Process evaluation of the Senegal-Community Nutrition

Project: an adequacy assessment of a large scale urban

project

Agnes Gartner, Bernard Maire, Yves Kameli, Pierre Traissac and Francis Delpeuch

Nutrition Unit, UR 106 (WHO Collaborating Centre for Nutrition), IRD (Institut de Recherche pour le Developpement), Montpellier,France

Summary objective Although essential for understanding the reasons for success or failure of large scale

nutritional interventions, process evaluation results are rarely reported. Our objective was to assess

whether the process output objectives of the Community Nutrition Project (CNP) in Senegal, West

Africa, were adequately met.

methods An adequacy assessment study based on monitoring data for individuals collected during the

CNP was used to assess ‘fidelity’, ‘extent’ and ‘reach’ of participants recruitment and of the services

provided. The CNP provided underweight or nutritionally at risk 6- to 35-month-old children in poor

districts with monthly growth monitoring and promotion and a weekly food supplementation for

6 month periods, provided that mothers attended weekly nutrition education sessions. An exhaustive

sample of the participating children (n ¼ 4084) in Diourbel was used for evaluation over the first

2 years.

results At recruitment, only 66% of children were underweight (vs. 90% expected) varying with the

CNP center and cohort, and the child’s sex and age. Attendance at growth monitoring reached expected

levels (93% vs. 90%) whereas numbers of food supplements distributed and education sessions attended

were lower than expected (45% vs. 90% and 62% vs. 80%, respectively). At the end of follow-up, 61%

of underweight children recovered vs. 80% expected.

conclusions Because of CNP design for underweight diagnosis and bias in the targeting process,

respect for selection criteria was low and consequently under coverage and leakage occurred. Besides a

globally satisfactory process, wide discrepancies were observed between CNP centres concerning the

utilization and effectiveness of services. This formative evaluation helped diagnose weaknesses; ongoing

feedback enabled the CNP to improve targeting and supply of supplements. It also informed a larger

impact evaluation. Some generalizable lessons for similar programmes have been highlighted.

keywords large scale nutritional intervention, nutritional recovery, process evaluation, underweight

diagnosis, West Africa

Introduction

The purpose of process evaluation is to relate impact and

outcome data to intervention activities. Process evaluation

results are not frequently reported, although they are

essential for understanding the failures and successes of

large scale interventions (Habicht et al. 1999). Three

components of process evaluation can be examined in a

process evaluation study: ‘fidelity’, ‘extent’ and ‘reach’

(Baranowski & Stables 2000). Fidelity concerns the

adherence of the project’s delivery to its design and stated

guidelines of operation, extent provides information on the

level of implementation of the intervention and reach

informs on the probability of the process outcomes to be

met. First, the quality of recruitment reflects the fidelity of

delivery. It influences the degree to which the program was

received by the targeted group (reach) and can therefore

influence global reach, i.e. the coverage of the targeted

group in the overall population. Second, the quality of

services provided by an intervention can influence partic-

ipants’ attendance. This attendance reflects, on the one

hand, the amount of services delivered (extent), and, on the

other hand, the maintenance of participants (reach). The

level of attendance of participants has a direct influence on

Tropical Medicine and International Health doi:10.1111/j.1365-3156.2006.01644.x

volume 11 no 6 pp 955–966 june 2006

ª 2006 Blackwell Publishing Ltd 955

the level of the expected process outcome, e.g. nutritional

recovery among malnourished participants.

The main focus of the present study was the process

evaluation of the Community Nutrition Project (CNP) in

Senegal, West Africa. As part of evidence based practice,

descriptive results of process evaluation were considered as

a third level of useful data on the intervention implemen-

tation (Rychetnik et al. 2004) after the nutritional problem

to be addressed was identified and the CNP design was

chosen. The main question addressed in this adequacy

assessment (Habicht et al. 1999) was ‘to what extent were

the CNP activities implemented and the expected process

objectives met?’ Besides the aim of improving CNP

operations whenever possible, the process evaluation

aimed at informing a larger impact evaluation.

Overview of the Community Nutrition Project in Senegal

In Senegal in the beginning of the 90s, the prevalence of

underweight among children under-five increased in urban

areas (WHO 2005) and marked differences in prevalence

were to be expected between neighbourhoods owing to

their contrasting socio-economic levels. In response to this

situation, the Government of Senegal initiated the nation-

wide CNP funded by the World Bank (World Bank 1995)

and implemented by a private agency AGETIP (Agence

d’Execution des Travaux d’Interet Public; Marek et al.

1999).

The CNP featured both a nutrition component and a

water component. The objectives of the nutrition compo-

nent were: (i) to halt further deterioration in the nutritional

status of children <3 years of age in targeted poor urban

neighbourhoods; (ii) through nutrition education, to

initiate changes in attitudes and feeding practices of

mothers. Services were provided in specific buildings called

Community Nutrition Centres (CNC), by legal entities

specifically created for the purpose which consisted of four

people (generally with a bachelor’s degree), usually

previously unemployed and living in the targeted neigh-

bourhood (Diallo et al. 1997). Physicians specially

employed for the project supervised the delivery of services.

To reach the most vulnerable groups among the poor,

the first level of targeting was geographical, focusing on

districts comprising a high rate of poor households (Sadio

& Diop 1994). Poor households were defined as those

whose average per capita monthly expenditure level was

below the cost of a food basket equivalent to 2400 kcal/

day. In the selected districts, every 6- to 36-month-old child

was theoretically eligible. However, as the priority out-

come was to bring malnourished children back to normal

growth, a second level of targeting was the children’s

nutritional status in order to select eligible children for

participating in the CNP nutrition component. According

to CNP terms of reference, malnutrition was defined as

underweight (low weight-for-age) identified with a colour-

based growth chart which used the threshold of approxi-

mately 80% of the median of the National Centre for

Health Statistics (NCHS) reference (WHO 1983). A child

aged 6–36 months was eligible if s/he was: malnourished;

the sibling of a malnourished child; or well nourished but

had not gained weight during the last 2 months, when

previously participating in CNP.

The project design has been documented in detail

elsewhere (World Bank 1995; Republique du Senegal,

AGETIP, Projet de Nutrition Communautaire 1997).

Basically, the CNP provided targeted children with

monthly growth monitoring and promotion and a weekly

food supplementation (a flour mix made of local ingredi-

ents), provided that their mothers attended weekly nutri-

tion and health education sessions, for a period of

6 months. CNP also provided targeted children with:

referral to health services for unvaccinated children, for

severely malnourished children, for children who failed to

gain weight over 2 months and for sick children; and home

visits to follow-up participating children who were referred

or who did not come to the services.

After a 6-month pilot phase in three cities, the CNP

started a 5-year programme in almost all urban areas in the

country. CNP activities were phased in gradually and after

4 years, a total of 121 000 children were enrolled in the

CNP in 25 towns (Republique du Senegal, AGETIP, Projet

de Nutrition Communautaire 1996–1999).

Expected processes of the Community Nutrition Project

in Senegal

Process objectives were developed and agreed upon with

the Government, AGETIP, and key stakeholders during an

objectives-oriented project planning (Ziel-Orientierte

Project Planung: ZOPP) participatory workshop held in

July 1994 in Dakar, Senegal. The objectives of the project

were then clarified, project activities and intended results

identified and indicators to monitor results defined (World

Bank 1995).

The CNP planned to offer a total number of seven

weightings (monthly), 24 rations of supplement (weekly)

and 24 educational sessions (weekly) per beneficiary during

each cohort of 6 month duration. Expected processes

comprised the recruitment of at least 90% of underweight

children in each cohort. Moreover, the CNP assumed that

20% of participating children would still present criteria to

be eligible at the end of a 6-month period and offered them

the opportunity of being recruited again. CNP’s objectives

were to weigh 90% of participating children monthly, to

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

956 ª 2006 Blackwell Publishing Ltd

deliver 90% of the planned food supplements and to reach

an attendance of 80% of the mothers at education sessions.

CNP objectives also included target values for the main

process outcome that is 80% of nutritional recovery at the

end of a cohort in children underweight at recruitment

(World Bank 1995; Republique du Senegal, AGETIP,

Projet de Nutrition Communautaire 1997).

Methods

Subjects of the process evaluation study

The present study focuses on two of the risk groups

targeted by the nutrition component of CNP: children aged

6–36 months and their mothers. Other targeted groups

such as pregnant or lactating women, or children not

targeted but allowed to follow some of the program were

not included in this study.

In Diourbel, an inland city of about 77 000 inhabitants

in 1988 (Republique du Senegal, Ministere de l’economie,

des finances et du plan, Direction de la Prevision et de la

statistique 1992), the district of ‘Keur Cheikh Ibra’ had the

highest rate of poor households (15%) and was the first to

be targeted by the CNP. It featured about 1500 children of

6–36 months of age and five CNCs were implemented. The

process evaluation covered the first 2 years, i.e. four

cohorts, including all participating children from these five

CNCs. Monitoring record cards of all the participating

children who underwent at least one body weight meas-

urement, i.e. the one used for recruitment, were collected in

the CNCs and computerized.

Data collected for the process evaluation

Data from the individual monitoring record cards provided:

individual characteristics of the child and mother; attend-

ance yes or no (y/n) of the child at each of the monthly

weighing; attendance (y/n) by the mother at each of the

weekly educational sessions; whether (y/n) each of the

weekly supplement rations was actually given to the mother

for the child; and the child’s growth in weight. Children’s

body weight measurements had been taken by CNC teams

to the nearest 100 g using a hanging baby scale (Salter). The

resulting colour as reported by the CNC workers on the

growth chart was entered in our files and used to code the

diagnosis of underweight by CNP workers. The reason for

recruitment reported by the CNC workers on individual

cards was entered as such in our files. Moreover, the child’s

age and body weight computerized from the individual

cards were also used to calculate the exact anthropometric

weight-for-age index and to classify the child as under-

weight or not with respect to the threshold of 80% of the

sex-specific NCHS reference median (WHO 1983).

Process evaluation components

Two kinds of factors (recruitment of participants and

services provided) were examined in the present study

through fidelity, extent and reach (Table 1). Fidelity to the

design of underweight diagnosis by CNP workers was not

tested in the present sample, but a study carried out during

the programme in five cities including Diourbel showed

that the quality of age determination, weighting and

charting by using the colour-based growth chart was good

(Diallo & Zeitlin 1998). However, we tested the con-

sequence of the design issue, which is using an average

chart for both sexes, on the validity of the diagnosis of

underweight and, consequently, on the reach at the

individual level. The fidelity of recruitment was assessed

through complying with various inclusion criteria. There-

fore, the reach at the CNP level was assessed here by the

rate of underweight at recruitment. The participants’

attendance at the services reflected the amount of services

delivered (extent).

Table 1 Process evaluation components

Process factor Process output Process evaluation component Process outcome

Recruitment of participants

Underweight diagnosis Underweight well classified or not Reach Coverage of underweight childrenin the overall population

of targeted neighbourhoods*

Inclusion Regard for recruitment criteria Fidelity

Rate of underweight at recruitment Reach

Child previous participant or not Fidelity

Services providedGrowth monitoring

and promotion

Attendance of child Extent Nutritional recovery among

underweight participating children

Food supplement Attendance of mother Extent

Educational sessions Attendance of mother Extent

* Outcome in population that cannot be assessed in this study by using process data.

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

ª 2006 Blackwell Publishing Ltd 957

Data management and statistical analysis

Computerization of data from individual record cards was

validated by double entry. The data entry and the

computation of weight-for-age index were performed with

Epi-Info 6.04d (Dean et al. 1994). Data management and

statistical analyses were performed using the SAS system

(SAS Institute Inc., Cary, NC, USA), release 8.0.

The validity of the diagnosis of underweight by CNC

workers was assessed by comparison with the diagnosis

based on calculation from weight, age and sex, considered

as the reference value, through a sensitivity/specificity

analysis (Selvin 1996). Sensitivity was the probability to be

classified as malnourished by the CNC workers when the

child’s computed weight-for-age index was <80% (ability

to correctly identify underweight children). Specificity was

the probability of being classified as non-malnourished by

the CNC workers when the child’s computed weight-for-

age index was ‡80% (ability to correctly classify non-

underweight children).

Prevalence ratios (PR; Rothman & Greenland 1998)

were used to compare rates of underweight at recruitment

between groups. Adjusted PRs were estimated using a

suitable generalized linear model, i.e. modified Poisson

regression (Traissac et al. 1999; Zou 2004).

In order to compare with the CNP’s process objectives,

performance in providing the services was assessed as the

ratio of the number of sessions actually attended by the

total number of participants to the number of sessions

proposed, calculated on the basis of seven weightings, 24

rations of supplement and 24 educational sessions

planned.

The sample of participating children resulting from the

collection of individual cards in the CNCs was exhaustive

with respect to the population studied. As the calculated

values for the means, rates and measures of association

were those of the population under study, there was no

need to take into account sampling variability and conse-

quently no confidence intervals and/or P-value for associ-

ations were computed (Korn & Graubard 1999).

Ethical considerations

Investigators involved in this study accessed information

on CNP participants by entering data from individual

forms stored in the CNCs with full agreement of CNP

leaders. The name of the subject was not entered in the

data file ensuring confidentiality protection for individually

identifiable information. Data were analysed independently

of CNP staff/employees and the investigators were given

the responsibility to submit this work for publication as

project coordinators signed authorization granted for any

analysing and writing. During the course of the interven-

tion, the results were used to provide recommendations to

CNP leaders and workers.

Results

Diagnosis of underweight

Results were obtained in children for whom the duration

of growth monitoring was at least 4 1/2 months, i.e. in

3864 children. At recruitment, sensitivity was higher

than specificity in the total sample (Table 2). Few

underweight children included were misclassified (sensi-

tivity of 90%); conversely, 39% of non-underweight

children were misclassified (specificity of 61%). On the

other hand, sensitivity was lower than specificity at the

end of follow-up. A high proportion of underweight

children (30%, i.e. sensitivity of 70%) were misclassified

at the end and only 3% of the non-underweight children

were misclassified (specificity of 97%) when they left the

CNP cohort. These results varied among CNCs and, to a

lesser extent, also among cohorts. However, important

variations appeared in the quality of the diagnosis of

underweight as a function of gender (Table 2), notably

for specificity at recruitment and for sensitivity at the

end of the cohort.

From diagnosis made by CNC workers, rate of under-

weight at recruitment was only 72.9% when the CNP

objective was 90%, suggesting a low fidelity to targeting

criteria and leading to a lower reach than expected. Using

the calculated weight-for-age index for underweight diag-

nosis showed a decreased reach, i.e. 66.4% of underweight

at recruitment. All the subsequent results presented are

based on the computerized weight-for-age index based on

sex-specific references.

Recruitment

The four cohorts included a total of 4084 children. The

fourth cohort included far fewer children (less than half)

than the previous ones (Table 3). Among the participating

children, the youngest were recruited more often than the

oldest and the sex ratio was 0.99.

Reach of underweight at recruitment (Table 3) varied

by CNC, and increased during the first three cohorts,

then declined to the lowest rate in the fourth cohort.

Youngest (6–17 months) participating children were

more often underweight at recruitment than

18–36 months old ones, whatever the CNC or the cohort

(detailed data not shown). A marked difference in the

rate of underweight at recruitment was observed between

boys and girls, leading to a sex ratio of 1.44 among

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

958 ª 2006 Blackwell Publishing Ltd

underweight participants. When adjusted for all five

variables in Table 3, no PR value changed markedly.

Not even one CNC or cohort showed the expected reach

of 90% underweight children recruited.

Among the children who were not underweight at

recruitment, only 2.2% and 3.8% were siblings of an

underweight child or had failed to gain weight, respect-

ively, as classified by the CNC workers. In the second,

third and fourth cohorts, 30.4% (26.3–37.7% per cohort

and 13.0–52.8% per CNC) of the children had already

been included in a preceding cohort, which was in excess

of the 20% rate planned. Among the previous partici-

pating children, 0.4% were classified as having not

gained weight during the three final weightings of the

previous cohort and only 61.6% (53.3–64.4% per cohort

and 46.1–80.5% per CNC) were underweight at

recruitment. All these data confirm the low fidelity to

recruitment criteria.

Attendance at services

The total of actual weighing sessions represented 93% of

the weighing sessions offered for all the participating

children, with no distinction between underweight and

non-underweight children. Nearly 92% of the children,

underweight or not, attended at least six of the seven

weightings planned (Table 4), with a proportion per CNC

ranging from 87% to 97%, and per cohort from 88%

(third cohort) to 96% (second cohort) (detailed data not

shown). With regard to the CNP objective of 90% of

children weighed monthly, extent of growth monitoring

was good whatever the underweight status, thus allowing a

satisfactory reach in the targeted group of underweight

children. Consequently, the mean duration was of

5.8 ± 0.9 months for a planned duration of 6 months.

The extent of food supplement for children was very low

as effective rations given represented 45% of the total

Table 2 Comparison of underweight diagnosis in participating children based on data from Community Nutrition Centres (CNCs) or

from our computed calculation at recruitment and at the end of the growth monitoring as a function of centre, cohort and gender

Group n Time

Anthropometrical status (% of children)

Sensitivity* Specificity*

Computed from weight

and age: weight-for-age <80%

Diagnosis based on

CNCs’ chart: underweight

Total 3864 Recruitment 66.4 72.9 0.90 0.61

End 28.2 22.1 0.70 0.97

Community Nutrition CentreA 867 Recruitment 79.2 87.5 0.97 0.47

End 29.7 24.5 0.73 0.96

B 1012 Recruitment 67.1 72.2 0.88 0.60

End 31.6 25.9 0.72 0.95C 764 Recruitment 63.4 65.0 0.85 0.70

End 29.8 22.4 0.71 0.98

D 687 Recruitment 60.5 75.4 0.93 0.52

End 21.3 13.9 0.59 0.98E 534 Recruitment 55.5 58.2 0.82 0.72

End 25.3 21.2 0.72 0.96

Cohort

1st 977 Recruitment 63.6 77.5 0.95 0.53End 22.6 17.9 0.69 0.97

2nd 1356 Recruitment 69.0 74.9 0.91 0.60

End 30.5 24.0 0.70 0.963rd 1000 Recruitment 70.0 70.2 0.86 0.66

End 32.8 25.3 0.70 0.97

4th 531 Recruitment 58.2 64.4 0.87 0.68

End 23.7 19.2 0.73 0.98Sex

Boys 1922 Recruitment 78.9 69.4 0.85 0.90

End 31.9 18.3 0.55 0.99

Girls 1942 Recruitment 54.1 76.3 0.97 0.48End 24.5 25.7 0.90 0.95

* Calculated for diagnosis of underweight based on CNCs’ growth chart when compared with rate of weight-for-age <80% computed

from weight and age and based on sex-specific references.

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

ª 2006 Blackwell Publishing Ltd 959

rations offered, with a higher coverage of underweight

(48%) than non-underweight children (39%), when the

CNP objective was to deliver 90% of the rations. More-

over, the fact that non-underweight children received some

food supplement (leakage) reflects a problem of fidelity to

criteria for service delivery. The percentage of children who

received ‡14 rations per CNC ranged from 25% to 44%.

In the second cohort no children received ‡14 rations

whereas the proportion was 27.7%, 56.8% and 73.6% in

the first, third and fourth cohort, respectively (detailed data

not shown). This reflects a clear improvement in extent

over time during the second year of the project.

Actual attendance at the education sessions by mothers

represented 62% of the total number of sessions planned,

again with a higher reach of mothers of underweight

children (64% vs. 56%). Therefore, extent was insufficient

as expected attendance was 80%. Extent by CNC ranged

from 15.6% to 63.6% of mothers who attended ‡18

sessions (detailed data not shown). There was a clear

increase in attendance at education sessions from the first

to the fourth cohort (20%, 30%, 41% and 58% of

mothers attended ‡18 sessions, respectively).

The only differences by gender were a higher mean

number of food supplement received (10.1 vs. 7.5) and a

higher number of education sessions attended by their

mother (14.0 vs. 12.2) in girls when compared with boys.

Outcome expected in the target group: nutritional recovery

in participating children

Nutritional recovery was assessed among the participating

children who were underweight at recruitment. Recovery

was defined as the ratio of children who were no longer

underweight at the end of follow-up to the children who

were underweight at recruitment. This was calculated

again when the duration of growth monitoring was at least

4 1/2 months (n ¼ 2570 children underweight at recruit-

ment). Nutritional recovery was 61% (between 57% and

67% per cohort, between 56% and 68% per CNC, and

there was no difference between boys and girls).

Discussion

The real value of a process evaluation is its ability to

compare observed programme processes with expected

processes. Moreover, our results were used to attempt to

improve the operations. Management of the data collected

from CNP monitoring system needed for the present study

was carried out after the end of the second year of the

programme. During the third year, analyses were per-

formed and results reported, notably at ‘mid-term work-

shop of the CNP and World Bank in Senegal’ (Kameli &

Gartner 1998). Then, during all the period of the CNP

evaluation, i.e. until 2003, we worked in permanent

collaboration with CNP leaders and workers and ongoing

feedback to CNP was performed via short regular (in

average monthly) meetings. Another interest of process

evaluation is to speculate about potential programme

impact. For that purpose, Table 5 contains some elements

of results and discussion in terms of process outputs and

outcome.

Underweight diagnosis and recruitment

The explanation of the incorrect selection of targeted

children may be found in a combination of several biases.

First, the main explanation of a ‘chart’ bias may be found

in the use of a single reference for boys and girls together.

The CNCs’ growth chart had a threshold determined from

Table 3 Distribution and anthropometrical status at recruitment

of the 4084 participating children according to centre, cohort, age,

sex and having previously participated

Distributionof children (%)

Rate of computed under-

weight* at recruitment

% of

children PR PRadjusted

Whole sample 100 66.3Community Nutrition Centre

A 22.1 78.2 1.38 1.44

B 26.2 67.7 1.19 1.16

C 20.0 62.7 1.10 1.10D 17.2 61.1 1.08 1.04

E 14.5 56.8 1 1

Cohort

First 25.2 62.3 1 1Second 34.0 68.9 1.10 1.11

Third 26.9 70.4 1.13 1.13

Fourth 13.9 59.3 0.95 0.96

Age of the child at recruitment6–11 months 30.0 67.3 1.10 1.03

12–17 months 25.4 70.8 1.16 1.12

18–23 months 20.2 65.2 1.07 1.0524–35 months 24.4 61.2 1 1

Sex

Boys 49.9 78.7 1.46 1.47

Girls 50.1 53.9 1 1Previously participated�

No 69.6 70.3 1.14 1.17

Yes 30.4 61.6 1 1

* Diagnosis based on the computed weight-for-age index based on

sex-specific references and the threshold of 80% of the median.� n ¼ 3055, i.e. excluding the first cohort.

PR, prevalence ratio; PRadjusted, prevalence ratio adjusted for all

the five variables in the table.

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

960 ª 2006 Blackwell Publishing Ltd

a ‘mean’ value of the two NCHS references of body weight

for the age of boys and of girls (WHO 1983), thus giving

an intermediate value between the correct one for boys and

the correct one for girls (FAO 1992; Latham 1997). This

threshold was too low for boys and too high for girls.

Therefore, it is likely that an underweight boy with a

weight just below the correct reference value for boys

would not be classified as underweight, and a normal

weight girl with a weight value just above the proper

reference for girls would be classified as underweight by

CNP workers. Many community nutrition programmes do

use a single chart for both sexes. The bias introduced by

this practice is important enough to underline that it is a

significant weakness of those programmes for at least two

reasons. First, it leads to an assessment of underweight that

differs from the diagnosis based on sex-specific references

largely used to evaluate underweight status in population

or impact of nutritional intervention. Second, it leads to

under coverage of targeted underweight girls in contexts

where female children could be already challenged with

other disadvantages. However, there was no disadvantage

towards girls concerning delivery of services from CNP.

Another source of bias could be that the objective of

CNC workers was to include as many underweight

children as possible at the beginning and to retrieve as few

as possible at the end. We could therefore suggest the

hypothesis of a ‘yield’ bias at the group (cohort) level.

Third, this kind of error could also be due to a ‘human-

itarian’ bias at the individual (child) level to avoid

excluding borderline normal weight children, as previously

reported (Soeters 1986). One reason for this systematic

bias could be that with the chart method, the measurer

knows immediately whether or not the child is malnour-

ished and tends, at recruitment, to classify children who are

slightly above the threshold point as being under it. Finally,

implementing the eligibility criteria can lead to perceptions

of unfairness (Marchione 2005). The individual nutritional

targeting among the population who came to the CNCs

was not always well accepted by mothers and the CNC

workers may have felt obliged to include non-target

children (‘social’ bias). Better accounting for such problems

met by programme workers is critical for the improvement

of program targeting (Lee et al. 2005).

For comparison purpose, sensitivity/specificity of the

assessment of very low weight-for-age by using the growth

chart in Africa when compared with weight-for-age<-3 z-

scores was of 62.0%/98.7% under conditions which

exclude some bias inducing constraints e.g. those from

targeting or meeting programme objectives (Hamer et al.

2004).

Inclusion of normal weight children could be considered

potentially useful in an intervention in terms of preventionTable

4A

tten

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1–5

67

<4.5

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14–24

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13–17

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Under

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ght�

(n¼

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(1.0

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)

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Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

ª 2006 Blackwell Publishing Ltd 961

Table

5C

om

pari

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ted

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tary

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ack

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ific

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ble

m

())

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NP

chart

-base

ddia

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ific

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ons

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ual

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ended

/giv

enby

the

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lnum

ber

of

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ber

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ions

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pose

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ula

ted

on

the

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seven

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ghti

ngs,

24

rati

ons

of

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men

tand

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educa

tional

sess

ions

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nned

for

each

part

icip

ant)

.

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

962 ª 2006 Blackwell Publishing Ltd

of malnutrition. However, a too low proportion of

underweight participants has to be taken seriously in the

case where all malnourished children in the overall

population would not be recruited: CNP services are

delivered at the level of participating children and their

mothers while improvement in nutritional status is expec-

ted as an impact at the level of the overall population.

Process outputs and outcome: attendance at the services

and recovery from underweight

One can assume that high attendance rate at the monthly

weightings should be considerably helped by the fact that

the other two services were delivered weekly. Moreover,

the weekly food supplement for the child could be one of

the reasons for the mother’s regular attendance at the

weekly education sessions. However, attendance at edu-

cation sessions was better than attendance at food

supplement delivery, which was only half the CNP

objective. This may be explained by a low fidelity of

implementation: the supplement was not delivered to

project staff on time or in sufficient quantities, especially

at the beginning of the programme. Over time, these

practical points improved and the two weekly services

showed higher attendance. Moreover, in the three

cohorts that followed the cohorts reported here, the

attendance at the education sessions reached 71–86% of

the total number of sessions planned and in five new

CNCs opened in Diourbel, the coverage of the education

sessions in their first three cohorts increased from 65%

to 81% (Republique du Senegal, AGETIP, Projet de

Nutrition Communautaire 1996–1999).

The higher rate of initially underweight children in the

groups of mothers who presented the best weekly

attendance suggests that CNC workers were efficient in

raising mothers’ awareness of the nutritional status of

their children and of the importance of attending the

sessions. However, out of the 100 g/child/day of food

supplement given to each child by the CNP, a child on

average ate only 25 g (Treche 1998), the food supple-

ment being diverted to the family. It was not possible to

confirm the output hypothesis, namely, that the supple-

ment will be consumed in addition to the normal daily

diet and thereby increase total daily caloric intake.

Generally, mothers were satisfied with the CNC’s servi-

ces, but they expected more activities, mainly diversifi-

cation of the food supplement, integration of health care,

literacy programs and income-generating activities

(Ndiaye 1999). Indeed, whatever the quality of the

services provided, their use by the mothers is often

determined by conflicts with income generating activities.

Even in the most efficient CNC or cohort, the expected

recovery rate of 80% was not reached during the first

2 years of the CNP in Diourbel.

Potential contribution to the Community Nutrition

Project’s impact

The expected impact of CNP is at least a stabilization, or

at the best, a decrease of the prevalence of malnutrition

of children in the population of the target neighbour-

hood. Among process outcomes, recovery from under-

weight in children under programme can have a direct

effect immediately on impact, whereas changes in feeding

practices of the mothers could have a less direct or

immediate effect provided they can have benefit on child

growth. A wrong underweight diagnosis, as well as

applying incorrect criteria for recruitment, harmed the

quality of individual targeting and therefore the CNP

reach of underweight children in the overall population,

thus compromising the potential extent of the direct

impact. Irregular supplies of supplement could certainly

have reduced, first, the direct impact through supplement

consumption, if any, and, second, the attendance of

mothers to education sessions; this problem needed to be

addressed through appropriate action. High attendance

of mothers to growth monitoring and promotion prob-

ably improved mothers’ awareness of the child’s growth,

but cannot be considered to have a positive impact alone

as its efficiency remains to be shown (Save the Children

UK 2003; Hossain et al. 2005). Good attendance to

growth promotion and temperate attendance to educa-

tion sessions cannot by themselves ensure effective

performance in mothers training. However, we showed,

in another city in Senegal, that changes in knowledge,

attitudes and practices of mothers were generally

favourable during the first 2-year period (Mejean et al.

2004). Therefore, a benefit for impact could be expected.

It has to be noted, further, that behaviour changes

resulting from education could strongly depend on the

context, e.g. household resources.

Finally, beyond process results, an explanation for lack

of recovery could rely on the design of choosing under-

weight as nutritional criterion. Indeed, many underweight

children are stunted but not necessarily wasted. The fact

that wasting or stunting are not differentiated by weight-

for-age index could prevent the right action to be carried

out toward the right problem.

The CNP leaders and workers took heed of process

evaluation results thus improving implementation success-

fully as demonstrated also by process results from follow-

ing cohorts carried out after the four ones studied here.

Such accountability is likely to be one of the ways that

could contribute to enhance potential of impact.

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

ª 2006 Blackwell Publishing Ltd 963

Generalizable interest

This study concerns one of the more recent large scale

community nutrition programs. Evaluation was integrated

into the CNP at the design phase (World Bank 1995) as

now clearly recommended (Habicht et al. 1999). Inde-

pendent and transparent presentation of the process

evaluation of such interventions is needed to show what

works in different contexts. From our study, it appeared

that: a wrong design of underweight diagnosis could

largely compromise reach of targeting and, moreover,

could imply a risk of disadvantage towards girls; even with

clearly defined design and objectives, incorrect criteria for

enrolment can be frequently applied; in this context of

program follow-up, growth monitoring could be effectively

implemented in routine settings and on a large scale;

dependence on the supplement supplier led to low fidelity

of implementation. As a more in-depth analysis of data

from CNP monitoring system, moreover done by an

independent source from CNP, our study allowed assessing

to what extent could the performances of an intervention

be misinterpreted or exaggerated, as also already reported

(Save the Children UK 2003). Training and supportive

supervision are at heart of a well functioning program.

Contrary to inadequate training and supervision of nutri-

tion workers reported for two other large scale nutrition

projects in Africa (Save the Children UK 2003), CNP

ensured training of all CNC workers by local consultants

or training institutions, and only the best supervisors

among those who entered the training were selected. Each

supervisor looks after five teams each managing a CNC.

This positive point is favourable to a possible generaliza-

tion of the implementation as described here.

Conclusion

The present findings showed to what extent the process

moved in the expected direction. The results were used

during the course of the intervention to provide recom-

mendations to CNP leaders and workers for subsequent

phases where changes occurred in the process, mainly in

underweight diagnosis and targeting, and in the provision

and delivery of the supplement. Beyond a globally satis-

factory process, the programme had to analyse the different

causes of the marked discrepancies observed between

CNCs concerning the utilization and the effectiveness of

the services, either because of CNCs’ workers initial or

further training, the quality of their work, or how they

dealt with the acceptance of the targeting selection by the

population.

Process evaluation results could reflect the effectiveness

of an intervention provided that delivery was adequately

carried through, and therefore it has an effect on the

interpretation that can be made of the final results (Save the

Children UK 2003). From CNP, that implemented the

contracting approach as a strategy to provide quality

services on a large scale (Marek et al. 1999), lessons can be

learned about factors affecting targeting, service delivery

and a hypothesis can be formulated about the obstacles to

nutritional recovery. In conclusion, this study confirms that

process evaluation, based on clear terms of reference and

ongoing monitoring data, is essential to assess potential of

impact of an intervention. On the basis of this study, it

could be recommended that large scale nutrition pro-

gramme focus on targeting design and process to avoid

under coverage and leakage, and it is suggested to choosing

an appropriate anthropometric indicator to ensure each

specific nutritional problem to be adequately addressed.

Acknowledgements

The authors are indebted to the CNP staff in AGETIP in

Dakar and Diourbel for having facilitated access to CNP

centres in Diourbel. We express our sincere thanks to them

for having allowed us to use the CNP individual benefici-

aries’ forms and to computerize their data. The authors

would also like to thank all the CNP workers in Diourbel

for their cordial welcome, as well as for having facilitated

access to their archives in the CNC, and for their kind help

when we collected information from their documents.

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Corresponding Author A Gartner, Nutrition Unit, UR 106, IRD, B.P. 64501, 911 Avenue Agropolis, 34394 Montpellier Cedex 5,

France. Tel.: +33 4 67 41 62 23; Fax: +33 4 67 41 63 30; E-mail: gartner@mpl.ird.fr

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

ª 2006 Blackwell Publishing Ltd 965

Evaluation du fonctionnement du Projet de Nutrition Communautaire du Senegal: une estimation de l’adequation aux objectifs d’un projet a grande

echelle en milieu urbain

objectif Bien qu’etant essentiels pour comprendre les raisons associees a l’echec ou au succes des programmes d’intervention nutritionelle a large

echelle, les resultats d’evaluation de fonctionnement sont rarement rapportes. Notre etude avait pour but d’evaluer si les objectifs de fonctionnement du

Projet de Nutrition Communautaire (PNC) du Senegal, en Afrique de l’ouest, ont ete atteints.

methodes Une evaluation de l’adequation aux objectifs, basee sur les donnees de suivi individuel des beneficaires collectees dans le PNC, a ete utilisee

pour estimer les criteres de ‘fidelite’, ‘etendue de couverture’ et ‘atteinte’ du recrutement des participants et des services procures. Le PNC procedait,

dans les quartiers pauvres, au suivi-promotion mensuel de la croissance des enfants de 6 a 35 mois presentant une insuffisance ponderale ou un risque

nutritionnel, et leur fournissait un complement alimentaire hebdomadaire pendant 6 mois, a condition que les meres participent a des sessions

hebdomadaires d’education nutritionnelle. Un echantillon exhaustif des enfants ayant participe au PNC a Diourbel a ete utilise pour l’evaluation des

deux premieres annees du projet (n ¼ 4084).

resultats Au moment du recrutement, seulement 66% des enfants presentaient une insuffisance ponderale, contre 90% attendus, et cela variait

selon le centre du PNC ou la cohorte, mais aussi selon le sexe et l’age des enfants. La participation au suivi de la croissance a atteint le niveau attendu,

soit 93% vs. 90%, alors que le nombre de complements alimentaires distribues et la participation aux sessions d’education etaient inferieurs aux

attentes, soit 45% vs. 90% et 62% vs. 80% respectivement. A la fin du suivi, 61% des enfants qui avaient une insuffisance ponderale au depart ont

recupere, contre 80% attendus.

conclusions A cause du mode de diagnostic de l’insuffisance ponderale choisi par le PNC et d’un biais dans le procede de ciblage, l’adhesion aux

criteres de recrutement etait faible, ayant pour consequence une faible couverture des enfants cibles ainsi qu’un detournement du projet vers des non

cibles. Au dela d’un fonctionnement qui s’est avere globalement satisfaisant, des discordances ont ete observees entre les differents centres du PNC pour

ce qui etait de l’utilisation et de l’efficacite des services. Cette evaluation ‘formative’ a contribue a identifier les faiblesses, et des retroactions regulieres

ont permis au PNC d’ameliorer le ciblage et la fourniture de complement alimentaire. Elle a aussi fourni des informations necessaires a une evaluation de

l’impact du PNC a un niveau plus large. Des lecons de portee plus generale ont ete tirees pour des programmes similaires.

mots cles intervention nutritionnelle a grande echelle, evaluation de fonctionnement, diagnostic d’insuffisance ponderale, recuperation nutritionnelle,

Afrique de l’ouest

Proceso de evaluacion del CNP-Senegal: valoracion sobre la adecuacion de un proyecto de nutricion comunitario a gran escala

objetivo A pesar de ser esencial para entender los motivos detras del exito o el fracaso de intervenciones nutricionales a gran escala, los procesos de

evaluacion son rara vez reportados. Nuestro objetivo fue el valorar si los objetivos y resultados esperados del proceso del Proyecto de Nutricion

Comunitaria (Community Nutrition Project (CNP)) en Senegal, Africa Occidental, habıan sido alcanzados de forma adecuada.

metodos Se utilizo un estudio de valoracion de la adecuacion basado en la monitorizacion de datos de individuos recolectados durante el CNP, para

evaluar la ‘‘fidelidad’’, la ‘‘extension’’ y el ‘‘alcance’’ del reclutamiento de participantes y los servicios provistos. El CNP proveıa a ninos con bajo peso o

riesgo nutricional de entre 6 y 35 meses de edad y provenientes de distritos de bajos recursos, con una promocion y monitorizacion mensual del

crecimiento ası como una suplementacion alimenticia semanal durante 6 meses, siempre y cuando las madres asistieran a las sesiones de educacion

nutricional que se impartıan semanalmente. Con el fin de llevar a cabo la evaluacion durante los primeros dos anos, se utilizo una muestra exhaustiva

(n ¼ 4084) de los ninos que participaron en Diourbel.

resultados Al ser reclutados, solo un 66% de los ninos tenıan bajo peso (vs. 90% esperado) encontrandose variaciones entre los diferentes centros

CNP y las cohortes, el sexo y la edad del nino. La asistencia a la monitorizacion de crecimiento alcanzo los niveles esperados (93% vs. 90%), mientras

que el numero de suplementos alimenticios distribuidos y las sesiones de educacion atendidas fueron menores de lo esperado (45% vs. 90%, y 62% vs.

80%, respectivamente). Al final del seguimiento, 61% de los ninos con bajo peso se habıan recuperado vs. un 80% esperado.

conclusiones Debido al diseno del CNP para el diagnostico de bajo peso y el sesgo en el proceso de asignacion, el respeto a los criterios de seleccion

fue bajo y consecuentemente se encontro una baja cobertura y perdidas. Ademas de un proceso global satisfactorio, se observaron amplias discrepancias

entre los centros CNP con respecto a la utilizacion y efectividad de los servicios. Esta evaluacion formativa ayudo a realizar el diagnostico de una

flaqueza; la retroalimentacion constante permitio que el CNP mejorase la asignacion y el suministro de suplementos alimenticios. Tambien ha servido de

informacion para una evaluacion de mayor impacto. Se resaltan algunas lecciones extrapolables a otros programas similares.

palabras clave intervencion nutricional a gran escala, proceso de evaluacion, diagnostico de bajo peso, recuperacion nutricional, Africa del oeste

Tropical Medicine and International Health volume 11 no 6 pp 955–966 june 2006

A. Gartner et al. Process evaluation of the Senegal-Community Nutrition Project

966 ª 2006 Blackwell Publishing Ltd