Title: Monitoring and Evaluation: Maternal and Child Nutrition
1Monitoring and EvaluationMaternal and Child
Nutrition
2Session 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
3Session Overview
- The problem of malnutrition
- Interventions and strategies
- ME frameworks for nutrition programs
- Common indicators data sources
- ME challenges
4The Problem
- Malnutrition contributes to over half of all
child deaths, (60) - Malnutrition is largely hidden, (mild, moderate,
?)
5Importance 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
6Micronutrient 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,
7- How maternal and child nutrition are linked
8Causes of Malnutrition conceptual framework
9Nutrition 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)
10Nutrition 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
11World 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
12- Interventions and Strategies
13Interventions Proven to Reduce Malnutrition When
Linked with Health Services (Essential Nutrition
Actions)
14Monitoring and Evaluation Frameworks
for Nutrition Programs
15Results 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
16Logical 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).
17- Common Indicatorsand Data Sources
18Categories of Nutrition Indicators
- Nutritional status
- Breastfeeding practices
- Complementary feeding practices
- Micronutrient supplements/fortified foods
- Household food security vulnerability to food
and nutrition insecurity
19Most 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
20Most 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
21Data 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
22Anthropometric 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
23Anthropometric 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
24Data 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
25Detecting 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
26Statistical 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
27Exercise 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?
28Feeding 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,
29Appropriate 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
30Coverage 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,
31Choices 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
32Examples 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
33Economic 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
34Example Use of Data to Assess Program Gaps
35- Monitoring and Evaluation
- Challenges
36Challenges 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)
37Challenges Comparisons Trends
- Sample design
- Sample size
- Cutoff points standards
- Seasonality
38References
- 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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41Madagascar 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.