsules reported in most health centres involved in the study. These shortages in stock may be due to several reasons including, wrong specification of the type and quantity of capsules required at the time of requesting for capsules from the donor organisation, wrong calculation of quantities for distribution through the Regions and the Divisions to the Health Centres, lack of stock management knowledge on the part of the heads of the health centres or indiscriminate supplementation of children at any given opportunity without keeping any individual records on the frequency of supplementation.


Besides vitamin A capsules, one of the important materials needed for the execution of VAS is the scissors for cutting the capsules.

There is an urgent need to review the logistic plans and the use and management of materials for the VAS.

Transportation

Materials for use in the VAS programme are systematically transported to the Regions alongside vaccines by UNICEF with some assistance from the government. These are subsequently redistributed to the Divisions and then to the Districts. Although the strategy of using trained community volunteers (such as in the projects manned by HKI) has been observed to improve on the coverage rate of VAS in some areas, there were complaints of lack of transportation in some health districts. This has an effect on the coverage rates in these areas. In fact, these complaints were mostly in areas recorded as ‘low coverage’ areas of the North West and South Regions.

The genesis of the short comings associated with the acquisition, management and use of materials in the VAS programme needs to be addressed and corrected to ensure a better execution of the programme. Analysis of this information will provide managers with specifications that can be taken to reduce programme vulnerability. These may include advocacy to strengthen government support, capacity-building to increase district efficiency, logistics management systems to improve vitamin A capsule availability and timely distribution, or addressing the specific concerns of districts with high coverage variability.

Activities

VAS is a low-cost high-impact strategy for improving the vitamin A status of children4..WHO and UNICEF recommend VAS of children in areas where infant mortality rates are greater than 70 per 1000. This rate stands at 132 per 1000 in Cameroon as revealed by the demographic health survey of 20118. UNICEF recommends that for substantial reductions to occur in the mortality rates due to VAD in a country, vitamin A supplementation must attend a minimum coverage level of 70%.

In this respect, a number of key activities must be properly planned and implemented so as to ensure a high supplementation coverage. Evidence from studies elsewhere point to ineffective communication for and information of parents as one of the main reasons for low VAS coverage.

Communication activities including advocacy and social mobilization are important strategies to improve coverage in health programmes, including VAS programme24, 25. Lack of information may prevent people from asking for and receiving interventions27. Effective use of communication strategies will help in raising awareness, creating and sustaining demand and encouraging acceptance of health interventions24. It can educate caregivers and decision makers about key behaviours. It can also motivate caregivers, health providers and decision makers to change or follow certain practices or policies and finally, it can inform the client population about where and when a service is available26.


Based on the above, the following challenging factors which must form the subject of the activities of the VAS programmewere evaluated:

i) Parental knowledge of the importance of vitamin A and VAD;

ii) Parental awareness of VAS;

iii) Health workers competence and knowledge on VAS.

In addition to the above, the availability in quantity and quality of VAC to needy populations was equally evaluated as an important activity for the VAS programme.

Knowledge of the importance of vitamin A and VAD

One of the factors that can spur a parent to take his children for VAS can be his knowledge of VAD. Knowledge and awareness of VAD as a health problem in children under the age of five was evaluated through an open ended as well as a closed question administered to the parents in the study group.

On the average, only a little less than one in four (23.3%) parents were knowledgeable of VAD as a possible health problem in their children. Of these, the lowest numbers (9.9%) were from the Far North Region while the highest (43.3%) were from the North West Region (Fig.4).

Figure 4. Variation in the population of parents knowledgeable of VAD

Of interest was the pattern of variation in the numbers of those knowledgeable on VAD with level of Education. In this respect, those with knowledge on symptoms of VAD tended to increase with increase in level of Education. Of the 225 parents with knowledge of VAD, 8.4% had no formal education, 15% had been to primary School, 31% to Secondary School and 47.8% to a tertiary school. On a global basis, parents with a primary School background were about six times (30.2% vs. 4.0%)


more likely to identify a vitamin A deficiency symptom than those who never went to school (Table 5).From a regional perspective, the percentage of parents with knowledge VAD varied significantly from one region to the other. The lowest (9.9 %) population was in the Far North Region while the highest (43.3%) was in the North West Region. The figures for the other locations were South: 12.6%, Yaoundé: 10.2% and Douala 24.0%. Within each Region/city, the proportion of parents with knowledge of VAD equally varied with the level of education (Figure 5).

Table 5. Percentage variation in numbers of parents with knowledge of VAD according to level of Education

Characteristic Level of education Total Non formal Primary Secondary Tertiary

VAD knowledge

Count 9 68 126 22 225

% Within VAD 4 30.2 56.0 9.8 100

% Within level of Education 8.4 15.0 31.0 47.8 22.3

No VAD knowledge

Count 98 384 280 24 786

% Within VAD 12.5 48.9 35.6 3.1 100

% Within level of Education 91.6 85.0 69.0 46 77.7

Observed differences in the variation of VAD in the different areas (ecological and urban) of Cameroon reflect apparent differences in nutritional habits10. It was reported that 40% of children less than 5 years had VAD while as many as 23% of them died as a result of VAD. That survey also revealed the Far North as the Region with the highest prevalence rate (62.5%) of VAD in children aged below 5 years.

In view of these finding, any strategy and activity aimed at improving the level of VAD knowledge of parents must take into consideration this factor of education. In fact one of the factors that can spur a parent to take his/her children for VAS is his knowledge of the consequences of VAD. When further asked to indicate the most important consequence of VAD on their child, 40% of that population associated VAD with poor growth, 31.1% with frequent illness (reduced immunity), 17.3% with poor vision and 11.6% with loss of appetite (Fig. 6).

Given that one of the main reasons for VAS is to improve on the vitamin A status of deficient children so as to enhance their resistance to diseases (and reduce child mortality), only about one out of every three parents (31%) who associated VAD in children with frequent illness can be said to be knowledgeable on the main objective of VAS programmes.

From a regional perspective, parents of children in the North West Region were most knowledgeable (71.4%) about the main reason for VAS i.e. to enhance resistance to disease, thereby reducing the “frequency of illness”. Following the North West from a distance was Centre (Yaoundé) with 12.9%, South Region (8.6%), Douala (4.3%) and lastly Far North (2.9%.)


Coincidentally, the Far North Region of the country reported to have the highest prevalence rates of VAD in Cameroon10 was also found to have the least number of parents (2.9%) with knowledge of VAD symptom – frequent illness which is an indication of low immunity (Figure 7.)

Figure 5. Percentage distribution of Parents with knowledge of VAD by Region and by Level of Education

Figure 6. Percentage distribution of parents according to their knowledge of the effect of VAD


Figure 7. Percentage distribution of parents according to their knowledge of symptoms of VAD and by Region

Information and awareness of VAS

Knowledge of VAS programme is an important determinant of its level of coverage. A strong positive correlation between information received by mothers/caregivers on VAS and supplementation coverage among children 6–59 months old has been reported28. Current strategies for the improvement of the awareness of VAS alongside other health programmes was found to include advocacy,interpersonal communication (IPC) involving mostly trained health workers, social mobilisation (SoM) involving community networks, civic, social and religious groups, and use of media (radio and television) at different levels of the health chain (Table6 ).

Table 6: Communication activities during health campaigns Level Role

Region

Sending request and information letters off to the administrations involved

Organizing a press conference

Circulating the communiqué and interventions on TV and radio

Capacity building of the HD team

Production of communication material

Monitoring and evaluation of communication and social mobilization activities (external monitoring).

District

Preparing letters of information for traditional, religious, political leaders and other associations

Distribution of communication materials to the health areas

Capacity building of the health area team

Interpersonal communication

Monitoring and evaluation of communication and social mobilization activities


Health Area

Sending letters of information to traditional, religious, political leaders and other associations

Distribution of communication materials to the population

Capacity building of social mobilizers

Diffusion of information in gatherings like markets, churches/mosques

Interpersonal communication

Monitoring and evaluation of communication and social mobilization activities

In order to determine the relative efficiency of these channels, parents of children who had received at least one dose of vitamin A supplementationwere asked to indicate the main source from which they learned about the programme. A significant association was found to exist between thenumber of children receiving vitamin A and their parents’ source of information on VAS. In this respect, the relatively most effective channel of communication was found to be that through interpersonal communication (IPC)- 54.7%.This was followed in decreasing order by social mobilisation (SoM)- 15.9%, the radio (15.2%) and TV (14%) (Table 7).

Within the different regions, noticeable variations also existed in the effectiveness of the information sources – in terms of percentage of respondents informed on VAS (Figure 8).

Table 7. Level of participation and non-participation in VAS programme as a function of the source of information on VAS

Status Count &% Source of Information Total Radio TV SoM IPC

Supplemented

Count 135 125 141 485 886

% of group 15.2% 14.1% 15.9% 54.7% 100.0%

% Within Info. Source 75.8% 85.0% 70.1% 100.0% 87.6%

% Total 13.4% 12.4% 13.9% 48.0% 87.6%

Not Supplemented

Count 43 22 60 0 125

% of group 34.4% 17.6% 48.0% 0.0% 10%


% Total 4.3% 2.2% 5.9% 0.0% 12.4%

TOTAL

Count 178 147 201 485 1011

% of group 17.6% 14.5% 19.9% 48.0% 100.0%


% Total 17.6% 14.5% 19.9% 48.0% 100.0%


Table 8. Variation in the percentage of children receiving vitamin A in each Region as a functionof the source of information on VAS received by the parents

Region Source of Information (%) Radio TV SoM IPC

Far North 31.5 6.6 34.8 27.1

North West 7.1 2.7 6.2 83.9

Douala (Littoral) 18.6 26.8 12.0 42.6

Yaoundé (Centre) 14.0 39.5 5.3 41.2

South 6.5 7.1 19.6 66.8

In the Far North Region, SoM was found to be the most effective (34.8%) medium followed by radio (31.5%), IPC (27.1%) and lastly TV (6.6%). In the North West Region, the patern in decreasing order was as follows : IPC(83.9%), Radio (7.1%), Som (6.2%) and TV(2.7%). In the urban area of Douala, the order of effectiveness was IPC (42.6%), television (26.8%), radio (18.6%) and SoM (12.0%). In Yaoundé (Central Region), the effectiveness of communication in decreasing order was IPC (41.2%), TV(39.5%), radio (14.0%) and SoM (5.3%). In the South Region the order was different and varied as follows : ICP(66.8%), SoM (19.6%), radio (6.5%) and TV(7.1%).

These findings provide evidencesfor the fact that the rule of ‘one size fits all’ cannot be applied in communication strategies aimed at raising the awarenes, interest and participationof the populations in Regions of the country. Because of certain intrinsic factors, the effectiveness of the medium of communication tends to vary with locality.

In order to achieve a measurable impact on child survival at the population level, countries tend to set an objective to reach at least 80% VAS coverage rate. Based on this projection, an analysis of the relative effect of information channel of the target group was carried out using the pareto diagram (Figure 8).


Figure 8. Pareto diagram presentation of the effectiveness of different modes of communication in the different Regions/Cities

The effectiveness of social mobilization (SoM) as a channel of communication was most evident in the Far North Region. Coupled with the radio, these two media can be effectively used within the region to reach over 80% of the populations. The relative effectiveness of SoM is to be expected as several NGOs have been involved in social mobilisation work on public health programmes in this Region and as such have served to create a reasonable awareness of the population on VAS. SoM often involves roles played by community and religious leaders who influence the awareness of the members of the community during and even long after health campaigns. On the other hand, the radio is a common household equipment in most of the Far North and it is widely used for sociocultural and religious communication. Given its added advantages of transmitting information wide and fast, it should be fully exploited within the Region as a communication tool alongside SoM in VAS and other public health programmes. Not only are they cheaper and more readily available in rural areas, their use can also be adapted to suit local needs in terms of language, culture and other values.

IPC channels involving health workers, school teachers and trained community health workers has the property of providing information in a more persuasive and credible manner with a resultant positive effect on the change in attitudes and knowledge of the target group. This medium of communication was found to be most effective in the North West and South Regions. It was found to have reached more than 80% of the parents whose children had received vitamin A supplementation.

In Yaoundé and Douala, television was found to be the next most effective medium of communication after ICP. Televisions have ‘invaded’ almost all houses in these cities since its conception in the mid 80’s. TV is watched mostly in the evening and as such can serve as an indispensable and effective means of communication. Communication of information on VAS programmes within this milieu, should as a matter of preference, use this medium so as to reach the highest number of people in a shorter time.


The selective choice and use of a communication medium within a given locality will allow for better planning for efficiency with respect to cost and output.

Capacity building

Capacity building occupies a critical role in the successful implementation of public health programmes. Secondary data and discussions with health officials indicate that the introduction of VAS in the Cameroon public health sector faced many problems related to the lack of the training of these actors. This led to the organization of the first ever National training workshop on Vitamin A in Obala from the 26 to the 27 of February 1998. Participants at this workshop included the Regional Delegates of Health, the Divisional, District and Health Centre heads. Subsequently, other training workshops were to be conducted through a cascade system at the Regional, District levels and Health Area levels. This method of training has become common practice in the Ministry of Public Health. The following were the main subjects covered at that first workshop:

The importance of vitamin A in relationship to infant morbidity and mortality;

Physiopathology of vitamin A deficiency;

Epidemiology of vitamin A deficiency;

Government strategy for combating vitamin A deficiency;

Protocol for the administration of vitamin A capsules;

Review of the vitamin A stock in each health sector ;

Monitoring and evaluation of the use of vitamin A capsules.

Following the integration of vitamin A supplementation into other public health programmes, training workshops/meetings for the field workers have been based on a training module developed in the Ministry of Public Health and used in the cascade training process up to the level of the community.

The incorporation of VAS into other public health programmes would require that the grouped training periods be longer. Unfortunately, this has not always been taken into consideration. Most often than not, these preparatory training programmes are organised prior to a planned public health intervention among the population.

The cascade system of training starting from the National level through the Regions to the Districts tends to be accompanied by a watering down or distortion and dilution of information and instructions as the training process progresses towards the target groups. This is evidenced by the following revelations obtained during the different processes (checklist observations, interviews etc.) of data collection in this study:

Non washing of hands before the start of vitamin A supplementation;

Inadequate knowledge of the appropriate number of doses per age group, hence evidence of multiple supplementation of the same child in a relatively short period of time;


Consideration of mega doses of Vitamin A capsules as ordinary vitamin and hence encouraging relatives to take them on a daily basis;

Lack of attention on expiry date of vitamin A capsules destined for supplementation;

Poor management of vitamin A stock. More than 80% of Health Districts and/or Health Centres reported cases of lack of vitamin A capsules for supplementation. In this respect, the blue coloured capsules were the most cited as lacking. The formula for calculating the need for this type of capsules needs to be revised as one of the steps to resolve this common problem;

In addition, there was evidence of disproportionate distribution of VACs to Districts and Health Areas thus contributing to declared shortage in the process of VAS;

Centres involved in study reported having experienced frequent reports of lack of Vitamin A capsules especially those meant for 6-59 months old children;

Use of teeth instead of scissors to cut vitamin capsules;

Poor transmission of knowledge to parents on the importance of vitamin A supplementation to children.

Output

Of the 1011 parents who were interviewed, the children of 886 (87.6%) of them had received vitamin A supplements during the six months preceding the study. Analysis of the level of supplementation by Region shows a coverage level of 90% for the Far North Region, 94.9% for the North West, 91% for Douala, 91.2% for Yaoundé and 74.2% for the South. No significant differences were observed in the supplementation coverage rates according to the documented ‘high’ and ‘low’ coverage areas except in the case of Yaoundé, Douala and the South Region (Figure 9).

Figure 9 : VAS coverage rates in ‘High’ and ‘Low’ coverage areas


Table 9 : Cumulative relative average frequency of VAS by age and by region Age Group (months)

Region Far North North West South Centre (Yaoundé) Littoral (Douala)

6 - 11 156 172 112 132 131

12 - 23 65 98 65 58 77

24 - 35 74 73 72 57 69

36 - 47 64 59 68 56 56

48 - 59 44 56 67 49 46

Based on the protocol for VAS to children, the cumulative frequency of supplementation of vitamin A with age was calculated for each age group and used as the denominator for the eventual calculation of the relative frequency of VAS per age group.

Irrespective of the region, it was observed that children within the first 6-9 months of age were found to have systematically received more than the stipulated number of vitamin A supplements. The relative frequency rates ranged from 112% for children in the South Region to 172% for children in the North West Region. The reasons for this trend of VAS may be explained by several reasons including, the supplementation of children when they are sick or whenever they come for vaccination and the poor keeping and use of VAS records to track children supplementation frequency. The relatively high frequency of VAS during the first six to nine months of life of the children coincides with the period when the parents come regularly for the statutory vaccination of their children.

Irrespective of the Region, the cumulative relative VAS frequency rate was found to fall with increase in age and to follow an inverse polynomial trend. A plot of the overall relative frequency of VAS against age (Figure 10) shows a ‘dropout syndrome’ in the VAS programme as the children grow older. The critical point at which this dropout syndrome starts is graphically shown in Figure 10 to start from about the age of nine and a half months (0.785yrs).

Figure 10 : Cumulative relative VAS frequency rate for 0.5-5 year olds


Except in the case of North West and South Regions where cumulative VAS frequency rates had dropped to 56% and 67% respectively, the rates in all the other provinces were below 50% i.e. children in the age range of 48 and 59 months had received less than 5 doses of vitamin A supplementation.

A juxtapositioning of this trend against documented trends of prevalence of diarrhoea and stunting for the under-5 year olds reveals an interesting comparative trend (Figure 11). The decreasing relative VAS frequency rate with age is accompanied by an increasing prevalence in diarrhoea. The same is true for stunting with age. This is to be expected as VAS has been reported to be essential for growth and the combat of illnesses such as diarrhoea in children.4

Figure 11 : Cumulative relative VAS frequency rate juxtaposed with prevalence of stunting and diarrhoea in less than five years old Children

The observation of this relationship which can be rightly classified as expected, however, puts to question the use of coverage rate information in VAS programmes. More often than not the VAS coverage rates do not take into consideration the ages of the children supplemented. This situation is compounded by the poor record keeping practices of health workers concerned with VAS programme. There is a need to address this situation.

There is a paradox in that there are high VAS coverage rates following health campaigns and at the same time there are reports of high VAD prevalence. Although some progress has been made in improving the VAS coverage rates in Cameroon over the years, this has not been accompanied by a commensurate drop in mortality rates of children. As a consequence, the prevalence of VAD is still very high in the country. The observation of the ‘dropout syndrome’ may be one of the factors favouring the slow drop in VAD prevalence. As children withdraw from the VAS programme they inadvertently run out of their vitamin A stores and so run the risk of suffering from VAD diseases.


This is demonstrated by the inverse relationship between the pattern of the ‘drop out syndrome’ and that of the prevalence of diarrhoea or stunted growth.

Besides the ‘drop-out syndrome’, another novel finding from this study which seems to throw more light on the above paradox is the revelation from observations, interviews and discussions with members of the target groups of the practice of ‘sham vaccinations’ with the resultant effect that figures of levels of vaccination coverage, and by implication VAS coverage (when the two are programmed together) are sometimes inflated. This phenomenon is characterised by the practice of field workers recording homes as having been covered by the vaccination or VAS programme when they visit homes in the absence of the tenants. This practice has a direct effect on the actual coverage rates of VAS and hence VAD. Innovative strategies need to be taken to discourage this practice.

As can be seen in Figure 11, the curve depicting the dropout syndrome suggests the existence of two groups of target populations along the time axis – those with a relatively normal cumulative VAS frequency and those without. A discriminate analysis of factors specific to these two groups showed that the sex of the parent, the age of the child and the source of information on VAS are the major factors that permit the identification of these groups.

This ‘dropout syndrome’ in the rate of VAS in 6-59 month old children compels a total review of the strategy for VAS of children in this age group in Cameroon with a particular attention for those older than two years. On the other hand, the link between the ‘drop out syndrome’ and the prevalence of VAD will need to be examined.


Conclusions and recommendations

The adoption of the strategy of VAS of 6-59 months aged children in the late nineties has been fraught with several difficulties which include the lack of a careful and an appropriate design of the programme, inadequate material and qualified human resources, poor record keeping and management. Meanwhile the programme is progressively being integrated into other public health programmes.

1. As a result of the fact that Government funding of VAS is indirect and limited, the VAS programme depends largely on the financial and material support of donor organisations which is not sustainable. Actions to improve this situation will include:

Carrying out a cost analysis of the implementation of VAS, taking into consideration the changing roles of partner organisations;

Developing and sustaining relationships with international organizations participating in VAS to achieve the optimal VAS coverage;

Having the political will to commit important and sufficient resources (human, financial and material) at the national, regional and district levels for the achievement of the ultimate goals of reducing by half child morbidity and mortality by 2020.

2. The VAS programme started without an initial design which should normally have taken into consideration such important items like appropriate funding and logistics. In order to have a clear logical framework which should provide information for monitoring and evaluation, it is desirable that the VAS programme should be:

Designed in close consultation with all partners and taking into consideration the heterogeneous nature of the target groups in terms of culture, education and the communication media;

Result-oriented and evaluable;

Specific to the target groups so as to avoid the consequences of applying the “one size fits all” approach.

3. The study showed that the VAS was bedevilled with many capacity building and communication difficulties. Efforts to reduce these should be directed at:

Developing information sharing among the stakeholders through meetings, workshops and seminars;

Improving the communication gap between the target groups and various stakeholders involved in the VAS programme implementation through:

o Production and publication of posters adapted to each region or culture.

The use of region specific communication strategies;

Educating the target population about the danger of the VAD and on the VAS programme at different levels,(regions, Divisions, Sub-divisions and community);


Regular training and retraining of the stakeholders for a better understanding of the activity (i.e the supplementation process).

4. Consultations among all the VAS stakeholders must be carried out to come out with appropriate actions for solving the triple critical problems facing the VAS programme in Cameroon, namely: “the paradox of high coverage rate and VAD”, “the dropout syndrome” and “the sham vaccination”. The existence of the ‘dropout syndrome’ in the programme for VAS to 6-59 months old children compels a total and urgent review of the strategy especially as it concerns children aged between 9 and 59 months. On the other hand, the link between the ‘dropout syndrome’ and the prevalence of VAD will need to be closely examined. Equally needing close examination is the phenomenon of “sham vaccination”.


References

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7. WHO (2007). Vitamin and mineral information systems (VMIS). WHO Global Database on vitamin A deficiency – Cameroon.

9. Mwadime R.K.N. (2001).Health sector actions to improve nutrition: challenges and opportunities in sub-Saharan Africa. African Journal of food and Nutritional Sciences Vol. 1 (1).

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12. Tanya A.N.K., Lantum D.N. and Tanya V.N. (2011). Nutrition and health in Cameroon: Combating the crisis. Forum Summary. Cameroon Academy of Sciences, Yaoundé, Cameroon.

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Annexes

Questionnaires

OBSERVATION CHECK LIST DURING VAS SESSION

Health District/Centre……………………....................…………Date…………………………………

Duration of the operation of VAS session………………….........................................……………….

Number of children attended to ……...............................................................................………………

1 - What was the main activity during the VAS…………...............……………………………………

…………………………………………….................................……………………………………….

2 - Did health personnel come on time? Yes None

3 - Did they have all the required materials for VAS? Yes No If “No” please skip to question 9.

4 - What were the contents of material for VAS? (Please list them):……………………………… ……………………………………………………………………………………………………………………………………………………………....................................................................................…

5 - Were all the parents attending served? Yes No

6 - If “No” say why?

- Insufficient quantity of VA C

- Lack of personnel to attend to every body

- Lack of money to pay for VA

- Others (specify)…………………………………………............……………………………

7 - What was the length of each VAS? .............................................................................................

8 - Were the parents informed about the date for the next VAS activities? Yes No

9 - Additional notes or comments: ………………….............…………………………………………


CAMEROON ACADEMY OF SCIENCES

PROCESS EVALUATION OF VITAMIN A SUPPLEMENTATION IN CAMEROON

QUESTIONNAIRE FOR TARGET GROUP

We are evaluating the process of vitamin A supplementation based programme for the children aged between 6 and 59 months in Cameroon. The overall objective of this exercise is to improve on the supplementation process of Vitamin A. In this respect we shall be highly grateful if you will take off some of your precious time to answer the questions which follow.

We assure you that your answers will be treated as highly confidential and so feel free and express your view. Thanks for your cooperation.

Tick as appropriate

1. Gender? Male Female

2. What is your age?

a) Less than 25 years b) (25-40) years c) 40 and above

3. What is your highest level of formal education?

a) Primary b) Secondary c) Tertiary

4. What is your marital status?

a) Single b) Married c) Widow(er)

5.How many family members do you have?

a) Less than 2 members b) (2-5) Members c) More than 5 members

6. How many children aged between 6-60 months live with Vitamin A? _____________

7. Do you know what Vitamin A deficiency is? a) Yes b) No

8. How does it affect children? __________________________________________________

9. In your opinion, how serious do you regard Vitamin A deficiency in children.


The numbers in the following table reflect the degree of seriousness (on a scale of 1-5) of the VAS participant. Please circle the number which accurately reflects your opinion.

1 2 3 4

Not very seriously Not seriously seriously Very seriously

‘1’ represents the lowest level of seriousness

‘4’ represents the highest level of seriousness

10. How did you learn about the existence of the Vitamin A supplementation (VAS) programme?

a) On radio b) on TV c) Through a friend/Pastore) My Doctor/Nurse/Health Worker

f) Others sources. Please specify_____________________________________________________

11. Has any of your children received vitamin A supplementation in the clinic?

a) Yes b) No

12. If yes, how old is the child? ______________________________________________________

13. How many times has a child received VAC?

a) one b) two c) three d) four e) five f) six

14. Do you have a child less than 60 months old?

a) Yes b) No

15. How old is the child?

a) 6 months b) 1 year c) 2 years d) 3 years e) 4 years and above

16. How many times has the child received vitamin A supplementation since he was born? _______________________________________________________________________________

17. Why did you enter the VAS programme?___________________________________________

20. Have there been occasions when you forgot to take your child for VAS? ____________________ _______________________________________________________________________________

21. Have there been occasions when you went for VAS and there were no services available?______ _______________________________________________________________________________

22. What reasons were given for the non-availability of service? ____________________________


23. How often do you participate in the VAS in a year?

a) Once in a year b) Twice in a year c) every vaccination campaign

24. During each participation how many capsules of VA were given to you?

a) 1 capsule b) 2 capsules c) more than 2 capsules

26. Did you spend some time before being attended to? a) Yes b) No

27. Did you pay to receive the VA capsule? a) Yes b) No

28. If yes how much did you pay?____________________________________________________

29. After being attended to, were you informed of the next date for VAS ?

a) Yes b) No

30. Does your child receive VA each time you come for vaccination or weight?

a) Yes b) No

31. How satisfied were you about the VAS programme delivery?

The numbers of the following table reflect the degree of satisfaction or degree of agreement level (on a scale of 1-5) of the VAS participant. Please circle the number which accurately reflects your opinion.

1 2 3 4

Not very satisfied Not satisfied Satisfied Very satisfied

‘1’ represents the lowest level of satisfaction; ‘4’ represents the highest level of satisfaction

THANK YOU VERY MUCH FOR YOUR COOPERATION.


Biographical sketch of the authors

Carl Moses F. MBOFUNG is Professor of Food and Human Nutritional Biochemistry in the College of Technology of the University of Bamenda. He is also Registrar of the University. He is a graduate of the University of Ibadan, Nigeria where he obtained a B.Sc. Honours degree in Biochemistry before proceeding to carry out research for his PhD degree which he obtained in 1982 while serving in the same University as a Teaching Assistant. Before coming to the University of Bamenda, he was the Director of the Advance School of Agro-Industrial Sciences (ENSAI) of the University of Ngaoundéré. Cumulatively with the post of Director of ENSAI which he held for over 14 years, he was the Head of Department of Food Science and Nutrition in the same School (1993 – 2006). Other posts held while at the University of Ngaoundéré were: the Coordinator of the Training Programme in Dietetics and Quality Control (1987 – 1997), Chief of the Division for Teaching and Academic Affairs of the University of Ngaoundéré (1993 – 1999) and Director of Academic Affairs and Cooperation of the University of Ngaoundéré (January to October 1999). Before joining the teaching staff of ENSAI as Senior Lecturer in 1986, he had served in that same capacity in the Department of Biochemistry of the College of Medical Sciences of Bendel State University at Ekpoma, Nigeria (1982 – 1984) and in the Department of Biochemistry of Awolowo College of Health Sciences of Ogun State University, Nigeria (1984 – 1986). For many years, he was a visiting lecturer and also examiner in the Department of Biochemistry of the University of Yaoundé I. Both at ENSAI in the University of Ngaoundéré and the College of Technology in the University of Bamenda, he teaches Foods and Nutrition, Food Science and Quality Control, Food security, Nutrient bioavailability, Functional Foods and New Product development, experimental methods in food and human nutrition at the Engineering, Master and Doctorate levels. He is a Fellow of the Cameroon Academy of Sciences and member of the Cameroon Biosciences Society in which he has served for many years as Vice President. He is a member and President of the Cameroon Nutritional Society. From 1982 – 1986, he was the Assistant Secretary General of the Nigerian Nutrition Society, a post he held cumulatively with that of the Assistant Editor of the Nigerian Journal of Nutritional Sciences. He is author of several book chapters and more than 160 articles in peer-review journals. He obtained the Knighthood of the Cameroon Order of Valour in 2009.

Agatha K. N. TANYA is Associate Professor of Dietetics and Nutrition in the Department of Food Science and Nutrition, College of Technology, University of Bamenda, Cameroon. She attended Purdue University, Lafayette, Indiana, U.S.A, the University of Wisconsin – Stout, U.S.A. and the University of Ibadan, Nigeria where she obtained a B. S. in Dietetics, an M.S. in Food Science and Nutrition and a PhD in Human Nutrition respectively. Since 2005, Professor Tanya has been the Assistant General Coordinator of the cycle of Biomedical and Health Sciences in the Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1. She teaches Nutrition and Dietetics in the Departments of Public Health, Paediatrics and Internal Medicine of that Faculty. She came to the University of Yaoundé from the University of Ngaoundéré where she had taught courses on diet


therapy, menu planning, food Science, food and nutrition, food additives, development of new food products, food conservation and human nutrition at ENSAI, from 1984 to 2004. At Ngaoundéré, She was Head of the Dietetics Laboratory at ENSAI, Head of the Department of Food Technology and Quality Control at IUT and Head of the Special Control Unit at the Rectorate of the University. She moved to the University of Bamenda in 2011 as Vice Dean in the Faculty of Health Sciences. With a number of colleagues, they started the Faculty of Health Sciences of the new University. She later moved to the College of Technology as Deputy Director and Head of the Department of Food Science and Nutrition. She is a member of the American Dietetic Association, the Cameroon Biosciences Society, the Nigerian Nutrition Society and the Cameroon Science and Nutrition Society. She has had the MASHAV Award for the 4th International Course on Food Technology from the Hebrew University of Jerusalem, and the Commonwealth Fellowship at King’s College London, University of London, UK. She has published widely in the area of nutrition, food science and technology.

Daniel SIBETCHEU is a Public Health Nutritionist. He is presently the Executive Director of OFSAD and Sub Regional Coordinator for Central Africa of the International Union for Health Promotion and Education. He is holder of B.Sc. in Biology and Chemistry and M.Sc. in Biochemistry of the University of Yaoundé. He also has a post graduate diploma in Public Health Nutrition and an M.Sc. in Public Health from the Free University of Brussels, Belgium. He is presently a PhD candidate in Food Science and Nutrition at the Advance School of Agro-Industrial Sciences (ENSAI) of the University of Ngaoundéré. Throughout his career, he has had short term training in areas such as health promotion in Africa, nutritional surveillance, food science and applied nutrition, project Programming and planning for food Security in Central Africa, methodology and techniques for the elaboration of food security projects and nutrition and public health. He has had a very rich career with the Ministry of Public Health in Cameroon where he has been a technical staff at the Nutrition Service (1983 – 88), Head of Bureau for Nutritional Survey, Surveillance and Education (1988 – 1995), National Coordinator of Nutrition Education Pilot Project (PPEN) from 1991 to 1998, Head of Nutrition Unit (1995 -2003) and Director of Health Promotion from 2003 to 2010. Since he left the public service, he has been a health specialist for the Global Funds 9 Malaria Project at Plan Cameroon (2011 – 2013). He has also been involved in many activities dealing with communication for support to the priority health programmes, nutrition and food, health promotion, training of health personnel, advocacy for health issues, governance and resource mobilization for health actions. He shares his rich experiences by teaching in professional health schools and in the professional master programmes of the University of Ngaoundéré and the Catholic University of Central Africa. He is also a consultant for many NGOs (MC CCAM, CARE).

Ndam Mama is an applied economist. He is presently the Head of Department of Marketing at the Higher Institute of Commerce and Management (HICM) of the University of Bamenda where he is actively involved in teaching and research with particular focus in the area of Marketing and Statistics as applied to Consumer Behaviour, Marketing Research, International Trade and Finance Practice etc. Prior to this position, he was an Assistant Lecturer and then Senior Lecturer (1999-2013) in the University of Ngaoundéré where he taught Microeconomics, Import and Export Strategies, Financial Microeconomics, Economics of Microfinance in the Faculty of Economics and Management and also


Agro-Industrial Economics, Food Economics and Business Communication in the National School of Industrial Sciences (ENSAI) of the same University. Between 1989 and 1994 he occupied an international managerial position as the Financial Manager of the Alliance Française (a French Government Cooperation) in Nigeria. There after he served as a Consultant in Economics and Electoral matters for African Conscience organisation from 1995 to 1998. He attended the University of Yaoundé-Cameroon, the University of Maiduguri-Nigeria, the London School of Economics-UK and the University of Abuja-Nigeria where he obtained a B.Sc. in Economics (Industrial Economics), an M.Sc.in Economics (Applied Economics), and a Post Graduate Diploma in Microeconomics respectively. He is presently a PhD candidate. He has co-written two books and published many scientific articles and is an active member of the group, LAREGO (whose research focus is on the Management of Business Organisation) of the Faculty of Economics and Management of the University of Ngaoundéré.

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