Nutrition Multiple Indicator Cluster Surveys Data dissemination and further analysis workshop

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


foods


Percent receiving


foods1


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


Percent receiving at least 2 milk

feeds1

Percent receiving solid, semi-solid and soft foods or milk feeds 4 times

or more


Percent with minimum meal

frequency2


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


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?????


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


Adjustment Procedure


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


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

37

Thank you!

Documents

Nutrition Multiple Indicator Cluster Surveys Data dissemination and further analysis workshop