Monitoring and Evaluation ofMaternal and Child Nutrition

Session Objectives

By the end of this session participants will be able to:

Apply basic M&E concepts to maternal and child nutrition interventions

Design and use M&E frameworks for nutrition programs

Identify nutrition interventions and common indicators for assessing their results

Describe M&E challenges of nutrition programs

Session Overview

Defining malnutrition

The problem of malnutrition

Interventions and strategies

M&E frameworks for nutrition programs

Common indicators & data sources

M&E challenges

Defining Malnutrition

Malnutrition: generic term includes both undernutrition and overnutrition

Undernutrition: is insufficient consumption to maintain good health caused by (any or all)

insufficient food

poor quality diet

disease

Undernutrition can lead to impaired growth, weak immune function and death if not treated

Defining Malnutrition

Overnutrition is the excess consumption of food, which can lead to obesity and chronic diseases such as heart disease and diabetes.

Most nutrition programs in developing countries have targeted undernutrition, which is the focus of this module.

However, many countries are beginning to experience dual malnutrition epidemics with high levels of both undernutrition and overnutrition.

The Problem

Maternal and child undernutrition is the underlying cause of 3.5 million deaths, 35% of the disease burden in children younger than 5, larger than any other risk category.

20% of children younger than 5 years in low- and middle-income countries are underweight (low weight for age).

32% were stunted (low height for age).

The Problem Among micronutrient deficiencies, the largest disease

burdens among children under 5 are attributed to vitamin A and zinc.

Iron deficiency anemia is highly prevalent (est. ~25% of pregnant women) and a risk factor for maternal mortality.

Iodine deficiency is the primary cause of preventable mental retardation in children and is associated with miscarriage, stillbirths and infant mortality.

How Maternal and Child Nutrition are Linked

Conceptual Framework—

Causes of Malnutrition

Human, Economic, andInstitutional Resources

Nutritional Status

Health Feeding practices

HouseholdFood Security

Potential Resources

Ecological Conditions

Care of motherand child…

gender

HealthServices, Hygiene,

Sanitation

Political and Ideological Structure BasicCauses

ImmediateCauses

UnderlyingCauses

Long term consequences: adult size, intellectual ability, economic productivity, reproductive performance,

metabolic, cardiovascular disease

Short-term consequences:

Mortality, morbidity

Adapted from UNICEF

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—associated with malnutrition

#5. Maternal health—anemia, iodine deficiency, low BMI associated with MCH indicators

#6. Infectious diseases and HIV AIDS—malnutrition worsens and makes them more susceptible to adverse outcomes

Scaling Up Nutrition (SUN)—Main Elements

Country ownership of nutrition strategies

Scale up of evidence-based interventions, with highest priority on the first 1,000 days (pregnancy through 24 months)

Multi-sectoral approach; integrating nutrition in related sectors/using indicators of undernutrition as measures of progress in related sectors

Scaled up domestic and internal assistance

Interventions and Strategies

Interventions Proven to Reduce Malnutrition When Linked with Health Services (Essential Nutrition Actions)

Vitamin A and iron Iodized salt

Breastfeeding Mother’s nutritionComplementary feeding

Sick/severe cases

Monitoring and Evaluation Frameworks for Nutrition Programs

Results Framework

SO: Vulnerable families achieve sustainable improvement in the nutrition and health status of seven million women and children by 2006

IR1 Service providers improve quality & coverage of maternal and child health & nutrition services & key systems

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

IR2 Communities sustain activities for improved maternal and child survival and nutrition

IR2.3 Stronger links between health systems and communities

IR2.2 Increase ownership and participation of community leaders and groups in monitoring health and nutrition services and behaviors

IR2.1 Increase awareness of households & other key audiences about desirable nutrition and health behaviors through multiple channels, e.g. ‘change agents’

Source: Adapted from CARE/India INHP II,

DAP II 2001-2006

Logical FrameworkASSUMPTIONS

 

- Stable political situation, sustained political commitment and financing

- Sufficient numbers of competent health care personnel and supplies in the government sector

- No natural disaster or disease epidemic

MEANS OF

VERIFICATION

1.Annual reports from MCH services, special surveys

2.Annual reports, special surveys

3.National / local tracking reports (surveillance) of high risk areas/ populations

PERFORMANCEINDICATORS  

1.Proportion of children 6-35 months who are malnourished

2. Coverage of essential nutrition actions: exclusive BF, appropriate CF, vitamin A, iron supplements /fortified foods, iodized salt use, coverage of sick and malnourished in special programs

3. Proportion of households at risk of or vulnerable to food insecurity

PURPOSE

 

Sustainable improvement in the nutrition and health status of women and children through improved services provision and community participation

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).

Common Indicatorsand Data Sources

Categories of Nutrition Indicators

Nutritional status (macro- and micronutrient)

Breastfeeding practices

Complementary feeding practices

Micronutrient supplements/fortified foods

Improved water & sanitation infrastructure and hand washing behaviors

Individual food consumption, household food security; vulnerability to food and nutrition insecurity

Most Common Indicators

Nutritional status Prevalence of stunting (low height-for-age) Prevalence of wasting (low weight-for-height) Prevalence of underweight (low weight-for-age) in

children; Body Mass Index in adults Anemia prevalence Prevalence of vitamin A deficiency

Most Common Indicators

Infant and young child feeding practices Timely initiation of breastfeeding (within 1 hr) Exclusive breastfeeding rate Introduction of solid, semi-solid or soft foods Continued breastfeeding at 1 years Continued breastfeeding at 2 years Extra feeding for malnourished/recently sick children

Most Common Indicators Micronutrient Interventions

Vitamin A supplementation

Iron supplementation

Coverage with iodized salt, other fortified foods

Zinc supplementation for tx of diarrhea

Household Food Security/Vulnerability

Daily meal frequency of family/individuals

Dietary diversity or dietary adequacy

Perceived adequacy of food reserves in the home/community

Data Collection Systems

Routine

Sentinel food and nutrition surveillance

Institutional health records- clinics, schools, GMP

Feeding & cash or food transfer programs records- daily/weekly/monthly attendance

Non-Routine

Population-based surveys

Special surveys

Emergency appraisals, rapid assessments

Experimental and operational research

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

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

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

Household surveys

Detecting Low Weight-for-Age

Option B

Table of weight-for-age cut-off points

Option A

Growth chart

Low wt/agebelow this line

Cut-Off PointsLow Weight-for-Age

Girls Boys

Age mths

Age mths

Low wt for age below this line

Statistical Presentation of Anthropometric Indicators

Prevalence

Percent below a cut-off, such as <-2SD or < -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

Exercise: Interpreting Standard DHS Nutrition Status Tables

If 50% of children are stunted (e.g. height-for-age Z-scores less than -2) what does this indicate?

What if, in the same population, 30% are underweight and 15% are wasted?

Which child is more vulnerable to die: a -3sd wasted or a -3sd stunted child? Why? In which age group?

By which characteristics would you recommend disaggregating these data?

Feeding Practices

Percentage of infants less than 24 months of age who were put to the breast within one hour of delivery

Percentage of infants aged 0-5 months who were fed exclusively with breast milk in the last 24 hours

Percentage of infants aged 6-8 months who received solid or semi-solid food the previous day

Feeding Practices

Percentage of infants and young children 6 to 23 months of age who receive a minimum acceptable diet:

6 to 8 months of age : Breastmilk + other food at least 2 times per day + 4 or more food groups

9 to 23 months of age : Breastmilk + other food at least 3 times per day + 4 or more food groups

For non-breastfed infants 6 to 23 months of age : 2 milk feedings + diversity and frequency of meals as above by age group

Coverage Indicators for Micronutrient Programs

Percent of children aged 6-59 months who received a high dose vitamin A supplement in the last 6 months

Percent of households consuming adequately iodized (i.e. 15+ ppm of iodine) salt

Percent of pregnant women who received the recommended number of iron/folate supplements during pregnancy

Choices in Program M&E 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

Examples of Flaws in Nutrition Evaluations

No comparison groups

No pretest or baseline

No control for age, e.g. < 6 mo.,< 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

Economic Analysis in Nutrition M&E 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

Additional Considerations

Gender:

Intra-household dynamics

Micronutrient requirements/deficiencies differ by sex

Geography:

Ecological zones

Proximity to markets

ENA Indicators

4635 41 42 47 52

65 59 58 53 4854

0

10

20

30

40

50

60

70

80

90

100

EBF in children<5 months

Weight/age -2SD in children

0-35 months

Vit A supp. forchildren 6-59months (one

dose)

Pregnantwomen whoreceived iron

tablets

Amount of foodis maintainedor increased

during dirrahea

Iodized saltconsuption(>15ppm)

Unmetneed

Currentcoverage

Example: Use of Data to Assess Program Gaps

M&E Challenges

Challenges of M&E

Multisectoral programs (attributing outcome?)

Clinical Indicators

May need large samples (e.g., xerophthalmia, feeding practices for 6-8 month old infants)

May be sensitive to enumerator training (e.g., goiter)

Measurement of iron deficiency (lack of specificity)

Selection bias (institution-based sample)

Challenges: Comparisons & Trends

Sample design

Sample size

Cutoff points & standards

Seasonality

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.

Black RE. 2008. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 371: 243-60.

Bhutta ZA et al. 2008. What works? Interventions for maternal and child undernutrition and survival. Lancet, 371: 417-40.

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.

References Victora CG et al. 2008. Maternal anc child undernutrition: consequences for

adult health and human capital. Lancet, 371: 340-57. 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 Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization, 2006

WHO. 2001b. Iron Deficiency Anaemia: Assessment, Prevention and Control - A Guide for Programme Managers. WHO/NHD/01.3. Geneva: World Health Organization.

WHO. Indicators for assessing infant and young child feeding practices part 1: definitions. Geneva, World Health Organization, 2008.

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.

MEASURE Evaluation is funded by the U.S. Agency for

International Development (USAID) and implemented by the

Carolina Population Center at the University of North Carolina at

Chapel Hill in partnership with Futures Group, ICF Macro, John

Snow, Inc., Management Sciences for Health, and Tulane

University. Views expressed in this presentation do not necessarily

reflect the views of USAID or the U.S. government. MEASURE

Evaluation is the USAID Global Health Bureau's primary vehicle for

supporting improvements in monitoring and evaluation in

population, health and nutrition worldwide.