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 International Nutrition

Nutrition Surveillance and

Program Monitoring

Philip Harvey MPH, PhD

Copyright 2005, Philip Harvey. All rights reserved. Use of these materials permitted only in accordance with license rights
granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all
liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned
by others. User is responsible for obtaining permissions for use from third parties as needed.

The USAID Micronutrient Program

Countries in which MOST works
or has worked

Countries in which
MOST works
The USAID Micronutrient Program
 Definitions

„ Surveillance: from French “surveiller”,

to watch over with great attention…
− term from infectious disease epidemiology
− adopted for nutrition at 1974 World Food Conference
„ Survey: collection of info at one point in time
„ Assessment: appraisal of available info
„ Evaluation: process of reaching a judgment
„ Monitoring: continuous observation, here
describes activity more specific than surveillance
Nutrition Surveillance

„ Based upon regular collection of data about

nutritional conditions & factors influencing them

„ Provide basis for decisions re: immediate action,

policy, planning, management of programs

„ Surveillance & service cannot be separated

data MUST by collected and analyzed in a way
that is useful for decision making

„ Concerned with data on populations, not

individuals
Information and Indicators
„ Levels of information (classification from WHO 1976)
A: Ecology -- meteorology, land, water, vegetation
Demography
Infrastructure - transport, communications, services
B: Resources & production -- ag. product’n, livestock, food
imports/exports/stocks, fuel
C: Income & consumption -- market data, income, food
consumption
D: Health status -- nutritional status, disease patterns
„ Intervening effectively to improve nutrition
requires understanding the causes of
malnutrition (UNICEF Framework)
 UNICEF’s Conceptual Framework of
Malnutrition
Manifestations
Nutritional Status

Immediate
Diet Health Causes

Household Care of Mother Environ. Health, Underlying

Food Security and Child Hygiene & Sanitation Causes

Human, Economic, and

Institutional Resources

Political and Ideological Structure Root

Ecological Conditions Causes
Adapted from UNICEF
4 Potential Resources
Cut-off points and trigger levels

„ Cut-off point -- a value that marks the boundary

of acceptability (e.g. < -2SD W/A)

„ Trigger level -- percent of observations below a

cut-off point required to initiate action (e.g. %
children < 5 y with W/A < -2SD greater than 10%)

„ Need to use the most sensitive indicators (in

terms of triggering action) that are feasible
Applications & system types
„ Surveillance used for
1. Early warning & intervention
2. Planning & advocacy
3. Program monitoring
4. Evaluation
„ Surveillance activities include
– Nutrition surveillance systems
– Special surveys (DHS, NNS)
– Routinely reported data (HMIS, program M&E)
– Sentinel Sites

The USAID Micronutrient Program

Application 1: Early warning
& intervention
„ FEWS Net -- Famine Early Warning System
Network, information system to identify
problems in the food systems in 17 sub-
Saharan countries <http://www.fews.net>
„ Data sources: USGS/EROS Data Center
satellite data monitor agricultural conditions
– Normalized Difference Vegetation Index (NDVI)
– Water Requirements Satisfaction Index (WRSI)
„ Monthly bulletin distributed to decision makers
NDVI (Normalized Difference Vegetation Index)

Maps courtesy of
FEWS NET,
http://www.fews.net.
WRSI for maize
(Water Requirements Satisfaction
Index)

Map courtesy of
FEWS NET,
http://www.fews.net.
Application 2: Planning & advocacy

„ Demographic and Health Surveys (DHS)

„ Multiple Indicator Cluster Survey (MICS)
„ National Nutrition Surveys (Philippines,
Central American countries)
„ WHO/FAO Projections
DHS History (Source: Mukuria A, ORC/Macro)

1972 - 1984 World Fertility Survey (WFS)

1976 - 1984 Contraceptive Prevalence

Surveys (CPS)

1984 - 1998 Demographic and Health

Surveys (DHS)

1998 - Present Demographic and Health

Surveys (MEASURE DHS+)
Measure/DHS+ Nutrition Data
Household Individual Child
• Iodized salt testing (less than 6 y)
• Heights/Weights
Individual Mothers • 24 hr. dietary recall
(given birth in past 6 y) (expanded)
• 7 day food
• Heights/Weights
frequency
• Anemia Testing • Frequency of solids
• Iron or semi-solids in
supplementation past 24 hrs.
• Night blindness • Vitamin A
supplementation
• Vitamin A
supplementation • Hemoglobin
(anemia) testing
 Presentation of DHS data
„ The Seminar
„ The reports and the data
„ The Chartbooks -- telling a story with pictures
– Immediate Influences
• Diarrhea and Cough with rapid breathing
– Biological and Behavioral Influences
• Undernutrition of children (6-23 months) by measles vaccination
status
– Underlying social and economic influences:
• Mother’s education
• Source of drinking water
• Type of toilet
– Basic influences:
• By region
• Urban-rural residence
 K
en
ya

0
10
20
30
40
B
50
19
en 98
in
G 20
ui
U ne 0 1
ga a
nd 19
a 99
20
R
w 00
-0
an
da 1
G 2
ha 000
na
M 19
al
Za aw 98
m i2
bi 00
a 0
Ta 200
nz 1-
an 02
B ia
ur 19
ki
n a Ma 9 9
Fa l i 2
so 00
19 1
33

Er 98-
itr 99
e
under 5 years, Sub-Saharan Africa

Et a
hi 2
op 002
ia
Prevalence of underweight in children

20
(Source: DHS/Measure+, ORC/Macro)

00
 Breastfeeding Practices by Age, Peru 1986
100
Weaned (Not Breastfed)
90
Breastmilk & Complementary Foods
80 Breastmilk and Other Milk/Formula
Breastmilk and Non-Milk Liquids
70 Breastmilk and Plain Water Only
Exclusively Breastfed
60
Percent

50

40

30

20

10

0
0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23
Age Group in Months

Breastfeeding Practices by Age, Peru 1992

100
90
80
70
Weaned (Not Breastfed)
60
Percent

Breastmilk & Complementary Foods

50 Breastmilk and Other Milk/Formula
40 Breastmilk and Non-Milk Liquids
Breastmilk and Plain Water Only
30 Exclusively Breastfed
20
10
0
0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23
Age Group in Months
(Source: DHS/Measure+, ORC/Macro)
 Breastfeeding Practices by Age, Peru 1996
100

90

80

70

60
Percent

Weaned (Not Breastfed)

50 Breastmilk & Complementary Foods
Breastmilk and Other Milk/Formula
40 Breastmilk and Non-Milk Liquids
Breastmilk and Plain Water Only
30
Exclusively Breastfed
20

10

0
0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23
Age Group in Months

Breastfeeding Practices by Age, Peru 2000

100

90

80

70 Weaned (Not Breastfed)

Breastmilk & Complementary Foods
60
Breastmilk and Other Milk/Formula
Percent

50 Breastmilk and Non-Milk Liquids

Breastmilk and Plain Water Only
40 Exclusively Breastfed

30

20

10

0
0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23
Age Group in Months
(Source: DHS/Measure+, ORC/Macro)
DHS contd:
24-h recall vs 7-d food frequency

„ 7-day Food Frequency

– How many days during the last 7 days
including yesterday did (name) drink (eat)
each of the following:
„ 24-Hour Recall
– In total, how many times during the last
day or at night did (name) eat (drink)
each of the following foods either
separately or combined with other food?
 Ethiopia 2000:
Comparing yesterday (Y/N) to 3 or more
days in the last seven days
100
Percent of children

77 77
80

60
40 42
40 33 35 35 34

20 12 11 10 12
9 9

0
St Le D Fl Vi O Fa
ap gu ai es tA th ts
le ry h/ fru /
s m eg (a oi
es ll) it l
g s v eg

Yesterday 3+ days

(Source: DHS/Measure+, ORC/Macro)

 Peru 1996:
Comparing yesterday (Y/N) to 3 or
more days in the last seven days
100 94 94

77 79 73 74
80
P ercent of children

70 69 67 68
57 59
60 50 51

40 34 33

20

0
St Le Da Fl Vi Vi O Fa
ap gu i ry es tA tA th ts
le m h/ (a or f ru /o
s es eg l l) an it il
gs ge ve
g

Yesterday 3+ days

(Source: DHS/Measure+, ORC/Macro)

UNICEF’s Indicator Cluster Surveys

„ UNICEF’s major tool for monitoring progress

to goals (2 surveys to date MICS1, MICS2)
„ MICS2 used for end-of-decade assessment
of World Summit for Children Goals, provided
data on 63 of 75 indicators. web site has indicators,
questionnaires, manuals etc.
„ UNICEF and ORC/Macro collaborate in
standardizing across surveys where possible
„ MICS3 will assess progress towards
Millennium Development Goals
Application 3: Program monitoring

„ HKI Nutrition Surveillance Systems,

Indonesia & Bangladesh (www.hkiasiapacific.org),
Nicaragua (SIVIN)
„ Monitoring for management
– USAID frameworks
– Cluster surveys for supplementation

„ Sentinel Site Surveillance

„ Cost analyses
Nutrition Surveillance Process

Source: HKI Indonesia Crisis

Bulletin, January 2000
Sampling framework for HKI/GOI NSS

Source: HKI
Indonesia
Crisis Bulletin,
January 2000
Map of the HKI/GOI NSS Project Sites

Source: HKI Indonesia Crisis

Bulletin, January 2000
Uses of Indonesia HKI/GOI NSS
„ Monitoring
– Impact of economic crisis (Crisis Bulletins)
– Implementation of vitamin A supp program
– Nutritional status and program information in specific
provinces
„ Targeting food aid (donors)
„ Providing survey vehicle for collaborations on
specific issues, e.g. malaria
„ Further issues forthcoming (e.g. anemia)

„ USAID funding for NSS recently ceased

The USAID Micronutrient Program

 USAID’s Results Framework:
ESSENTIAL NUTRITION ACTIONS AND CHILD SURVIVAL

SO: Vulnerable families achieve sustainable improvement

in the nutrition and health status of seven million women
and children by 2006

IR1 Service providers improve IR2 Communities sustain

quality & coverage of maternal
and child health & nutrition
services & key systems
IR1 .1 Coordinate/converge
services provided by the De pt.
of s ocial se rvices (ICDS ) and
MOH, e.g. through Nutrition
and Health Days, and Block
planning
IR1 .2 Build capacity of service
provide rs, supervisors and
ma nagers in t he dept . of social
services (ICDS) and MOH
activities for improved maternal
and child survival and nutrition
IR2.1 Increase awareness of
households & other key audiences
about desirable nutrition and health
behaviors through multiple
channels, e.g. ‘change agents’
IR2 .2 Increase ownership and
participation of community
leaders and groups in
monitoring health and nutrition
services and beha viors

IR2 .3 Stronger links betwee n

health syst ems and
Source: Adapt ed from comm unit ies 26
CARE/India INHP II,
DAP II 2001-2006
Logical Framework
Nutrition Program Example

PURPOSE PERFORMANCE MEANS OF ASSUMPTIONS

INDICATORS VERIFICATION
Sustainable 1.Proportion of children 6-36 1.Annual reports - Stable political situation,
improvement months in any grade of from MCH sustained political
in the malnutrition services, commitment and financing
nutrition and 2. Coverage of essential special - Sufficient numbers of
health status nutrition actions: surveys competent health care
of women and exclusive BF, personnel and supplies in
children appropriate CF, 2.Annual reports, the government sector
through vitamin A, iron special - No natural disaster or
improved supplements /fortified surveys disease epidemic
services foods, iodized salt use,
provision and coverage of sick and 3.National / local
community malnourished in tracking
participation special programs reports
(surveillance)
3. Proportion of households of high risk
at risk of HH food areas/
insecurity or populations
vulnerable
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). 27
 Supplement coverage in Nepal
1997-2001*

100
Estimated
co verage in
80 pro gram
districts
60
Percent

% o f districts
with >80%
co verage
40

20

0
Apr Oct Apr Oct Apr Oct Apr Oct Apr Oct
1997 1998 1999 2000 2001

*Based on a weighted average of multiple representative district surveys applied nationally.

Data from non-NIDs vitamin A supplementation efforts in Nepal. Source Houston R, 2002.
 Ghana VA supplementation 2000-2002

Coverage from tally reports compared with the 'mini-

survey' results, July 2000, May 2001 and May 2002
120% 104% 100.70%
100% 89% 91% 90.60% 89.20%
80%
Percent

60%

40%

20%

0%
2000 2001 2002
Tally Mini-survey

Amouful E. IVACG XXI, 2003

 Reasons for not receiving Vit A supplement, Ghana
(July 2000, May 2001 and May 2002)

50.0%
45.0% 2000
40.0% 2001
35.0% 2002
Percent (%)

30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
reasons

Child was
capsule
distribution

community

Distribution
know about

Was out of

Out of

site too far

Other
Did not

sick
Amouful E. IVACG XXI, 2003
 What care givers reported being told (among those dosed) Ghana,
(May 2000 N=2169, July 2001 N=3436 and May 2002 N=3451)

60.0%
2000
50.0% 2001
2002
40.0%
Percent (%)

30.0%

20.0%

10.0%

0.0%
Vitamin A
Nothing

encouragement

din't participate
Prevents

Needed twice

safe
Other
Illness

Amouful E. IVACG XXI, 2003

Sentinel Site Surveillance
„ Refers to the application of epidemiological
surveillance to limited populations or sites to detect
trends in health events, or events that mandate a
specific response (e.g. polio outbreaks)
„ Limited in scope, less costly, less complex, but not
representative
„ Community-based Surveillance (CBS), UNICEF in
Central America, 1980s-early 1990s (Andersson et al. 1989)
– CBS as capacity building process, part of development
process: generates motivation and commitment
– Response to limitations of data routinely collected through
health service
– 4 components: List objectives, questionnaires, contingency
tables, data entry format

The USAID Micronutrient Program

Program Costs: Increasingly important
(Austin JE 1978)

Three types
„ Biological cost-effectiveness: e.g. $/ change in
infant mortality, $/ change in malnutrition
„ Delivery system cost-effectiveness: $/ recipient,
$/ target group recipient, $/ nutrient delivered, $/
nutrient deficit reduction
„ Operating-effectiveness measures: do not
incorporate costs but measure other program
dimensions -- coverage, nutrients, permanency,
personnel, leakages

The USAID Micronutrient Program

Application 4: Evaluation
„ Measuring performance (Stoltzfus & Pillai J Nutr 2002; 132:845S-848S)
Applied framework of Habicht et al. 1999 to Iron
Deficiency Anemia programs
„ Three questions --
– Who is the evaluation for?
– What questions will the evaluation answer?
– How will the evaluation be conducted to generate useful
answers?
„ Three designs --
– Monitoring: Severe VAD in Denmark, Pellagra in Mississippi
– Plausibility: Effective anemia programs in Thailand
– Probability: Progresa in Mexico
Designs for program evaluation
From Stoltzfus & Pillai 2002
Severe vitamin A deficiency in
Denmark disappeared after
margarine was fortified
25
Hospital admissions

20

15

10

0
1913 1914 1915 1916 1917 1918 1919
 Thailand: Anemia prevalence in
pregnant women, two national surveys
and surveillance data, 1986-1999.
45
40
35
30
Percent

25
20
15
10
5
0
86
87
88
89
90
91
92
93
94
95
96
97
98
99
19

19
19
19
19
19
19
19

19
19
19
19

19
19
Modified from: Winichagoon
J Nutr 2002.
Decrease in anemia prevalence
resulted from IFA program - Plausible?
„ Nutrition/anemia incorporated into national
development policy & primary health care in 1970s
„ Community volunteers established (cadre now 500,000)
„ 98% Thai women attend ANC, 84% attend 4 times,
encouraged to attend early
„ Universal supplementation
„ Supplies adequate, needs estimated by provinces
„ Clear messages about dose, frequency, duration &
coping with side effects
„ Surveillance data used in feedback
Source: Winichagoon 2002
References
„ WHO Methodology of nutritional surveillance WHO Tech Rep
Series No. 593 WHO Geneva 1976
„ Austin JE; The perilous journey of nutrition evaluation Am J Clin
Nutr 1978 31:2324-2338
„ Habicht J-P, Mason J. Nutrition Surveillance: Principles and
practice. 1983
„ Andersson et al. 1989. The use of community-based data in health
planning in Mexico and Central America. Health Policy and
Planning 1989 4(3):197-206
„ UNICEF, Multiple Indicator Cluster Surveys, access from
http://www.childinfo.org/MICS2/Gj99306k.htm
„ 5th Report of the world nutrition situation, SCN, March 2004,
http://www.unsystem.org/scn/Publications/AnnualMeeting/SCN31/
SCN5Report.pdf

For more information Contact pharvey@istiinc.com or visit

www.mostproject.org.

The USAID Micronutrient Program