Monitoring and Evaluation: Maternal and Child Nutrition

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Monitoring and EvaluationMaternal and Child
Nutrition
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Session Objectives

• By the end of this session participants will be
  able to
• Apply basic ME concepts to maternal and child
  nutrition interventions
• Design and use ME frameworks for nutrition
  programs
• Identify nutrition interventions and common
  indicators for assessing their results
• Describe ME challenges of nutrition programs

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Session Overview

• The problem of malnutrition
• Interventions and strategies
• ME frameworks for nutrition programs
• Common indicators data sources
• ME challenges

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The Problem

• Malnutrition contributes to over half of all
  child deaths, (60)
• Malnutrition is largely hidden, (mild, moderate,
  ?)

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Importance of malnutrition as an underlying
factor in under-five mortality in Ethiopian
Children.
Others
Diarrheal Diseases
Malnutrition 58
Perinatal Complications
Acute Respiratory Infections
Measles
Malaria
WHO 98
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Micronutrient deficiencies

• Micronutrient deficiencies have severe
  consequences
• Iodine deficiency damages intellectual
  development,
• 50 of pregnant women and 40-50 of children lt
  5 in developing countries are iron deficient,
• VAD affects gt 100 million children, and is
  responsible for as many as one out of every
  four child deaths in places with Vitamin A
  deficiency,

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• How maternal and child nutrition are linked

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Causes of Malnutrition conceptual framework
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Nutrition and Development

• Nutritional status is a key indicator of progress
  in attaining MDGs
• Eradicate extreme poverty and hunger (Goal 1),
• Achieve universal primary education (Goal 2),
• Promote gender equality and empower women (Goal
  3),
• Reduce child mortality (Goal 4),
• Improve maternal health (Goal 5),
• Combat HIV/AIDS, malaria and other diseases (Goal
  6),
• Ensure environmental sustainability (Goal 7),
• Develop a global partnership for development
  (Goal 8)

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Nutrition is Critical in Achieving MDGs

• 1. Poverty alleviation - an indicator is
  children underweight
• 2. Primary education - benefits can accrue when
  nutrition and cognition are adequate
• 3. Gender equality- better nourished girls
  likely to stay in school longer

• 4. Child mortality - 60 associated with
  malnutrition
• 5. Maternal health - anemia, iodine deficiency,
  low BMI associated with health indicators
• 6. Infectious diseases and HIV AIDS-
  malnutrition worsens and makes them more
  susceptible to adverse outcomes

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World Fit for Children Goals

• Reduction of child malnutrition among children
  under five years of age by at least one third,
  with special attention to children under two
  years of age.
• Achieve the sustainable elimination of iodine
  deficiency disorders by 2005
• Achieve the sustainable elimination of vitamin A
  deficiency by 2010
• Reduce the prevalence of anemia (including iron
  deficiency) by one third by 2010

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• Interventions and Strategies

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Interventions Proven to Reduce Malnutrition When
Linked with Health Services (Essential Nutrition
Actions)
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Monitoring and Evaluation Frameworks
for Nutrition Programs
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Results Framework
SO Vulnerable families achieve sustainable
improvement in the nutrition and health status of
seven million women and children by 2008
IR1 Service providers improve quality coverage
of maternal and child health nutrition services
key systems
IR2 Communities sustain activities for improved
maternal and child survival and nutrition
IR1.1 Coordinate/converge services provided by
the Dept. of social services (ICDS) and MOH, e.g.
through Nutrition and Health Days, and Block
planning
IR1.2 Build capacity of service providers,
supervisors and managers in the dept. of social
services (ICDS) and MOH
Source Adapted from CARE/India INHP II, DAP II
2001-2006
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Logical Framework
NOTE A logic model would allow a program to
select indicators that monitor all stages
(inputs, process, outputs) of their activities
e.g. funds and staff available (inputs), training
sessions completed (process), number of skilled
workers or villages with trained volunteers
(outputs).
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• Common Indicatorsand Data Sources

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Categories of Nutrition Indicators

• Nutritional status
• Breastfeeding practices
• Complementary feeding practices
• Micronutrient supplements/fortified foods
• Household food security vulnerability to food
  and nutrition insecurity

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Most Common Indicators

• Nutritional status
• Weight-for-age and/or height-for-age
• Body Mass Index in women
• Anemia prevalence
• Vitamin A deficiency
• Infant and young child feeding practices
• Timely initiation of breastfeeding
• Exclusive breastfeeding rate
• Complementary feeding rate
• Extra feeding for malnourished/recently sick
  children

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Most Common Indicators

• Micronutrient Interventions
• Vitamin A supplementation
• Iron supplementation
• Coverage with iodized salt, other fortified foods
• Household Food Security/Vulnerability
• Daily meal frequency of family/individuals
• Perceived inadequacy of food reserves in the
  home/community

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Data Collection Systems

• Routine
• Sentinel food and nutrition surveillance
• Institutional health records- clinics, schools
• Feeding cash or food transfer programs records-
  daily/weekly/monthly attendance
• Non-routine
• Population-based surveys
• Emergency appraisals, rapid assessments
• Experimental and operational research

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Anthropometric Measures (1)

• Children
• Weight-for-age (underweight)
• Reflects chronic or acute malnutrition or both
• Height-for-age (stunting)
• Reflect chronic (prolonged, cumulative)
  malnutrition
• Weight-for-height (wasting)
• Reflects acute and recent malnutrition

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Anthropometric Measurements (2)

• Adults
• Body Mass Index (BMI)
• Low weight-for-height ( kg/m2) reflects chronic
  /or acute
• Mid-upper arm circumference (MUAC)
• Thin reflects chronic /or acute

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Data Sources for Anthropometry

• MCH programs/clinic records
• School feeding- school heights.
• Food and nutrition, epidemiological surveillance
• Poverty mapping/school height census - heights
  for chronic, weights for current
• Reports from emergency/refugee programs

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Detecting Low Weight-for-age
Option B Table of weight-for-age cut-off points
Option A Growth Chart
Cut-Off Points Low Weight-for-Age
Girls
Boys
Age mths
Age mths
Low wt/age below this line
Low wt for age below this line
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Statistical Presentation of Anthropometric
Indicators

• Prevalence
• Percent below a cut-off, such as lt-2SD or lt -3
  SD
• Mean Z-score values (in SD units)
• Z score refers to how far and in what direction
  the measure deviates from the median of the
  NCHS/WHO international reference standard

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Exercise Interpreting Standard DHS Nutrition
Status Tables

• If low HFA is 50, WFA is 30, WFH is 15, which
  is the worst problem? Why?
• Which child is more vulnerable to die a -sd
  wasted or a -3sd stunted child? Why? In which
  age group?
• Which characteristics are more important for
  program targeting rural/urban, region, sex, age,
  or birth order?

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Feeding Practices ME Considerations

• Proportion of infants aged 0-5 months who were
  exclusively breastfed in the last 24 hours,
• Proportion of infants less than 12 months of age
  who were put to the breast within one hour of
  delivery,
• Proportion of infants aged 6-9 months receiving
  breastmilk complementary foods,
• Mean number of food groups eaten in the last 24
  hours by children 6-23 months of age,

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Appropriate Complementary Feeding

• Percentage of infants and young children 6 -23
  months of age who receive appropriate
  complementary feeding
• 6 to 8 months of age Breastmilk other food at
  least 2-3 times per day variety of food groups
• 9 to 11 months of age Breastmilk other food
  at least 3-4 times per day variety of food
  groups
• 12 to 23 months of age Breastmilk other food
  at least 3-4 times per day variety of food
  groups

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Coverage Indicators for Micronutrient Programs

• Proportion of children aged 6-59 months who
  received a high dose of vitamin A in the last 6
  months,
• Proportion of households consuming adequately
  iodized (i.e. 15 ppm of iodine) salt,
• Proportion of pregnant women who received the
  recommended number of iron/folate supplements
  during pregnancy,

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Choices in Program ME Design

• Which age groups to measure
• Anthropometry, infant and young child feeding,
• How to obtain valid measurements
• Anthropometry micronutrients infant and young
  child feeding
• Timing
• Trends seasonality
• Evaluation design

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Examples of Flaws in Nutrition Evaluations

• No comparison groups
• No pretest or baseline
• No control for age, e.g. lt 6 mo.,lt 2 and 3 yrs
• Not accounting for confounding factors
• Seasons not comparable
• Not controlling for mortality reduction
• Non-representative samples, small samples
• Pilot projects, not replicable

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Economic Analysis in Nutrition ME

• Cost-effectiveness analysis
• compares two or more alternatives for achieving
  coverage or scale or behavior change, or a
  process outcome such as training to build
  capacity
• Answers the question which is the more efficient
  option?
• Used more in evaluations
• Cost-benefit
• compares the resources required to achieve impact
  and the monetary value of that impact
• Answers the question is the investment
  worthwhile?
• Based on many assumptions with limited empirical
  evidence

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Example Use of Data to Assess Program Gaps
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• Monitoring and Evaluation
• Challenges

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Challenges of ME

• Multisectoral programs (attributing outcome?)
• Clinical Indicators
• May need large samples (e.g. xerophthalmia)
• May be sensitive to enumerator training (e.g.
  goiter)
• Measurement of iron deficiency (lack of
  specificity)
• Selection bias (institution based sample)

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Challenges Comparisons Trends

• Sample design
• Sample size
• Cutoff points standards
• Seasonality

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References

• Arimond, Mary and Marie T. Ruel. 2003.
  Generating Indicators of Appropriate Feeding of
  Children 6 through 23 Months from the KPC 2000.
  Washington, D.C. Food and Nutrition Technical
  Assistance Project, Academy for Educational
  Development.
• Cogill, Bruce. 2003. Anthropometric Indicators
  Measurement Guide. Washington, D.C. Food and
  Nutrition Technical Assistance Project, Academy
  for Educational Development.
• Wasantwisut, Emorn. 2002. Recommendations for
  monitoring and evaluating vitamin A programs
  outcome indicators. Journal of Nutrition, 132
  2940S-2942S.
• Ruel, M.T., K.H. Brown, and L.E. Caulfield.
  2003. Moving Forward with Complementary Feeding
  Indicators and Research Priorities. Food
  Consumption and Nutrition Division Discussion
  Paper 146. Washington, D.C. International Food
  Policy Research Institute.
• WHO. 2001a. Assessment of Iodine Deficiency
  Disorders and Monitoring their Elimination A
  Guide for Programme Managers. Second Edition.
  WHO/NHD/01.1. Geneva World Health Organization.
• WHO. 2001b. Iron Deficiency Anaemia Assessment,
  Prevention and Control - A Guide for Programme
  Managers. WHO/NHD/01.3. Geneva World Health
  Organization.
• Wellstart Internationals Tool Kit for Monitoring
  and Evaluating Breastfeeding Practices and
  Programs.

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Madagascar Nutrition Case Study
During 1996-2002, Madagascar followed a
comprehensive model, the essential nutrition
actions (ENA) framework, which coordinated
efforts from the community level through national
policy making, and included both government and
non-government entities. The model was first
implemented in two districts in the Antananarivo
and Fianarantsoa provinces. It focused on a set
of proven interventions covering micronutrients
and dietary practices for mother and young
children. From 1995 to 1998, the overall focus
was placed on designing mechanisms that linked
nutrition interventions more directly with other
child health and RH services, and national- and
community-level actions. Further instructions are
provided in the handout.