Sonya Olson Transcultural fund recipient
Summer 1998, Guatemala, Costa Rica

Title: Monitoring of Salt lodization Programs 

Learning Objectives: 

• Through language training and the immersion experience I will be able to better communicate in Spanish. My oral and written Spanish skills are much improved after this summers experience. As the summer progressed I became more and more comfortable with communicating in Spanish. 
• In collaborating with the national nutrition program managers and UNICEF project officers in Central America, experience will be obtained in external program appraisal.  I gained much experience in external appraisal.  I was asked to report on the state of the programs during and at the conclusion of site visits in three countries.

The data collection, analysis and reporting will enable learning of how to best communicate about strengths, weaknesses and recommended improvements in applying a public health program. I learned through trial and error in this regard. At the conclusion of my visit to Panama I presented my findings to UNICEF, KIWANIS, and the Ministry of Health where I discussed strengths and weaknesses of the program. Receiving instant feedback on my recommendations, I learned quickly how to best make suggestions.

• Through my interactions with KIWANIS, UNICEF, program officials and the salt sector, skills will be obtained of collaboration with the many and multi-sectoral "stakeholders" in an international, collaborative public health endeavor. In Guatemala worked with a wide variety of persons and organizations that are involved in fortification efforts. These included UNICEF, INCAP (Institute of Nutfition of Central American and Panama), Ministry of Health's Food Regultion officers, the National Fortification Commission. I also met with a private group working on food fortification issues, a biochemistry research group, the national association of salt producers, and visited a salt fortification plant and store owners. I learned how these groups work together and of the challenges involved when various partners have different approaches to solving a problem. 

Project Objectives: In salt iodization programs worldwide, monitoring of the progress is needed to ensure elimination of Iodine Deficiency Disorders forever. The purpose of the study was to add to knowledge on the qlality of supply and access of iodized salt in Costa Rica, Panama and Guatemala. This will permit UNICEF programs in Central America to more effectively prioritize their ongoing work to ensure salt iodization.

• Assess salt iodization process and merchandizing in Costa Rica, Panama and Guatemala in order  to evaluate whether consumers are receiving an adequate level of iodine. 
• Determine what percentage of the salt reaching customers in Costa Rica, Panama, and Guatemala is iodized. 

Discription of Field Activities: Several methods were used including observation, questionaires, field testing, and laboratory testing. Observation: Visits were made to salt industries and wholesale, retail, and grocery stores. Salt industries were visited to observe procedures in assuring the quality and consistency of iodized salt. Questionaires: Wholesale and retail stores were visited to observe whether sheltered storage and first-in-first-out practices for iodized salt are being applied. Grocery stores were visited to check branded and non-branded salt for iodine. Grocers were given a questionnaire to determine knowledge, attitudes, practice and behavior with regard to iodized salt. The questionnaire was based on a sample questionnaire in the ISPAT monitoring tool produced by the international Council for Control of Iodine Deficiency Disorders and the Program Against Micronutrient Malnutrition. Field testing: A rapid field testing kit available through UNICEF was used to identify iodized salt. As representatives of their community, school children were asked to bring in salt samples from home for rapid testing. Laboratory testing: Titration processes were used to determine salt iodization levels in parts per million. This was done in accord with the "Quality Control Laboratory for Iodized Salt" reference procedures in the guide, Salt lodization for the Elimination of

Preliminary Results: Very generally, Costa Rica's program seemed to be most effective in ensuring the production of iodized salt. The country had a very extensive laboratory testing and follow-up program.  In poorer and rural areas, some people have been consuming coarse salt meant for animals, and this salt is uniodized. Costa Rica is currently developing a sentinel surveillance system to monitor all of fortified foods at the household level. 

Panama has a limited laboratory testing system, however, the salt samples I collected were iodized sufficiently, and above set levels in some cases. A poorer rural province of Panama historically has had high goiter prevalence. The iodization program is conducting an educational campaign to encourage consumption of iodized salt in this area. Legislation has just been passed for iodization of all salt for animals. 

Guatemala's salt iodization program is still struggling. Of the twenty-eight salt samples I gathered in various communities in Guatemala, only 5/28 were sufficiently iodized. The problem is complicated, including low governmental priority for funding and regulation, lack of commitment of some salt producers, and lack of consumer education and demand. 
 

Personal and Career Impact: On a personal level, this experience was very beneficial to me. I had been a bit concerned about safety issues as I was traveling independently in foreign countries, however I remained safe and thoroughly enjoyed the experience. I gained valuable experience in "thinking on my feet" and in analyzing situations.  My

Spanish communication skills improved and this promises to open greater opportunities for me in the future. 

Expected Products and Follow-Up: I recently completed titration testing of the salt samples at the CDC. My next steps will be to analyze the results in reference to the Governmental regulations and complete country reports for Costa Rica, Panama, and Guatemala. I plan to submit these reports to the UNICEF offices in these countries and to my KIWANIS supporters in hopes that improvements will be made in their salt iodization programs, and use these reports to fulfill special research project guidelines for graduation. Over Christmas vacation I will be reporting to KIWANIS clubs in the Northwest about my experience and in the spring I will discuss the findings for students and faculty at Rollins School of Public Health.