*Public Nutrition:Assessment and Advanced Analysis

INHL 709Spring 2010Tues Thurs: 9.0010.30+ troubleshooting 1.30-3.00 Fridays in 2200-23

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M/CDates 2010TopicRefAssignment1 1 2Tues 12 JanThur 14 JanIntroductionPANDA Ch 1 Go through PANDA Ch 12 3 4Tues 19 anThur 21 JanData cleaning (intro)Data cleaning (progress)PANDA Ch 2Clean bdeshd1.savDue Tue 26 Jan3 5 6Tues 26 JanThur 28 Jan One way analyses: district aggregated data (intro)Review cleaning results.One way (progress)PANDA Ch 3, pp 1-2Situation analysis and ranking for Bdesh district data (bdeshc.sav). Due Tues 2 Feb4 7 8 9 10 Tue 2 FebThur 4 FebTues 9 FebThur 11 FebReview one-way results. Associations in aggregated data (Bdesh).Associations (progress, Bdesh). Intro Indonesia assignment.Indonesia assignment (progress)Review Indonesia resultsChild level, intro.PANDA Ch 3, p3Examine associations in Bdesh dataset. Due Fri 5 Feb.Set up and analyse Indonesia provincial dataset. Due Wed 10 Feb5 11 12Thur 18 FebTues 23 FebChild-level dataTest.PANDA Ch 3Use Kenya data for ranking and associations, due Thurs 25 Feb6 13 14 15Thu 25 FebTue 3 MarThu 4MarTwo-way analyses by tabulation and regression; causal factors.PANDA Ch 4Use Kenya data for 2-way analyses, due Fri 5 Mar7 16 17 Tue 9 MarThu 11 MarMulti-way analysis, confounding and interactions.Targetting and coverage evaluation.PANDA Ch 5PANDA Ch 3 p2; Chs 4&5.Use Kenya data for associations controlling for confounders, assemble all results, due Fri 12 Mar

*Note: Trouble shooting on Friday afternoons, 1.30-3.00.

PANDA (Practical Analysis of Nutritional Data) is main material for course, available on web Tulane.edu/~panda3; also can be got on CD if needed..

18-26Tue 16 Mar - Thurs 27 AprilAnalyse different Kenya dataset for:(a) situation analysis, (b) targetting priorities, (c) program design (d) program coverage and targetting.All PANDA, incl. Ch 7Analysis of provincial Kenya datasets. Assignments and class discussion:Due dates to be discussed

*Readings.

Beaton, G., Kelly, A., Kevany, J., Martorell, R. & Mason, J. (1990) Appropriate Uses of Anthropometric Indices in Children. ACC/SCN StateoftheArt Series, Nutrition Policy Discussion Paper No.7. ACC/SCN, Geneva. http://www.unscn.org/archives/npp07/index.htm

UNICEF Survey (MICS) Manual. http://www.childinfo.org/files/Multiple_Indicator_Cluster_Survey_Manual_2005.pdf

SMART nutrition survey methodology manualhttp://www.smartindicators.org/SMART_Methodology_08-07-2006.pdf

Public Health Surveillance: A Tool for Targeting and Monitoring Interventions. Nsubuga et al. 2006. DCP2 Ch 53 p997http://files.dcp2.org/pdf/DCP/DCP53.pdf

Developing Nutrition Information Systems In Eastern And Southern Africa.Report of Regional Technical Working Group Meetings Nairobi, 1-3 February and 19-21 April 2007. By: UNICEF Eastern and Southern Africa Regional Office (ESARO) andTulane University, Department of International Health and Development(p:\niaer\FNB publn\Wshops report.doc)

Nutritional surveillance in relation to the food price and economic crises. J Mason. Workshop Summary, Institute of Medicine, July 2009, pp 67-72.http://books.nap.edu/openbook.php?record_id=12698&page=67

*Introduction (lectures 1 & 2)

Assessment and AnalysisPlanning framework: questions to addressResearch questions and dummy tablesLanguage, variables, indicatorsData sourcesData transformations, units of analysis.

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"PUBLIC NUTRITION

includes the following activities:

an understanding and a raising of awareness of the nature,

causes and consequences of nutrition problems in society;

epidemiology, including monitoring, surveillance, and evaluation;

nutritional requirements and dietary guidelines for populations;

programs and interventions: their design, planning, management, and evaluation;

community nutrition and community based programs;

public education, especially nutrition education for behavioral

change;

timely warning and prevention and mitigation of emergencies, including use of emergency food aid;

advocacy and linkage with, for example, population and environmental concerns;

public policies relevant to nutrition in several sectors, for example, economic development, health, agriculture, and education.

Source: letter to Am J Clin Nutr, March 1996,63399-400, Mason, Habicht, Greaves, Jonsson, Kevany, Martorell, and Rogers.

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Surveillance: to watch over ... to make decisions that will lead to improvements in populations ...

Surveillance cycle

Decide on action

Monitor

Evaluate

Detect new

problems

Take action

(Implement)

Data

Observation

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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

*2. Planning framework:questions to address(and dummy tables)

*Coverage: how many people?Targeting: who?Intensity: resources/headContent: what activities (components)?You need to decide:For programme planning

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*Research questions

Specify keep going till you answer them refer back to them when you get lost

*Research questions

Dummy tablesDefine variablesDesign questionnaire

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Research questions on malnutrition (examples):How serious/extensive is it? (Compare to norms)Is it worse in some places/for some populations? (Compare between groups at one time)Is it getting better or worse, for whom? (Compare between times, for groups: norm 0.5 1 ppt/yr)What is cause of current situation, or changes? (Analyze associations; includes evaluation)

You could also ask: what problems are we trying to solve, and what resources do we have this would come in at question 1, but then continue to ask how the resources address the problems ...

*How serious/extensive is malnutrition?

E.g. prevalences of underweight, wasting, GAM etc.

Note: interpretation may need to differ by population group, e.g. pastoralists vs agriculturalists; mortality risk varies in relation to GAM. 10% cut-point for agriculturalists may be equivalent to 20% for pastoralistsE.g. of cut-points: 10% warning, 20% emergencyE.G of dummy table

Wasting %(Cis)Stunting %(Cis)Oedema %District A

*Is malnutrition worse in some places/for some populations?

Example of dummy table: compare districts A and BDont forget precise title!Prevalences of wasting and stunting in children < 110 cms in Northern province, January 2007

GroupWasting %Stunting %% IDPsDistrict ADistrict BTotal

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3.Is malnutrition getting better or worse, for whom?Example of dummy tablePrevalences of wasting in children 6-59 months in January and July 2007 in Northern province

GroupWasting: Jan 2007Wasting:July 2007District ADistrict BTotal

*orPrevalences of underweight children (6-59 mo) in 2001 (May-July) and 2005 (June-Nov)Sources: DHS, 2001; MICS, 2005

GroupUnder-weight 2001Under-Weight2005U5MR 2001U5MR 2005Province AUrbanRuralProvince BUrbanRuralTotalU+R

*4A.What are possible causes of the current levels of malnutrition?Prevalence of underweight in children (6-59 mo) by food security and district, controlling for education level

Food securityEducation highEducation lowTotalDistrict AInsecureOKDistrict BInsecureOK

*4B.What are possible causes of changes in malnutrition? Changes in prevalences of malnutrition Jan July 2007 in children (6-59 months) with receipt of food aid, for food insecure and secure households.

District A1/07 food insecure7/07 food insecure1/07 food secure7/07 food secureWith food aidNo food aidTotal

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Questions to answer 1

For overall program planning

Where and who are the malnourished?

By area

By biological status

By SES, environment

What types of malnutrition?

Is it getting better or worse?

Trends by year

Seasonality

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Questions to answer 2

For community-based programs and service delivery

What services and programs do people with higher prevalences of malnutrition have access to?

Coverage (# with service )

Targeting (prevalence in covered group vs. population)

Intensity ($/hd, fac/mob/hd, )

Program content: relevance of activities to problems to be solved

What causes of malnutrition are important and can be addressed through community-based programs and services?

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*3. Language, variables, indicators

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Some key variables

for HPN program

planning

Outcomes

Intermediate

outcomes

Difficult to measure

Commonly measured

Mortality

Nutritional status

Anthropometry

Morbidity

Fertility

Immunization

Ante-natal care

Health services

Caring practices

Diet

Contraceptive prevalence rate

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LANGUAGE

Analysis gives many shortcuts for communication, with conventions, drawings, and symbols. Use, get familiar with these, but query as we go along if they are unclear.

Some conventions.

Outcome (variable) = dependent, goes on y-axis, in cells of tables, LHS of equations.

Classifying, determining (variable) = independent, goes on x-axis, defines columns (or rows in 2-way) tables, goes on RHS of equations.

Scatterplot frequently (x-y plots of individual datapoints), draw lines from regressions. Correlations are very dependent on N, so treat with caution, but they give useful shorthand.

Regression gives more language like residuals, interactions, and controlling: easier with examples later.

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VARIABLES

Outcome

Classifying

Determining

Process

All are interchangeable, but important to decide which is which.

Outcome variables are usually the dependent variables; content of cells in tables, LHS of equations. [NB don't usually put #s - frequencies - in cells]

Classifying variables are often area (district) or things like occupation that have no clear order. [Dummies in equations; independent variables]

Determining variables are usually expected to be associated with the dependent variable (eg education, water supply). They define columns, or are on the RHS of equations, as independent variables. They may be there as possibly causing the outcome; as getting in the way when a cause is investigated (confounding); or modifying the effect of another cause (interacting).

Process variables measure things like program delivery, coverage, access to services, etc.; can be dependent sometimes, depending on the question.

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OUTCOME VARIABLEStc "OUTCOME VARIABLES"

ADVANCE \d 18Anthropometry - birth weight, underweight, stunting, wasting.

ADVANCE \d 19Micronutrient deficiencies.

Iodine - eg total goitre rate in school children

ADVANCE \d 0Vit A - clinical signs (nightblindness, Bitot's spots, ) - serum retinol,

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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]

Figure 1.8.

Conceptual framework for the causes of malnutrition

in society

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CAUSAL FACTORS -- MEASURES

Outcomes and immediate causes -- birth weight, underweight, stunting, wasting

inadequate dietary intake -- seldom measured

disease -- also difficult, but some measures done

Underlying causes

food -- household food security

health -- access to h services, health environment

care -- breastfeeding, compl. foods

Education years of schooling; literacy

Basic causes -- access to and control of resources in principle:

human resources

economic resources

organizational resources

People: Productive assets -- landholdings, animals...

Education level

Access to information Etc

Programs: village committees

mobilizers/facilitators.. .

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Table 1

Indicators of micronutrient deficiencies as established by WHO.

Indicator

Deficiency

Vitamin A

Iodine

Iron

Clinical

Xerophthalmia night blindness (XN) (24-71 months). Bitots spots (X1B) also. Sum XN + X1B used here.

Goitre

Grade 1 = palpable but not visible.

Grade 2 = visible when the neck is in a normal position.

Sum of grades 1 + 2 used here.

Anaemia

Hemoglobin in g/dl:

15 years)

15 years) < 13 g/dl, children 6 mo-5yrs

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DATA

Sources

Handling units of analysis, file structure

Cleaning errors: sources, detection, coping

Transformations

Language

VARIABLES

Anthropometric

Micronutrients

*4. Data sources

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*5. Data transformations, units of analysis

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*Units of analysis (file structure) Preserve information Decide early Usually most disaggregated, repeating if needed (e.g. individual, household) Beware confounding, ecological fallacies if aggregated (e.g. district) data Care with hierarchical data, clusters, design effects.

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