LAUSR

Objectives High population coverage of fortified foods is needed for a fortification program to be impactful yet there is a dearth of data on the extent of consumption of foods targeted for fortification and foods in a fortifiable form (i.e., processed in an industry or value chain where fortification can occur). This is driven in part by a lack of tools to assess coverage. The objective of this work was to develop standardized indicators to assess coverage of fortified foods in population-based fortification programs. Methods A Fortification Assessment Coverage Toolkit (FACT) was developed to assess household coverage defined as: 1) consumption of a vehicle; 2) consumption of a fortifiable vehicle; and 3) consumption of a fortified vehicle. Validated risk factors associated with poor micronutrient intakes (e.g., poverty, rural residence, low dietary diversity) are also assessed to determine equity in coverage across vulnerable population subgroups. The FACT method was piloted in Ghana in 2013 then operationalized in 16 countries in 2014-2017. Results FACT results were found to be actionable and to drive programmatic and policy decisions. In Nigeria, results revealed universal coverage of fortifiable bouillon (>99%) indicating its potential as a fortification vehicle and were used to advocate for bouillon fortification in West Africa. In Pakistan, results revealed a large proportion of fortifiable wheat flour consumed was from small-scale chakki mills (32-60%), which resulted in a feasibility assessment of chakki mill fortification to understand the program's potential for impact. In Nigeria and Tanzania, large differences in coverage of fortifiable and fortified foods (8-17% for wheat flour, 3-34% for maize flour, 16-39% for oil and 11-33% for salt) revealed quality issues, which resulted in increased donor funding to improve quality and compliance. In 2018, coverage indicators were tested in PMA2020 surveys in Kenya and Burkina Faso to determine their potential in large surveys such as Demographic Health and Multiple Indicator Cluster Surveys. Conclusions FACT has filled a gap in standardized tools to assess fortification program coverage and generate data for decision-making. The integration of FACT indicators in recurring national surveys will allow for more comprehensive tracking of coverage over time. Funding Sources Bill & Melinda Gates Foundation and USAID.