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Monitoring and Evaluation: Maternal and Child Nutrition

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By the end of this session participants will be able to: Apply basic M&E concepts to maternal and child ... May need large samples (e.g. xerophthalmia) ... – PowerPoint PPT presentation

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Title: Monitoring and Evaluation: Maternal and Child Nutrition


1
Monitoring and Evaluation Maternal and Child
Nutrition
2
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

3
Session Overview
  • The problem of malnutrition
  • Interventions and strategies
  • ME frameworks for nutrition programs
  • Common indicators data sources
  • ME challenges

4
The Problem
  • Malnutrition contributes to over half of all
    child deaths, (60)
  • Malnutrition is largely hidden, (mild, moderate,
    ?)

5
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
6
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,

7
  • How maternal and child nutrition are linked

8
Causes of Malnutrition conceptual framework
9
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)

10
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

11
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

12
  • Interventions and Strategies

13
Interventions Proven to Reduce Malnutrition When
Linked with Health Services (Essential Nutrition
Actions)
14
Monitoring and Evaluation Frameworks
for Nutrition Programs
15
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
16
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).
17
  • Common Indicators and Data Sources

18
Categories of Nutrition Indicators
  • Nutritional status
  • Breastfeeding practices
  • Complementary feeding practices
  • Micronutrient supplements/fortified foods
  • Household food security vulnerability to food
    and nutrition insecurity

19
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

20
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

21
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

22
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

23
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

24
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

25
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
26
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

27
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?

28
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,

29
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

30
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,

31
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

32
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

33
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

34
Example Use of Data to Assess Program Gaps
35
  • Monitoring and Evaluation
  • Challenges

36
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)

37
Challenges Comparisons Trends
  • Sample design
  • Sample size
  • Cutoff points standards
  • Seasonality

38
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.

39
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40
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41
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.
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