nutrition multiple indicator cluster surveys data dissemination and further analysis workshop
TRANSCRIPT
Nutrition
Multiple Indicator Cluster SurveysData dissemination and further analysis workshop
Overview of presentation
• Nutritional status• Breastfeeding• Micronutrients
– Vitamin A– Iodized salt
• Low birthweight
Table NU.1: Nutritional status of childrenPercentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Country, Year Weight for age
Number of children
under age 5
Height for age
Number of children
under age 5
Weight for height
Number of children
under age 5
Underweight
Mean Z-Score (SD)
Stunted
Mean Z-Score (SD)
Wasted Overweight
Mean Z-Score (SD)
percent below percent below percent belowpercent above
- 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SDSex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total
reflects a child’s total body mass
cumulative deficient growth
recent nutritional deficiency
Undernutrition indicators refer to children whose z-scores fall below -2 SDs (moderately and severely) and -3 SDs from the median of the reference population
International reference population:• Note that the WHO Child Growth Standards is used for these calculations• Not comparable to the NCHS/CDC/WHO reference –refer to appendix
Key data considerations
• Note that if height and weight data are missing for more than 10% of children under-five, caution should be exercised in the interpretation of the results.
• Accurate age reporting is also an essential component of anthropometric indicators (underweight and stunting)
• Do not attempt to do any trend analysis with the wasting indicator due to seasonality of wasting prevalence
Table NU.1: Nutritional status of childrenPercentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Country, Year Weight for age
Number of children
under age 5
Height for age
Number of children
under age 5
Weight for height
Number of children
under age 5
Underweight
Mean Z-Score (SD)
Stunted
Mean Z-Score (SD)
Wasted Overweight
Mean Z-Score (SD)
percent below percent below percent belowpercent above
- 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SDSex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total
MICS4 country example
Table NU.1: Nutritional status of childrenPercentage of children under age 5 by nutritional status according to three anthropometric indices:
weight for age, height for age, and weight for height,
Underweight Weight for age:
StuntingHeight for age:
WastingWeight for height:
% below -2 sd [1]
% below -3 sd [2]
Mean Z-Score
(SD)
Number of
children
% below -2 sd [3]
% below -3 sd [4]
Mean Z-Score
(SD)
Number of
children
% below -2 sd [5]
% below -3 sd [6]
% above +2 sd
Mean Z-Score
(SD)
Number of
childrenSex Male 13.3 3.4 -.8 3085 33.4 13.6 -1.4 2928 6.2 2.2 7.5 .0 2954
Female 12.0 3.0 -.8 2986 33.6 13.1 -1.4 2878 5.5 1.9 7.6 .0 2909Area Urban 10.5 3.2 -.7 1800 28.0 14.0 -1.2 1713 6.5 2.3 10.0 .1 1713
Rural 13.6 3.2 -.9 4271 35.8 13.1 -1.5 4093 5.6 1.9 6.6 .0 4150Total 12.7 3.2 -.8 6071 33.5 13.3 -1.4 5805 5.9 2.0 7.6 .0 5863
Breastfeeding
Background• Several documents provide guidance on indicators for assessing infant
and young child feeding practices
Continuum of feeding practices
Infant and young child feeding patterns from birth to two years
* Excluding China, due to lack of data.Source: UNICEF global databases 2010, from MICS, DHS and other national surveys.
Table NU.2: Initial breastfeedingPercentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Country, Year
Percentage who were
ever breastfed1
Percentage who were first breastfed: Percentage
who received a prelacteal feed
Number of last-born children in the two
years preceding the survey
Within one hour of birth2
Within one day of birth
Region Residence Months since birth Assistance at delivery Place of delivery Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total
Note denominator = women surveyed having a live birth within the 2 years prior to the survey
Table NU.3: BreastfeedingPercentage of living children according to breastfeeding status at selected age groups, Country, Year
Children age 0-5 months Children age 12-15 months Children age 20-23 months
Percent exclusively breastfed1
Percent predomi-
nantly breastfed2
Num-ber of childre
n
Percent breastfed (Continued
breastfeeding at 1 year)3
Number of
children
Percent breastfed (Continued
breastfeeding at 2 years)4
Number of
childrenSex
Region
Residence
Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total
Indicators based on current status (24 hour recall period)
The prevalence of exclusively breastfed children should be less than or equal to the prevalence of children who are predominantly breastfed.
only breastmilk (exceptions for medicine, vitamins)
breastmilk, water, non-milk liquids
According to the 2010 Chad MICS, only 3% of children <6 months are exclusively breastfed.
What’s going on?
Figure 4. Répartition en pourcentage des enfants de moins de 2 ans par type d'alimentation, par tranche d'âge, Tchad, 2010
MICS4 Survey Design Workshop
Table NU.4: Duration of breastfeedingMedian duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Country, Year Median duration (in months) of
Number of children age 0-35 monthsAny breastfeeding1
Exclusive breastfeeding
Predominant breastfeeding
Sex Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head
Median Mean for all children (0-35 months)
Table NU.5: Age-appropriate breastfeedingPercentage of children age 0-23 months who were appropriately breastfed during the previous day, Country, Year Children age 0-5
months Children age 6-23 months Children age 0-23
months
Percent exclusively breastfed1
Number of
children
Percent currently breastfeeding and
receiving solid, semi-solid or soft foods
Number of
children
Percent appropriately breastfed2
Number of
childrenSex Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head
Total
NEW!
Assess appropriate breastfeeding practices throughout recommended period of birth to age 2 years of age
Table NU.6: Introduction of solid, semi-solid or soft foodsPercentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Country, Year
Currently breastfeeding Currently not breastfeeding All
Percent receiving
solid, semi-solid or soft
foods
Number of children age 6-8 months
Percent receiving
solid, semi-solid or soft
foods
Number of children age 6-8 months
Percent receiving
solid, semi-solid or soft
foods1
Number of children age 6-8 months
Sex Male Female
Residence Urban Rural
Total
Children should start receiving food at 6 months of age
New standard indicator – not comparable to previous indicator on complementary feeding
NEW!
Table NU.7: Minimum meal frequencyPercentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Country, Year Currently breastfeeding Currently not breastfeeding All Percent
receiving solid, semi-solid and soft foods the
minimum number of times
Number of children age 6-23 months
Percent receiving at least 2 milk
feeds1
Percent receiving solid, semi-solid and soft foods or milk feeds 4 times
or more
Number of children age 6-23 months
Percent with minimum meal
frequency2
Number of children age 6-23 months
Sex Age Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head
Total
Appropriate number of meals varies according to child’s age and breastfeeding status
NEW!
Table NU.8: Bottle feedingPercentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Country, Year Percentage of children age 0-23
months fed with a bottle with a nipple1
Number of children age 0-23 months
Sex Age Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head
Total
Things to think about
• “Current status approach” is used to calculate indicators – asks about feeding status within 24 hours of the survey.
• Precision of indicators poor - The number of children in age ranges of interest (< 6 mos , 6-9 mos, 12-15 mos, 20-23 mos) are likely to be small, and therefore the precision of indicators may lower than that of others
• While exclusive breastfeeding among infants remains uncommon in some countries, exclusive breastfeeding patterns are often similar for boys and girls and across household residence area and wealth quintile
MicronutrientsVitamin A and Salt Iodization
Table NU.10: Children's vitamin A supplementationPercent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Country, Year
Percentage who received Vitamin A according to: Percentage of children
who received Vitamin A during the last 6 months1
Number of children age 6-
59 monthsChild health
book/card/vaccination cardMother's
reportSex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total
• Not all countries have Vitamin A programmes
• While there may be some expectation of vitamin A deficiency in poor and rural areas, keep in mind that these are also the areas specifically targeted by campaigns.
Either recorded in health book/
vaccination card or mother’s report
Proxy measure of recommended 2 doses
per year
Things to remember• Survey data for vitamin A tend to be underreported as a result
of - Timing: data collection may precede campaign - Recall error - Mothers’ don’t know if infant received supplement - Often not recorded on child health card
• May be discrepancies between data obtained through household surveys and those obtained from National Immunization Days and routine service statistics
MICS4 Country ExampleTable NU.10: Children's vitamin A supplementation
Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months,
Percentage who received Vitamin A according to:
Percentage of children who
received Vitamin A during the last
6 months [1]
Number of children aged 6-
59 months
Child health book/ card/
vaccination card Mother's reportSex 1 Male 8.0 58.8 60.7 1760
2 Female 7.5 59.5 61.2 1743Wealth index quintiles 1 Poorest 9.5 55.1 58.9 818
2 Second 8.0 59.3 60.8 6693 Middle 7.8 62.9 64.7 6694 Fourth 5.6 63.3 63.8 7005 Richest 7.7 56.0 56.7 648
Total 1.00 Total 7.8 59.2 60.9 3504
Table NU.9: Iodized salt consumptionPercent distribution of households by consumption of iodized salt, Country, Year
Percentage of households in which salt was
testedNumber of households
Percent of households with
Number of households in which salt was
tested or with no saltNo salt
Salt test resultNot iodized 0
PPM>0 and <15
PPM 15+ PPM1 TotalRegion Residence Wealth index quintile Total 100.0
Take note of % households in which salt tested
15+ PPM is international standard
MICS4 Country Example
Table NU.9: Iodized salt consumptionPercent distribution of households by consumption of iodized salt, Country, Year
Percent of households in
which salt was tested
Number of households
Percent of households with salt test result
Total
Number of households in
which salt was tested or with no salt
>0 and <15 PPM 15+ PPM [1]
Percent of households with no salt
Not iodized 0 PPM
Area Urban 96.7 2,612 2.7 40.5 15.3 41.5 100.0 2,596Rural 97.1 1,209 2.3 34.3 15.3 48.1 100.0 1,201
Wealth index quintiles
Poorest 97.0 780 2.4 39.7 15.9 41.9 100.0 776Second 96.2 811 3.4 41.8 16.2 38.6 100.0 807Middle 96.0 778 3.2 34.2 15.4 47.3 100.0 772Fourth 97.3 756 2.2 35.6 14.7 47.6 100.0 752Richest 97.5 696 1.6 41.6 14.0 42.8 100.0 691
Total 96.8 3,821 2.6 38.5 15.3 43.6 100.0 3,797
Low Birth Weight
Table NU.11: Low birth weight infants
Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Country, Year
Percent of live births:
Number of live births in the last 2 yearsBelow 2500 grams1 Weighed at birth2
Region
Residence
Mother’s education
Wealth index quintile
Religion/Language/Ethnicity of household head
Total
Methodological Issues
Percentage of births NOT weighed
*: Excluding ChinaNote: Regional averages of births not weighed are not available for Latin America and Caribbean, East Asia and Pacific and Central and Eastern Europe/Commonwealth of Independent States (CEE/CIS), due to lack of data.Source: UNICEF global databases 2010, from MICS, DHS and other national surveys.
How can we measure low birth weight when
high proportion of children not
weighted?????
Methodological Issues
In MICS, two items in the questionnaire are used to estimate low birth weight based on an adjustment procedure was proposed by Boerma and colleagues (1996) .
– Mother’s recall of the child’s size at birth (i.e. very small, smaller than average, larger than average, very large)
– Mother’s recall of the child’s weight or the weight recorded on a health card if the child was weighed at birth
Methodological Issues
Adjustment Procedure
Methodological Issues
Heaping of Birth Weight, Tanzania 1999
Methodological IssuesAdjustment steps
1. 25 percent of children reported as weighing exactly 2500 grams are treated as weighing less than 2500 grams to adjust for heaping on 2500 grams -- this is based on empirical distributions from DHS surveys
2. Tabulate children’s size by their weight for those weighed at birth to obtain proportion of births in each size category who weighed <2,500 grams
3. Multiply this proportion by the total number of children in size category to obtain estimated number of children by size category with low birth weight
4. Sum the estimated number of children in each size category with low birth weight in order to obtain the total number of low birth weight children
5. Divide by the total number of live births to obtain the percentage with low birth weight
Example from Gambia
MICS4 Survey Design Workshop
Methodological Issues
Effect of Adjustment
Table NU.11: Low birth weight infantsPercentage of last-born children in the 2 years preceding the survey that are estimated to have
weighed below 2500 grams at birth and percentage of live births weighed at birth
Percent of live births:
Number of live births in the last
2 years
Below 2500 grams
Weighed at birth
Area Urban 29.1 9.7 602Rural 31.3 3.5 1889
Wealth index quintiles Poorest 34.0 1.9 464Second 33.0 2.3 539Middle 28.4 2.7 485Fourth 30.3 6.4 490Richest 28.4 11.7 513
Total 30.8 5.0 2491
Table NU.11: Low birth weight infantsPercentage of last-born children in the 2 years preceding the survey that are estimated to have weighed
below 2500 grams at birth and percentage of live births weighed at birth,
1.00 Percent of live births:births Number of live births in last two years
Below 2500 grams [1]
Weighed at birth [2]
Area 1 Urban 4.2 98.9 9972 Rural 5.6 97.9 657
Wealth index quintiles 1 Poorest 5.7 97.6 3542 Second 4.2 97.6 3283 Middle 5.5 98.4 3654 Fourth 4.1 100.0 2975 Richest 3.8 99.3 310
Total 1.00 Total 4.7 98.5 1654
Some ideas for further analyses
• Undernutrition is the result of a combination of factors: lack of food in terms of quantity and quality; inadequate water, sanitation and health services; and suboptimal care and feeding practices . Until improvements are made in these three aspects of nutrition, progress will be limited.
• As such, there is a desperate need to further understand and document relationships between WASH and undernutrition.
• Examine associations between early initiation of breastfeeding and skilled attendants at delivery or antenatal care with a skilled professional
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Thank you!