The document describes ProPAN (Process for the Promotion of Child Feeding), a step-by-step tool to identify nutritional problems, determine why they occur, and design and evaluate interventions. It was created to address gaps in quantitative dietary assessment and program design/evaluation. ProPAN guides users through assessment of feeding practices, recommendation development based on findings, intervention planning, and monitoring/evaluation. The document provides examples of how ProPAN has been used in various countries to develop infant and young child feeding programs and evaluate their impact.

1. .
• .
ProPAN (Process for the Promotion
of Child Feeding)
Dr. Chessa Lutter for the ProPAN Team
CORE Group Meeting
May 1, 2012

2. ProPAN: What and for who?
• A step-by-step tool to
– identify nutritional, feeding and dietary problems
– determine why these problems occur
– design and evaluate an intervention based on the
problems identified
• Aimed at Ministries of Health, NGOs and
international organizations interested in improving
IYCN

3. Background
• Designing by Dialog excellent
for developing interventions
using qualitative methods
• Gap in the area of quantitative
dietary assessment, program
design, implementation and
evaluation
• A tool to assess both
quantitative and qualitative
aspects of IYCF and design and
evaluate an intervention
identified as a gap for effective
programming

4. Background
• ProPAN includes both
BF and CF
• Relative emphasis is on
CF because information
on assessment and
programming most
lacking
• First released in 2003
• Currently undergoing
major updating

5. “Ideal BF practices”
1. All infants are breastfed within the first hour of
birth
2. All infants are not fed with prelacteal feeds
3. All infants are fed colostrum
4. All infants and young children are breastfed
on demand, during the day and night
5. All infants are exclusively breastfed for the
first 6 months
6. No children are weaned before 24 months of
age

6. “Ideal CF practices”
7. All infants are fed semi-solid CFs beginning at 6
months of age
8. All infants and young children meet recommended
daily energy requirements
9. All infants and young children fed nutrient- and
energy-dense foods
10. All infants and young children are fed recommended
number of meals daily
11. All infants and young children fed meat, fish or
poultry daily
12. All infants and young children are responsively fed

7. Conceptual framework
12 Ideal Practices
Practices
followed?

8. Conceptual framework
12 Ideal
Practices
Yes
Practices Why?
followed?
No

9. Conceptual framework
12 Ideal
Practices
How motivate
Yes to follow?
Practices Why?
followed?
Could they be
followed
No
(modified)?

10. Conceptual framework
Recommendations

11. Conceptual framework
Feasible?
Recommendations
Will have an
impact?

12. Conceptual framework
No
Necessary
Feasible? and possible
Yes strategies?
Recommendations
Yes
Will have an
impact?
No

13. Conceptual framework
No
Necessary
Feasible? and possible
Yes strategies?
Recommendations
Design of
Yes intervention,
Will have an monitoring and
impact? evaluation plan
No

14. Modules of the ProPAN manual
I. Assessment
IV. Monitoring and II. Recipe Creation
Evaluation and Trials of
Recommendations*
III. Design of Action Plan
* Dickin et al., 1997 (TIPs)

15. Methods: Module I. Assessment
• Quantitative
• General survey: BF, SES, communication
• 24-hour dietary recall
• Market survey
• Qualitative methods
• Opportunistic observation
• Semi-structured interview
• Food attributes

16. Methods: Module I. Assessment
• Analysis via
– Software program
– Matrices
• Integration of data, analysis
of practices and formulation
of recommendations
Photo credit: Maria Reyna Livia

17. Results: Module I. Assessment
• Problems with diet and
feeding practices
• Context of practices
• Recommendations to
address problems
Photo credit: Helena Pachón

18. Methods:
Module II. Recipes & Recommendations
• Creation of new or modified
recipes and/or adoption of new
behavior
– Groups of caregivers and
children, recipe preparation
and acceptability
– Groups of health care
providers
• Trials of Recommendations
– 1-week home/health center
trials and feasibility
(Dickin et al., 1997 (TIPs))

19. Results:
Module II. Recipes & Recommendations
• Nutritious recipes and/or
behavior with a greater
chance of being adopted
• Feasible and acceptable
recommendations
Photo credit: Helena Pachón

20. Methods: Module III. Plan of Action
• Review research results
• List possible intervention
strategies
• Choose among intervention
strategies
• Design plan of action
Photo credit: Helena Pachón

21. Results: Module III. Plan of Action
Detailed and Complete Plan
of Action
 Strategies
 Activities
 Personnel
 Materials
 Implementation
timeline
Photo credit: Helena Pachón

22. Methods:
Module IV. Monitoring & Evaluation
• Specify objectives
• Identify inputs, outputs,
results, impact and benefits
• Design monitoring and
evaluation system
Photo credit: Helena Pachón

23. Results:
Module IV. Monitoring & Evaluation
Comprehensive
Monitoring and
Evaluation Plan
Indicators
Sampling
Timeline
Photo credit: Helena Pachón

24. Where ProPAN has been used
Bolivia
Brazil
Ecuador
Guatemala
Honduras
Jamaica
Mexico
Panama
Peru
Bangladesh Lao PDR
Uruguay
Cambodia (www.hawaii.edu)

25. Bolivia
• Study conducted in El Alto, department of La Paz,
• Between June and September, 2001, in a population
located in various blocks in the Health District 2-3 of
the city.
• 205 families were surveyed, covering almost 100% of
the homes in the selected blocks
• Interviewed or observed 10 informants for the Market
Survey, 16 pairs of caregiver-children for the
Opportunistic Observation, 9 representatives for the
Survey of Personnel in Health Organizations, and 17
mothers for the Recipe Creation Exercise.

26. Bolivia project timeline
June July August September
-Logistics -Training -Training -Presentation
-Work plan -Data collection -Data collection of results
development -Data analysis, -Data analysis,
-Hiring of integration and integration and
personnel interpretation: interpretation:
-Training Market Survey Attributes
General Survey Recipe Creation
24-Hour Recall -Presentation of
Mothers’ results
Interview
Observations
Survey to
Personnel of
Institutions

28. Recipes developed and tested by mothers,
Brazil, 2003
Recipe name: Rice with chicken liver and squash
Energy and nutrient density
Ingredients Energy Protein Iron Vit. A Vit. C Ca
(kcal/g) (g/100kcal) (mg/100kcal) (( g/100kcal) (mg/100kcal) (mg/100kcal)
Chicken liver 1.25 14.40 6.85 4930.66 27.03 8.80
Rice 3.61 1.86 0.17 0 0 2.22
Squash 0.18 6.67 2.21 183.33 100.0 105.56
Onion 0.38 3.05 0.56 0 16.84 52.63
Soy oil 8.84 0 0 0 0 0
Salt 0 0 0 0 0 0
Total 14.26 25.98 9.79 5113.99 143.87 169.21

29. Frequently Consumed Foods – Kingston
Entire sample (n = 75) 6 - 11 months (n = 35) 12 - 23 months (n = 40)
Food % Food % Food %
Brown Sugar 10.6 Brown Sugar 14.3 Brown Sugar 8.3
Cream of wheat w/ 5.3 Cream of wheat w/ 6.7 Cream of wheat w/ 4.5
honey honey honey
Juice - Fruit Punch, 4.4 Cornmeal porridge 5.1 Juice - Fruit Punch 4.2
natural
Green banana 3.0 Juice - Fruit Punch, 4.8 Formula: Alacta 1+ 3.4
natural
Cornmeal porridge 3.0 Green banana 3.2 Formula: Lactogen 2 3.4
Whole milk powder 2.8 Whole milk powder 2.9 Limes, raw 3.0
Irish potato 2.6 Irish potato 2.9 Whole milk powder 2.8
Chicken, brown stewed 2.5 Cheese, hard 2.2 White rice 2.8
Limes, raw 2.4 Chicken, brown stewed 2.2 Green banana 2.8
Cheese, hard 2.3 Rice Cereal 1.9 Chicken, brown stewed 2.6

30. Qualitative Phase Activities
• Key Foods List
• Food Attributes Testing
• Semi-Structured
Interviews
• Opportunistic
Observations
• Recipe Creation
• Household Testing of
Recommendations

31. Recipe Creation Exercises
• 6 sessions
• 29 participants
– Kingston only
• 12 recipes created
• All recipes analyzed and
ranked
• 2 recipes chosen for
household testing

32. Recipe Rankings
Recipe Name Iron rank Calcium rank Zinc rank
Calypso Liver 1 11 1
Sardine Fiesta with Margarine 9 1 9
Chicken, Callaloo Irish 2 2 3
Liver Dish 3 10 2
Veggie-Liver 4 8 4
Chicken & Callaloo Surprise w/ Crushed 5 6 5
Irish and Mango, Orange, & Pawpaw
Delight
Chicken and Callaloo Dish with Irish 6 9 6
Crushed Carrot and Irish with Liver 7 12 7
C.C. Baby Style with Potato Wedges and 8 7 8
Tropical Paradise
Pumpkin Sardine One-Pot 10 5 10
Seasoned Rice, Fruit Punch 11 4 11
Sardine Seasoned Rice with Mash 12 3 12
Pumpkin and Zesti Fruit Punch

33. Recommendations Tested in Households
• Give the child fruit with main meals
• Make the child’s porridge thick, like the consistency of
mashed potatoes
• Feed the child iron-dense foods (example recipe of
“Calypso Liver”)
• Feed the child calcium-dense foods (example recipe
of “Sardine Fiesta with Mangorine”)

34. Results of Test of Recommendations
Compliance Criteria Sardine Calypso Give Fruits Thicker
Fiesta with Liver with Meals Porridge
Mangorine
Mothers who put it to 78% 63% 89% 100%
practice at least once
during 10-day follow-up
period*
Number of times they put Cooked 1-3 Cooked 1-4 days 1-3 days
recommendation to times 1-2 times
practice
Number of times a day 1-3 1-3 1-3 times 1-2 times per
they fed it to the child per day day
Child’s acceptability Most Children Almost all Some babies
children who liked it babies love like it and
were served and easily the fruit and others don’t,
the meal ate it eat it well. about evenly
liked it and mixed
ate a lot
Intention to Continue 67% 63% 78% 44%

35. Mexico: Foods with the highest energy and
nutrient values (peso)
Vitamin C
Vitamin A
(µg RE/1
CHO (g/1
Calcium
Protein
Energy
(kcal/1
Order
(mg/1
(mg/1
(mg/1
(mg/1
peso)
peso)
peso)
peso)
peso)
peso)
peso)
peso)
peso)
(g/1
Zinc
(g/1
Iron
Fat
1 Sunflower Sunflower Chickpeas Rice Sesame Sesame Chicken Guava Sesame
Oil Oil (19.8) (115.2) seed seed liver (205.8) seed
(959.6) (108.6) (12.9) (6.9) (6164.7) (860.4)
2° Safflower Safflower Beans Tortilla Chicken Chickpeas Beef liver Orange Tortilla
Oil Oil (18.3) (white liver (3.5) (3296.7) (113.9) (white
(871.6) (98.6) maize) (8.6) maize)
(77.7) (291.7)
3° Corn Oil Corn Oil Chicken Chickpeas Chickpeas Chicken Carrot Broccoli Milk (Fluid,
(605.6) (68.5) liver (62.1) (6.4) liver (2269.9) (82.2) filled)
(18.0) (3.7) (166.0)
4° Rice Sesame Sesame Noodles Beans Beans Sweet Black Dry Whole
(523.2) seed seed (enriched (6.4) (2.2) potato Zapote Milk
(43.9) (15.6) with iron (2112.6) (62.0) (136.6)
(56.2)
5° Sesame Sweet Broad Corn Noodles Broads Spinach Papayas Añejo
seed Cookie Beans dough (enriched Beans (1537.8) (42.5) Mexican
(505.7) (14.7) (13.3) treated with with egg) (1.8) Cheese
lime (3.6) (128.8)
(53.0)

36. Examples of how ProPAN has been Used
• Lao PDR 2001
• Used to train in, collect,
and analyze formative-
research data
• An infant-feeding
intervention was
http://www.flag-zone.com developed
(Source : Hilary Creed-Kanashiro)

37. Examples of how ProPAN has been Used
• Ecuador 2002-2003
• The ProPAN software was
used to evaluate the diet
of children participating in
an evaluation of a national
nutrition program
http://www.flag-zone.com
• 2008: To enter and
analyze 24-h recall data
from a survey of pregnant
women
(Source : Chessa Lutter, Alicia Rodríguez)

38. Examples of how ProPAN has
been Used
• Mexico 2004
• Used in a summer course
offered at the INSP:
Design, Implementation
and Evaluation of
Communication
Interventions in Nutrition
http://www.flag-zone.com
(Source : Hilary Creed-Kanashiro)

39. Examples of how ProPAN has
been Used
• Cambodia 2006
• A food composition table
was developed based on
ProPAN’s table
• 24-hour dietary recall data
were analyzed as part of a
http://www.flag-zone.com formative study on infant-
feeding practices
(Source : Tita Picado)

40. Examples of how ProPAN has
been Used
• Guatemala 2006
• 28 persons were trained in
ProPAN with an emphasis
on formative research and
to develop education and
communication strategies
http://www.flag-zone.com
to improve infant-feeding
practices
(Source : Hilary Creed-Kanashiro)

41. Examples of how ProPAN has
been Used
• Peru 2006
• Was used in the Iowa-IIN
Course in International
Nutrition in the Nutrition
Education and
Communication Module
http://www.flag-zone.com
(Source : Hilary Creed-Kanashiro)

42. Examples of how ProPAN has
been Used
• Uruguay 2007
• Used the software to
calculate intakes and
nutrient adequacy in
breastfed and non
breastfed children
http://www.flag-zone.com • Basis for proposal to
World Bank
(Source : Chessa Lutter)

43. Examples of how ProPAN has
been Used
• Honduras 2008
• Used the manual to
assess breast and
complementary feeding
practices in Honduras
http://www.flag-zone.com
(Source : Evelia Kory)

44. Advantages
• Leads to the identification of specific nutritional and
dietary problems and an understanding of the context
in which these problems occur
• Presents a method for identifying, ranking and
selecting practices that are practical, feasible, and
acceptable by the community
• Provides electronic forms for data collection forms
and software for standardized output of nutrition,
feeding and diet information

45. Advantages
• Jointly considers breastfeeding and complementary
feeding practices
• Integrates quantitative and qualitative methods
• Explains how to analyze information
• Offers guidelines on how to convert data into an
implementable program
• Modules can be used separately “cafeteria style”
• Incorporates a globally relevant Food Composition
Table
• Can be useful to training in nutrition research
methods

46. Updates (ProPAN 2.0)
• Uses the WHO Child Growth Standards
• Incorporates the WHO/UNICEF Infant and Young
Child Feeding Indicators
• Measures responsive feeding
• Includes questions on HIV and infant feeding
• Produces output to use with WHO’s OPTIFOOD’s
program
• Is available in French, English and Spanish

47. ProPAN Team
• Chessa Lutter, PAHO/WHO
• Helena Pachón, Emory Rollins School of Public Health
• Kevin Sullivan, Emory Rollins School of Public Health
• Roger Mir, CDC
• Edith Chung, UNICEF
• Christine Rudart, UNICEF
• Hilary Creed de Kanashiro, Institute for Investigation in
Nutrition, Peru