regional technical working group meeting on developing nutrition information systems
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Regional Technical Working Group Meeting on Developing Nutrition
Information Systems
Nairobi, 1-3 Feb 2007
Aims of Nutrition
Information
John B Mason, Tulane SPHTM
Inadequate dietary intake Disease
Malnutrition and death
Inadequate access to food
Inadequate care for mothers and children
Insufficient health services and un- healthy environ-
ment
I na d e q u a t e e d u c a t i o n
Potential resources
Political and ideological superstructure
Economic structure
Formal and non- formal institutions
Outcomes
Immediate causes
Underlying causes
Basic causes
Source: Redrawn from UNICEF, 1990 [39]
Conceptual framework for the causes of malnutrition in society
Surveillance: “to watch over ... to make decisions that will lead to improvements in populations ...”
Data Observation
Decide on action
Take action (‘Implement’)
Monitor Evaluate
Detect new problems
Surveillance cycle
National Trends in Underweight Prevalence
0
5
10
15
20
25
30
35
Date
Prev (%)
Lesotho
Malawi
Mozambique (6Provinces)Zambia
Zambia (S.Prov.)Zimbabwe
Figure 2.1. Trends in national prevalences of children underweight.
0
5
10
15
20
25
30
35
40
45
50
1994 1996 1998 2000 2002 2004 2006
%
Eritrea
Ethiopia
Kenya
Uganda
Note: child ages are 6-59 months for Kenya and Uganda, 3-59 months for Ethiopia, and 0-36 months for Eritrea. Underweight is < - 2SDs by WHO/NCHS standards.
0
5
10
15
20
25
30
35
40
Coast
Eastern
North East
Rift Valley
Area level survey results, Kenya: GAM % by season
0
5
10
15
20
25
30
Area level survey results, pooled & smoothed: Kenya, GAM%, by season
0
5
10
15
20
25
30
Area level survey results, pooled & smoothed: Ethiopia, GAM%, by season
Uses of information can be distinguished into:
• long-term planning and policy-making
• programme monitoring and evaluation
• timely warning to pre-empt and mitigate crises
Usual sources of data are:
• repeated large-scale surveys (e.g. natl, DHS, MICS)
• area level surveys (e.g. 30 by 30)
• reporting systems using data from clinics, screeening, programmes
• sentinels systems, from sites (e.g. clinics) or special surveys
Source
Long-term planning
Program monitoring and evaluation
Timely warning to prevent crises
A. Repeated national surveys
Yes, main use Possible but rare as process data limited and design not ideal
No, too infrequent and too long lag
B. Area level surveys
Not usually, but some potential with further analysis
Possible but rare as process data limited, design not ideal, and external validity may be unclear.
Main use, together with other data (e.g. prices)
C. Reporting systems
Not usually, as less reliable than A.
Potential use for process monitoring if lag can be reduced.
Potential main use if lag can be minimized.
D. Sentinel systems
Potential: e.g. Zimbabwe
Potential for evaluation if carefully designed.
Potentially important use
• Trends give the most useful information
• Note: evaluation only really works with before-after + with-without data
Technical issues for surveys
• sampling procedures
• mortality estimates
• indicators
Sampling procedures
• PPS, then issue is at last stage
• Options: spin-the-bottle; segmentation-full enumeration; segmentation then sample
• Consider bias; re-estimating pop numbers (for weights)
• Depends on feasibility (incl. habitation features: e.g. along road/river vs round); and use
• Compare results with norms, use for targeting, get trends
Child mortality estimates from area level surveys
Issues are
• Estimate and state confidence intervals, which will be wide with 30*30 design, and calculate design effect
• Care in interpreting these -- e.g. what does 0.5-2.0/10,000/day over last 3 months mean?
Indicators
• Malnutrition can worsen without showing in wasting -- see Srn Africa 02-3: use wt/age if possible
• Evidence suggests: interpret wasting WITHIN populations, not across, because of different growth patterns and relations to mortality
• More focus on getting ages?
Kenya
0
5
10
15
20
25
30
35
40
K: NE K: Nyanza
Pre
vale
nce
%
Stunting
Wasting
Underweight
Differences in stunting and wasting in two regions of Kenya
0
10
20
30
40
50
60
m0-6 m6-12 m12-24
m24-36
m36-48
m48-60
Age group
%
Somalia-W
Somalia-St
Uganda-W
Uganda-St
Differential growth patterns in Uganda and Somalia
Low birth weight, %
Maternal mortality
ratio
Prevalence BMI <18.5 in women
Kenya 11% 1000 12%
Uganda 12% 880 9%
Ethiopia 15% 850 26%
Somalia 16% 1100 -
Eritrea 21% 630 41%
Sudan 31% 590 -
India 30% 540 41%
Maternal and new born data
Birth weight relates to maternal BMI, but that is not directly related to MMR as indicator of health care ...
overall GAM Prevalence
50403020100
U5M
R2
7
6
5
4
3
2
1
0
- 1
Country Code
Uganda
Ethiopia
Sudan
Somalia
Kenya
Mortality
Different relations between GAM% and child mortality in different populations
Hence interpret GAM within populations, not across ...
Nutrition Surveillance Information Flow & Decision Making Process
Sentinel sites Data Collection, Decision-Making
Food & Nutrition Sub-Division MHSS
Data entry, Analysis and Reporting
Monthly Nutrition and Health Data
MHSS
Review Reports & Make Decisions
VAC
Prepare Food Security & Nutrition Bulletin and Make Recommendations for Action
Nutrition Surveillance Bulletin
Internal Nutrition Surveillance Report
National Emergency Management
Committee
Review VAC Recommendations & Decision-Making
Decisions for MHSS Action/Intervention
EMU, Line Ministries, UN, NGOs, Donors
Intervention
Food Secu./ Nut. Bulletin & Recommendations
Decisions for Intervention
Regions (MHSS, REMU) Decision-making
District (MHSS) Decision-making
Internal Nut. Surveillance Report
Internal Nut. Surveillance Report
Internal Nut. Surveillance Report
System/ Data source
Eth
Ken
Som
Uga
Bots
Les
Mal
Moz
Nam
S A
Zam
Zim
A. Repeated natl surveys (# 90 on)
Y (6 )
Y (4)
?
Y (2)
Y (1)
Y (3)
Y (4)
Y (3)
Y (2)
?
Y (3)
Y (4)
B. Area level Surveys (ad hoc) # 2000 on
399
163
107
100
-
-
2/~30
N
-
2/32
N
C. Reporting systems Clinics
(Y) Chanis
Thru HMIS
Y (food distrn points)
Y?
Selected clinics
Proposed
Thru DHIS
Screening
EOS twice yrly
Progs CBNP D. Sentinel Systems
Survey
F-up asst surveys
ALRMP In FSAU Y
Site
Proposed
In FSAU Proposed
Fitting systems together and deciding priorities
Capacity
• Enough people?
• Is this useful for them?
• Needed skills?
• Resources and priorities?
• How to meet these needs…?
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