title: Can fortification be implemented in rural African communities where micronutrient deficiencies are greatest? Lessons from projects in Malawi, Tanzania, and Senegal.
abstract: BACKGROUND
  Fortifying common foods with micronutrients is an effective strategy for decreasing micronutrient deficiencies at a population level. National fortification initiatives often do not impact remote communities that are unreached by commercially produced food. The feasibility and sustainability of small-scale fortification as a mechanism to overcome this barrier are not well documented.
  
  
  OBJECTIVE
  To document the process and assess the feasibility of implementation of community-based fortification of staple grains in rural communities in Malawi, Tanzania, and Senegal.
  
  
  METHODS
  In the late 1990s, World Vision piloted community-level fortification within a large-scale, multicountry, integrated nutrition and health program. The exploratory approach focused on developing appropriate community-based methods and processes for flour fortification. An external review in 2012 documented the implementation process, identified barriers and enablers for sustainability and effectiveness, and evaluated the potential for replication and/or scale-up of the intervention.
  
  
  RESULTS
  Strong advocacy influenced national policy and legislation for mandatory national-level fortification of staple grains. Piloting community-based fortification led to community acceptance of the consumption of fortified foods; however, lack of realistic funding mechanisms limited sustainability.
  
  
  CONCLUSIONS
  Despite the complexity and challenges of community-based fortification, it demonstrates great potential to address unmet needs for micronutrients in vulnerable populations. Further work is needed to determine contextually feasible and sustainable mechanisms for premix supply, quality control, and cost recovery. Incorporating community-based fortification into national fortification frameworks is recommended for countries where a significant proportion of the population may have very limited access to commercially fortified foods.
authors.forename: Alison
authors.initials: A
authors.lastname: Mildon
authors.forename: Naomi
authors.initials: N
authors.lastname: Klaas
authors.forename: Melani
authors.initials: M
authors.lastname: O'Leary
authors.forename: Miriam
authors.initials: M
authors.lastname: Yiannakis
mesh_terms: D003365:Costs and Cost Analysis; D002523:Edible Grain; D005240:Feasibility Studies; D005527:Food, Fortified / Q000191:economics; D006284:Health Plan Implementation; D006801:Humans; D008295:Malawi; D018977:Micronutrients / Q000008:administration & dosage* / Q000172:deficiency*; D018673:Nutrition Policy / Q000331:legislation & jurisprudence; D011786:Quality Control; D012424:Rural Population; D012675:Senegal; D013636:Tanzania
chemical_list: D018977:Micronutrients