8. Proportion of target population who participate in an adequate number of distributions (adherence)

8. Proportion of target population who participate in an adequate number of distributions (adherence)

VERSION

V5.0 - 2026.03 — Existing

INDICATOR CODE

8

TECHNICAL OWNER

PRG-S Nutrition

INDICATOR TYPE

Country Level Outcome Indicator

INDICATOR CLASSIFICATION

Complementary

INDICATOR SCOPE

Programme specific

APPLICABILITY

The selection of this indicator is recommended against the following sub-activities in CSPs logframes. Selection of the below sub-activities will NOT trigger in COMET the mandatory selection of this indicator:

1. Prevention of micronutrient deficiencies (PMD)

2. Prevention of acute malnutrition (PREV)

3. Prevention of stunting (STUN)

4. HIV care & treatment (HIV/TB_C&T)

   
   

UNIT OF MEASUREMENT & ANALYSIS

Percentage of individuals

DEFINITION

This indicator measures the percentage of eligible individuals who receive at least 66% of the planned distributions of nutrition prevention transfers within a specified recall period. It reflects the extent to which beneficiaries consistently access and utilise scheduled programme distributions, whether these are specialised nutritious foods, cash, or vouchers, including those for fresh foods.

The indicator requires a minimum recall period of three (3) distributions and allows a maximum recall period of six (6) distributions to observe adherence trends. If fewer than three distributions have occurred but reporting is required (e.g., for ACR purposes), data can still be collected and reported with a clear notation of this limitation.

The following terms are important for this indicator:

Planned distribution: The number of scheduled transfers (food, cash, or vouchers) that a beneficiary is intended to receive during the recall period, based on the programme design and distribution calendar.

Distribution: A single transfer event that may include specialised nutritious foods (e.g., Plumpy’Doz, Super Cereal, micronutrient powders), cash, or vouchers for food, including fresh produce.

Minimum of 66%: The threshold for adherence. A beneficiary is considered adherent if they have received at least two-thirds of all planned distributions within the recall period.

Recall period (3–6 distributions): The period during which distribution attendance is assessed. A minimum of three distributions is required for calculating adherence; up to six distributions may be used to assess trends over time. If fewer than three distributions occurred, data can still be reported but must be accompanied by a note indicating that the minimum requirement was not met.

Eligible individuals: The population identified as eligible for the prevention programme based on programme criteria (e.g.,).

RATIONALE

This indicator is used to assess the extent to which beneficiaries consistently receive the planned nutrition prevention transfers over a defined period. Adherence reflects how regularly individuals access the services they are eligible for and therefore serves as a proxy for the programme’s ability to deliver interventions at the frequency required to achieve intended nutrition outcomes. High adherence strengthens the likelihood of preventing wasting, micronutrient deficiencies, and stunting, particularly during critical periods such as the first 1,000 days of life.

Measuring adherence is essential because even well‑designed prevention programmes cannot achieve their intended impact if eligible individuals do not regularly receive the scheduled transfers. Understanding adherence levels helps identify operational, behavioural, or access‑related challenges that may reduce programme effectiveness.

DATA COLLECTION TOOL

The data source for this indicator depends on the type of transfer delivered and the availability of reliable distribution records.

1. Programme Databases (Desk Review)

Where individual‑level distribution data are recorded in digital systems such as SCOPE, financial service provider records, or electronic voucher platforms adherence can be measured through a desk review.

This approach is feasible when the system reliably tracks how many transfers each beneficiary received over the recall period.
It is commonly applicable for:

• cash‑based transfers,

• vouchers, and

• some in‑kind transfers, where distribution attendance is consistently captured.

When using programme databases, the sample should be exhaustive (all beneficiaries with available records). If this is not possible, a representative sample may be used.

2. Beneficiary Survey

If individual‑level distribution records are not available, incomplete, or stored in formats that are difficult to analyse (e.g., paper registers kept by community volunteers), primary data collection is required.

In such cases, adherence must be estimated through a beneficiary survey with a statistically significant sample. Post‑Distribution Monitoring (PDM) surveys can be used for this purpose when they include the required questions on distribution attendance.

Survey respondents provide recall‑based information on the number of transfers received during the defined recall period (3–6 distributions).

The electronic vers ion of the questions (listed below) for survey can be found in Survey Designer in the Nutrition Module, Adequate number of distributions – adherence (Indicator 8) sub-module or by selecting the indicator Proportion of Target Population who Participate in an Adequate Number of Distributions (adherence).

SAMPLING REQUIREMENTS

Sampling requirements depend on the availability and completeness of programme data.

1. When programme data allow for an exhaustive sample

If individual‑level distribution data are available and reliable (e.g., through SCOPE, electronic vouchers, or complete distribution registers), the sample should be exhaustive, meaning all eligible individuals with usable data are included in the calculation.

2. When a survey is required

If programme records are incomplete, not accessible, or insufficient to determine adherence, a statistically representative beneficiary survey must be conducted. The following parameters guide sample size calculation for this indicator:

• Population size:
  The sampling frame is the total number of individuals enrolled in the programme at the time of the survey

• Expected prevalence:
  Adherence is expected to be around of 66%, meaning that two-thirds of beneficiaries should meet the minimum frequency of transfers. The expected prevalence should be

• previous adherence results

• contextual factors (e.g. stock-outs or interruptions) that may reduce adherence.

• Non-response rate:
  A 10% non-response adjustment is recommended to account for households or individuals who cannot be reached or decline to participate.

• Design effect (DEFF):
  If cluster sampling is applied, the design effect must be incorporated.

• When previous DEFF estimates exist, they should be applied.

• If not, a default value of 1.5 may be used.

• Adjust upward or downward depending on the homogeneity or heterogeneity of the surveyed population..

• Confidence level:
  A 95% confidence interval is strongly recommended to ensure statistical reliability.

INDICATOR CALCULATION FOR REPORTING

To calculate the indicator, divide the number of beneficiaries who met the adequate adherence rate by the total number of beneficiaries surveyed, expressed as a percentage.

Survey Calculation:

Example 1: Programme NOT meeting the 66 percent target for participation indicator

X: Enrolled in the programme but not participated in the distribution

√: Enrolled in the programme and participated in the distribution

Example 2: Programme that DOES meet the 66 percent target for participation indicator

X: Enrolled in the programme but not participated in the distribution

√: Enrolled in the programme and participated in the distribution

What happens if a beneficiary does not enter the programme at the beginning?

It is common for beneficiaries to enrol in a programme after the distribution cycle begins. The example below outlines how to calculate the participation of beneficiaries who enrol late. Note that participation of late enrollers is not calculated in the same way as for beneficiaries who have already been enrolled but do not participate.

Three beneficiaries (beneficiaries 1, 2 and 5) have enrolled late and have therefore missed some of the six distributions. Any beneficiary who has had the opportunity to participate in at least three distributions (in a programme with more than three distributions carried out) must be included in the final calculation of participation.

In the example below, even though Beneficiaries 1 and 5 enrolled late, they still had the opportunity to participate in at least three distributions. Their participation is included in the calculation of overall participation. Note that the denominator used for the participation of late enrollees must be adjusted to reflect the total number of distributions those individuals had the opportunity to participate in. If a beneficiary enrolled late and participated in less than three distributions, that beneficiary should be excluded from the calculation for reporting purposes. This is because a beneficiary who does not participate in at least three distributions would not have a chance to attain the minimum target (66 per cent) for adequate participation.

In the example below, Beneficiary 2 was not enrolled in the programme until after four distributions were completed. Therefore, when measuring participation after the fifth distribution, Beneficiary 2 should be omitted from the sample (for calculation and reporting), as this beneficiary participated in less than three distributions overall.

Example 3: What happens if a beneficiary does not enter the programme at the beginning?

X: Enrolled in the programme but not participated in the distribution

√: Enrolled in the programme and participated in the distribution

*Beneficiary should not be included in the analysis

What if the minimum of three distributions could not be met, and the indicator needs to be included due to ACR requirements?

Consider a scenario where data is collected after two distributions and a beneficiary only attended one distribution. In this case, the beneficiary will be counted as attending only 50 per cent of distributions and will not meet the two-thirds (66 per cent) target. Using this measure at the two-month point creates a measurement bias that unfairly represents the programme’s operations and seriously influences the indicator's relevance. If this is reported in the ACR, this limitation should be noted, and results should be interpreted with this limitation in mind.

Scripts in R, STATA and SPSS and sample data are available onGithub for calculating this indicator.

DATA ENTRY AND DISAGGREGATION IN CORPORATE SYSTEMS

Values are recorded in the logframe. Each value has a reporting combination which is created based on:

• Sub-activity

• Country

• Target Group

Mandatory disaggregation (for follow-up value only):

• Sex

BASELINE

Baselines are set only once, at one of the following points:

1. At the beginning of the CSP, or

2. When the indicator is selected for reporting after the commencement of the CSP, or

3. When a change in target, location and/or modality triggers a new reporting combination (target, location and modality) for an existing indicator.

Baselines remain fixed for the entire CSP period and are not recalculated annually, unless applicable above. For a new programme, the baseline is N/A, therefore please use the “no data” function and its sub-function “Not applicable”. For programmes that continue into the next CSP cycle, the baseline should not reset to zero. Instead, it should use the previous year’s adherence value, since this reflects the most recent and realistic level of performance.

TARGET SETTING

Annual targets:

The minimum target should be 66%, but it can also be set higher depending on program design and efforts made to increase adherence and baseline value if available. If feasible and relevant, an increment of the prevalence of adherence can be set but should be linked to programmatic efforts to increase adherence. It is important to set a feasible target, and thus if uncertain, 66% is recommended.

End of CSP target:

The minimum target set should be 66%, but it can also be set higher depending on program design, efforts made to increase adherence and baseline value if available. It is important to set a feasible target, and thus if uncertain, 66% is recommended.

FREQUENCY OF DATA COLLECTION

A minimum of three distributions are required to collect this indicator. In the event that the minimum of three distributions cannot be met and the indicator is required for ACR reporting, an explanatory note should accompany the results.

It is recommended to regularly collect data at a minimum twice a year through PDM exercises or closely after distribution for programme monitoring and course correction. At a minimum data should be collected close to the ACR and/or after the last planned distribution. If the indicator can be collected through secondary data, the frequency of data collection can be scheduled after each distribution cycle to allow for close monitoring and program adaptations if required.

The table below is a hypothetical example of six planned distributions requiring PDM (no desk review possible).

The green crosses (×) represent distributions that have been planned.

The blue ticks (√) are potential PDM data-collection activities, where the participation indicator can be measured during these PDMs (and used to inform future programming).

The red tick (√) represents a PDM where data should be collected for ACR reporting on the participation indicator and a representative sample should be taken. The data should be taken from the PDM conducted closest to the ACR reporting period for ACR reporting.

Table: Hypothetical example of distribution and PDM (post-distribution monitoring) data collection activity schedule

INTERPRETATION

Adherence reflects how consistently beneficiaries receive the planned nutrition prevention transfers. It is shaped by multiple factors, including the quality and reliability of services provided (e.g., whether transfers occurred as scheduled) and the ability and willingness of beneficiaries to access those services. Access barriers may relate to distance, travel time, security, seasonal conditions, or inadequate communication about distribution schedules. Demand‑side factors such as caregivers’ competing priorities or limited understanding of the programme may also influence adherence.

This indicator complements coverage, which measures how many eligible individuals are enrolled. For prevention programmes to achieve their intended nutrition impact, two conditions must be met:

1. eligible individuals need to enroll, and

2. they need to receive transfers at least 66% of the time.

When adherence falls below the 66% minimum threshold, it signals significant programme delivery challenges or access constraints that may undermine the effectiveness of the intervention in preventing malnutrition among enrolled beneficiaries.

Adherence should therefore be interpreted in terms of both service delivery performance and beneficiary access, guided by the following key questions:

• Did transfers occur as frequently as planned?
  Consider supply chain issues, pipeline breaks, stock‑outs, delayed cash disbursements, or irregular distribution schedules.

• Why are beneficiaries missing distributions?
  Assess whether barriers such as distance, transport costs, security risks, competing priorities, or insufficient communication about distribution timing and location are preventing attendance.

This indicator provides essential insight into whether enrolled beneficiaries are receiving prevention services at a frequency required to achieve programme objectives.

REPORTING EXAMPLE(S)

A Post‑Distribution Monitoring (PDM) survey conducted in Uganda in 2025 assessed adherence among pregnant and breastfeeding women (PBW) enrolled in the Acute Malnutrition Prevention (AMP) programme in refugee settlements. The survey measured the proportion of women who received at least 66% of the planned distributions during the recall period.

The results showed that 93% of participating women met the minimum adherence threshold, demonstrating strong and consistent attendance at scheduled distributions. These findings indicate that programme delivery was reliable and that women were able to access the services regularly, supporting the likelihood of achieving the intended prevention outcomes.

INDICATORS COLLECTED & ANALYSED AT THE SAME TIME

The following indicators may be reported along with this indicator:

• 7. Proportion of eligible population reached by nutrition preventive programme (coverage)

For a better interpretation of adherence to a nutrition prevention programme, underlying factors influencing adherence, such as barriers, should be considered. This should be from secondary data and beneficiary perception surveys. Barriers can include but are not limited to those associated with service delivery and the supply chain.

COMPLEMENTARY QUALITATIVE RESEARCH

Qualitative approaches, including Focus Group Discussions and Key Informant Interviews, to complement quantitative data should be implemented to complement quantitative data and establish reasons for performance should be utilized. Qualitative data can also inform required actions and recommendations for improvement.

DECISIONS DATA CAN INFORM

The data generated from this indicator can guide corrective actions in programme delivery and help identify beneficiaries who may require follow‑up support. In addition, trends in adherence provide valuable insight for improving the quality, design, and effectiveness of prevention programmes. This may include adjustments to delivery modalities, revisions to programme locations, or refinements to the type and mix of prevention services offered to ensure intended results are achieved.

VISUALIZATION

Example:

LIMITATIONS

This indicator doesn’t indicate that sufficient coverage is met, and thus only represents the frequency of transfer in those beneficiaries enrolled.

There are a lot of factors that influence adherence, and the indicator doesn’t indicate the reason why the minimum standards are not met. In addition, recall without a beneficiary card might be challenging and could result in a bias.

FURTHER INFORMATION

Nutrition M&E guidelines