Category Archives: Nutrition

11 Dec 2019

Meeting Emerging Nutrition Data Needs in DHS-8

Nutrition is central to the health, well-being, and economic development of individuals, communities, and nations. Comprehensive and credible data are needed to capture the current state of nutrition and track the implementation of nutrition interventions. The DHS Program is a leading source of nutrition data in low and middle-income countries.

The DHS Program has standard Model Questionnaires, updated every 5 years, which form the basis for the data that are collected in each country. In 2019, we underwent a rigorous process to update the questionnaires for DHS-8. A total of 89 nutrition-related questions are now in the Woman’s Questionnaire, up from 54 questions in DHS-7.

The DHS-8 questionnaires meet several current and emerging nutrition data needs which can be used to track progress and inform national and global decisions on nutrition policies and programs. This week we are highlighting the new and revised nutrition questions in DHS-8.

These new and revised questions strengthen the nutrition portfolio in DHS surveys, filling major data gaps and enhancing countries’ ability to address malnutrition in all its forms.

Click the icon below to view the new nutrition information by topic:

Anthropometry Measurement
Nutrition Counseling
Food or Cash Assistance
Iron Supplementation
Minimum Dietary Diversity for Women
Unhealthy Foods for Children
Growth Monitoring
FIES

Click the life cycle below to view all nutrition data collected in DHS surveys:

When will updated nutrition data be available?

The DHS-8 Model Questionnaires will be ready for use in surveys with fieldwork starting in late 2020 with data released starting in late 2021. In the meantime, The DHS Program will:

  • Translate the questionnaires
  • Revise training manuals and materials
  • Develop an adaptation guide for questions which require country-specific adaptation, such as infant and young child feeding and minimum dietary diversity for women
  • Create data processing applications
  • Define indicators, design table templates, and draft report templates
  • Pilot select new questions, modules, and alternative approaches for entering data in CAPI

The status of DHS surveys can be found here.


Visit The DHS Program website and subscribe to The DHS Program Nutrition eNewsletter for more nutrition updates in The DHS Program. You can also join the Data for Nutrition Community of Practice as a free, online platform for more nutrition resources.

Featured Image: © 2017 Riccardo Gangale, USAID, Courtesy of Photoshare.

 
10 Sep 2019

Nutrition in the Health System: Linking SPA and DHS Surveys

Global momentum on quality of care in the health system continues to expand. The United Nations Decade of Action on Nutrition (2016-2025) recognizes that the health system is a key pillar in providing universal coverage of essential nutrition actions. Reliable data for monitoring is central to understanding and improving the health system for nutrition. In addition to data from Health Management Information Systems, Service Provision Assessment (SPA) surveys also provide nationally representative facility information that can be used to explore the quality of facility-based health services.

­SPA surveys are a rich source of nutrition information providing insight on the availability and quality of services. Similarly, DHS surveys provide a significant amount of information about nutrition behaviors of populations. By linking SPA and DHS surveys, users can examine how the health facility environment contributes to these behaviors.

Two recently released DHS Working Papers examine the health service environment for key nutrition interventions: breastfeeding counseling and iron folic acid supplementation. The papers use Haiti and Malawi as case studies to describe the facility readiness, such as the availability of trained providers and essential medicines (see infographics below), and service delivery including observations of provider-client consultations of the two interventions in the context of antenatal care. The papers go on further to link SPA and DHS surveys to examine relationships between the health service environment and the nutrition behaviors.

The papers illustrate how linking SPA and DHS surveys can be useful for enhancing essential nutrition actions at the facility by identifying key programmatic gaps that can be strengthened to improve effective intervention coverage.

Download Working Papers 160 and 161 to find out more about the results in each country and their implications. And now, Analytical Briefs are available for DHS Program Analytical Reports. Download the Analytical Briefs for a shorter, more concise summary of these working papers.

Facility readiness to provide iron folic acid supplements
and counseling during antenatal care.



23 May 2019

Luminare: Field Testing Solutions to Anthropometry Data Collection in Nigeria

© 2018 Hanna Useem/ICF

This blog post is part of Luminare, our new blog series exploring innovative solutions to data collection, quality assurance, biomarker measurement, data use, and further analysis. This is the first post in the series that focuses on innovations to improve the quality of anthropometry data.  


Anthropometry, the measurement of the human body, gives a snapshot of the malnutrition situation in a country. Yet, the collection of accurate height and weight measurements, especially for young children, is difficult during data collection. To address this challenge, The DHS Program has tested new innovations to enhance the quality of the anthropometry data in the 2018 Nigeria Demographic and Health Survey (NDHS)

The 2018 NDHS is the sixth DHS survey conducted in Nigeria. The National Population Commission (NPC), in collaboration with the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health (FMOH), implemented the survey. Thirty-seven field teams closely monitored by coordinators and quality controllers collected data from August 14, 2018, to December 29, 2018. Each field team included a supervisor, field editor, two male interviewers, three female interviewers, and a biomarker team consisting of a lab scientist and nurse. 

Introducing a Biomarker Checklist to strengthen supervision

This image has an empty alt attribute; its file name is IMG_2598-683x1024.jpg
State coordinator administering the Biomarker Checklist during field practice.
© 2018 Sorrel Namaste/ICF

The DHS Program has developed a Biomarker Checklist to assess the performance of and provide feedback to field staff. The checklist includes a core set of tasks required to collect biomarker data. Each task is a crucial action that, if missed, can result in poor quality data. The Biomarker Checklist is administered by supervisors and coordinators during collection of biomarkers in households.  

The Biomarker Checklist was tested during the 2018 NDHS pre-test and biomarker main training using a mixed-method design which included administering anonymous questionnaires and conducting key informant interviews with the supervisory staff who used the checklist to assess its’ viability and usefulness. Feedback on the Biomarker Checklist was positive, so the Biomarker Checklist was used during the 2018 NDHS data collection. A Biomarker Checklist will be publicly available at a later date.  

“it [Biomarker Checklist] has helped a lot because you are able to monitor what the biomarkers are doing so [you] can actually give corrective action”

Reducing errors while still in the field through re-measurement of children

The shift from paper questionnaires to a CAPI-based data collection approach provides an opportunity to easily identify children who may have been mismeasured and return to the household to measure these children again. To identify children with incorrect measurements requires performing a complicated calculation – a child’s body measurements are compared against a healthy population by transforming their measurements into anthropometry Z-scores. Extreme measurement results are then detected by calculating anthropometry Z-scores and flagging cases with higher or lower Z-scores than expected. The DHS Program has developed a program to automatically calculate anthropometry Z-scores and flag extreme cases in the CAPI system. A user-friendly interface on the tablet produces a report with the children who need to be re-measured.  

The DHS Program relies on field check tables that are run periodically during data collection. While an important data quality tool, a major limitation of the field check tables is that enough data need to accumulate before problems can be identified. At that point, the information can only be used to improve collection of data moving forward; these corrections do not fix data previously collected. The real-time ability to re-measure children while still in the field is a major step forward and can easily be applied to other CAPI surveys. 

Re-measuring anthropometry in a random subsample of children

The CAPI system interface shows flagged cases, selection of household for random re-measurement and comparison of results between the first and random measurement.

A random re-measurement of height and weight in a subsample of children was also piloted in Nigeria. The DHS Program has developed a CAPI program that randomly selects one household in each cluster for the biomarker team to revisit. The program then compares differences between measurements and reports precision, or how close the first measurement is to the second measurement, as acceptable or unacceptable.  

The aim is measurements will be of better quality as a result of instituting random re-measurement. The biomarker team may be more careful and not rush measurements if they know poor measurements will be exposed. The data produced on precision can be used as a motivational tool for biomarker teams and provide an opportunity to identify and re-train in cases where there is a high degree of discrepancy between measurements. Precision estimates will also help better assess data quality post-data collection.  

Results 

A review of the anthropometry data from the 2018 NDHS indicates it meets data quality targets. Results from the 2018 NDHS Key Indicators Report (KIR) show that 37% of children under 5 are stunted. Stunting generally increases with age, peaking at 47% for children age 24-35 months. Overall, 7% of children under 5 are wasted, while 23% of children are underweight.  

Lessons learned in the implementation of the quality assurance activities in Nigeria are being used to conduct similar activities in DHS surveys in other countries. 

About the survey 

The 2018 NDHS was implemented by the National Population Commission (NPC) in collaboration with the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health, Nigeria. Funding for the 2018 NDHS was provided by the United States Agency for International Development (USAID), Global Fund, Bill and Melinda Gates Foundation (BMGF), the United Nations Population Fund (UNFPA), and World Health Organization (WHO). ICF provided technical assistance through The DHS Program, a USAID-funded project that provides support and technical assistance in the implementation of population and health surveys in countries worldwide.  

Additional information about the 2018 NDHS may be obtained from the headquarters of the National Population Commission (NPC), Plot 2031, Olusegun Obasanjo Way, Zone 7, Wuse, P.M.B. 0281, Abuja, Nigeria (telephone: 234-09-523-9173; fax: 243-09-523-1024; email: info@population.gov.ng; internet: www.population.gov.ng).

28 Feb 2019

Strengthening Nutrition Data Quality at The DHS Program

A health technician tests a child for anemia during a survey training. © 2018 ICF/Sorrel Namaste

“Everything bad can go wrong at collecting the sample, and you can’t get any good results from a bad sample. ” – Informant from the Enhancing Nutrition Data Quality Report

Data for decision-making is vital as countries work to reduce the burden of malnutrition and to measure progress towards the Sustainable Development Goals and the Global Nutrition Targets 2025.

The DHS Program, a leading source of nutrition data globally, has invigorated its focus on the quality and depth of the types of nutrition data collected. To this end, a qualitative study was undertaken to identify how to enhance the quality of nutrition data. Interviews were conducted with 50 experts internal and external to The DHS Program, and DHS staff participated in focus group discussions. Informants highlighted critical challenges that exist in collecting anemia, anthropometry, and infant and young child feeding data in large surveys while also offering solutions to strengthen data quality.

The outcomes from the study are summarized in the report “Enhancing Nutrition Data Quality in The DHS Program” which calls for the implementation of 32 recommendations. The DHS Program is already addressing most of these recommendations (21 out of the 32) and plans to take up additional recommendations throughout DHS-8. These include revising hemoglobin cutoffs in STATcompiler, working with the WHO to develop a technical error of measurement value for passing an anthropometry standardization exercise, and testing new procedures and indicators for real-time monitoring of fieldwork. Future blog posts will explore the application of these recommendations across the stages of a DHS survey.

Recommendations to enhance nutrition data quality were identified across The DHS Program survey stages. © 2018 ICF

The DHS Program is committed to continuous quality improvement and is uniquely positioned to implement new data quality measures. Yet, the report is not only intended to inform operations at The DHS Program. The lessons learned are applicable to wider audiences involved in the collection and use of nutrition data throughout the world. Strengthening the quality of nutrition data will lead to improved data-driven nutrition actions.


Written by Sorrel Namaste and Rukundo K. Benedict

Dr. Sorrel Namaste is the Senior Nutrition Technical Advisor for The DHS Program. She is an epidemiologist with expertise in nutrition assessment and implementation research. 

Dr. Rukundo K. Benedict is the Nutrition Technical Specialist for The DHS Program. She is a public health nutrition practitioner with expertise in infant and young child feeding (IYCF), water-sanitation hygiene (WASH), community health systems, and the delivery of integrated interventions in low-resource settings. 

12 Oct 2017

The New Nutrition Team

Hemoglobin analysis in DHS surveys in carried out with a portable HemoCue analyzer.

Did you know that nutrition is one of the most published topics using data from The DHS Program? This shows what a major resource The DHS Program is for nutrition-related policy, programs, and research. Recognizing the important contribution of nutrition data, two new nutrition experts have recently joined The DHS Program team, Drs. Sorrel Namaste and Rukundo K. Benedict.

As our new nutrition experts, they will manage all aspects of nutrition data collection and use, working to:

  • Ensure provision of high-quality nutrition data within The DHS Program
  • Explore innovations for nutrition data in low- and middle-income countries
  • Support evidence-based programming and policies with relevant and timely nutrition data
  • Build capacity in nutrition data measurement, analysis, and use around the world

Some of The DHS Program’s recent activities on nutrition include the new Hemoglobin report, and we are also currently seeking applications for the 2018 DHS Fellows Program. To stay up-to-date with more nutrition activities, sign up for our upcoming nutrition newsletter.

So join us in welcoming our new nutrition team in the comment section, and learn more about them in their bios below. If you still have any questions or comments, you can reach out to them directly at nutrition@dhsprogram.com.


Dr. Sorrel Namaste is the Senior Nutrition Technical Advisor for The DHS Program. She is an epidemiologist with expertise in nutrition assessment and implementation research. Dr. Namaste has a particular interest in the use of data to strengthen the feedback loop between the scientific, policy, and implementation communities. Prior to joining The DHS Program, she was the Anemia Team Lead for the USAID-funded SPRING project. In this capacity, she provided technical assistance to governments to develop national strategies, supported program implementation, and contributed to the formation of global policies. Previously, she also worked for the National Institutes of Health (NIH) where she was responsible for supporting large-scale global nutrition research projects. While at NIH, she served as the co-principal investigator on the Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA) Project. She completed her DrPH at George Washington University and holds an MHS from the Johns Hopkins Bloomberg School of Public Health in Global Epidemiology.

Dr. Rukundo K. Benedict is a Nutrition Technical Specialist for The DHS Program. She is a public health nutrition practitioner with expertise in infant and young child feeding (IYCF), water-sanitation hygiene (WASH), community health systems and the delivery of integrated interventions in low-resource settings. Prior to joining The DHS Program, she worked as a postdoctoral associate at Cornell University on policy and program relevant projects. She led a project with UNICEF South Asia to examine the epidemiology of breastfeeding in South Asia and to explore the effectiveness of strategies to support breastfeeding and maternal nutrition and infant feeding counseling. She also conducted implementation research on the delivery of nutrition and nutrition sensitive interventions by community health workers in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. She has a PhD in International Nutrition from Cornell University and an MSPH from Johns Hopkins Bloomberg School of Public Health.

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Photo Caption: Hemoglobin analysis in DHS surveys in carried out with a portable HemoCue analyzer

16 Dec 2014

The Nutrition Landscape in India

This post is part of a series commemorating 30 years of The DHS Program.

By Fred Arnold

Historically, India has suffered through devastating periods of famine, but due to the Green Revolution, improved food storage and distribution, and other factors, famine has been all but eradicated in the country. However, malnutrition continues to threaten the health of India’s population.

NFHS-3

NFHS-3

The National Family Health Surveys (as DHS surveys are known in India) have been documenting the nutrition situation in India since 1992 (by measuring the height, weight, and anemia status of children and adults, and by assessing infant and young child feeding practices). These surveys have brought to the nation’s consciousness the excessively high levels of stunting, wasting, underweight, and anemia that young children in India continue to suffer from. The most recent NFHS survey (NFHS-3) found that nearly half of children under five are stunted, 43% are underweight, 20% are wasted, and 7 out of every 10 children are anemic. Stunting among children was as high as 60% in the lowest wealth quintile, but was still considerable (25%) even in the highest wealth quintile. These findings were widely reported in the media, were agonized over by international organizations and NGOs, and were prominently discussed at the highest levels of government. In two national addresses, Prime Minister Manmohan Singh revealed that he had seen the results of the National Family Health Survey, and he declared the poor nutrition of India’s children to be “a national shame.” He immediately responded by writing a letter to the Chief Ministers of every state in the country, ordering them to take up the fight against malnutrition “on a war footing” and to report back to him every quarter on the progress that had been made.

Based on the NFHS-3 findings, that same year I wrote a paper on the nutrition landscape in India, which was published in Demography India and presented as the keynote speech at the Annual Meeting of the Indian Association for the Study of Population. That reached yet another important constituency that joined the national dialogue on nutrition.

Another aspect of nutrition that was documented in that paper was the emerging dual burden of simultaneous undernutrition and overnutrition among Indian adults. About one-third of women and men were abnormally thin and about 1 in 8 were overweight or obese, meaning that only about half of adults had a normal nutritional status. The figures are even more alarming in certain segments of the population. Thirty to forty percent of women were overweight or obese in some of India’s largest cities, and even in urban slums, 20-30% of women fell in that category.

Since NFHS-3, there have been encouraging signs of improvements in nutrition in some places, but discouraging signs of stagnation or deterioration in others. The results of the NFHS-4 survey, which is just about to go into the field, are eagerly awaited to provide more definitive information on the current nutrition situation. And when the next chapter in India’s nutrition history is written, NFHS will be there to monitor trends and provide vital information to guide informed policymaking and program planning.

————————————————-

Fred Arnold, Technical Deputy Director—Dr. Arnold is responsible for setting the overall technical direction for The DHS Program and coordinating the design of DHS questionnaires. He has coordinated technical assistance to four large-scale National Family Health Surveys in India, which have included interviews with more than one million women and men, working with more than 40 organizations (government ministries, funding agencies, international organizations, and implementing agencies) in the conduct of the surveys. He has been involved in the design and implementation of surveys in 15 additional countries. Dr. Arnold has a Ph.D. in economics/demography from the University of Michigan. He has authored more than 150 publications in areas such as malaria; HIV; maternal, newborn and child health; nutrition; son preference; international migration; and the value of children.

The information provided on this Web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.

The DHS Program, ICF
530 Gaither Road, Suite 500, Rockville, MD 20850
Tel: +1 (301) 407-6500 • Fax: +1 (301) 407-6501
dhsprogram.com

✴ New
♲ Revised

Women of reproductive
age and pregnancy

  • Anemia testing
  • Anthropometry measurement
  • Clothing and hairstyle interference withanthropometric
    measurements ✴
  • Coverage of breastfeeding counseling during antenatal care ✴
  • Coverage of nutritional counseling during pregnancy ✴
  • Cash-assistance programs for pregnant women ✴
  • Household salt iodization ♲
  • Deworming medication during pregnancy
  • Iron-containing supplement consumption during pregnancy ♲
  • Source for iron-containing supplements taken during pregnancy ✴
  • Minimum dietary diversity for women ✴

Infants

  • Anthropometry measurement
  • Clothing and hairstyle interference with anthropometric
    measurements ✴
  • Size at birth
  • Skin-to-skin contact, including timing of skin-to-skin contact ♲
  • Weighed at birth
  • Early initiation of breastfeeding
  • Exclusive breastfeeding
  • Bottle feeding
  • Introduction of any liquids or foods in the first three days
  • Postnatal breastfeeding counseling and observation ♲
  • Coverage of breastfeeding counseling during postnatal care
  • Feeding liquids during recent diarrheal episode
  • Feeding foods during recent diarrheal episode
  • Zinc treatment for diarrhea for children

Young children

  • Anemia testing
  • Anthropometry measurement
  • Clothing and hairstyle interference with anthropometric
    measurements ✴
  • Complementary feeding, including sugary drinks and
    unhealthy foods ✴ ♲
  • Coverage of nutrition counseling for infants ✴
  • Coverage of growth monitoring for children ✴
  • Deworming medication for children
  • Iron-containing supplements for children ♲
  • Vitamin A supplements for children
  • Zinc treatment for diarrhea for children
  • Feeding liquids during recent diarrheal episode
  • Feeding foods during recent diarrheal episode


Nutrition counseling is an important intervention during antenatal care, postnatally, and throughout early childhood. The Woman’s Questionnaire now includes questions on nutrition counseling during antenatal care, breastfeeding counseling during antenatal care, and nutrition counseling for young children. With this information, countries will be able to track the coverage and impact of nutrition counseling interventions. The reference period is 3 years to improve women’s recall and reduce survey burden.

Food or cash assistance programs for pregnant women are implemented in many countries around the world to improve maternal and child nutrition and other welfare outcomes. For the first time in the Woman’s Questionnaire, women will be asked to recall if they received food or cash assistance during pregnancy in the last 3 years.

Daily iron supplementation during pregnancy reduces the risk of maternal anemia and low birth weight and preterm births. The DHS survey already collects information on women’s consumption of iron supplements during pregnancy, but now the recall period has been reduced from 5 to 3 years. There is a new question about the source of iron supplements, so countries can understand where women access iron supplementation.

Information on iron-containing supplements for children is also collected in DHS surveys. This question has been updated to align with WHO guidelines on suggested schemes for iron delivery. The recall period has been increased from 7 days to the last 12 months, and the type of iron vehicle will now be recorded (i.e. multiple micronutrient powders or iron pills/syrups).

The Woman’s Questionnaire now includes Minimum Dietary Diversity for Women to assess the micronutrient adequacy of women’s diets and their intake of healthy and unhealthy foods. This fills an important data gap in women’s diet quality. Countries will be able to assess women’s diets at the national and sub-national levels and take appropriate action.

Given the global increase in overweight and obesity among children, the new questionnaire will collect information on unhealthy food and sugary drink consumption. These questions will help countries understand the extent of the problem and provide evidence to guide country programs and policies.

The Food Insecurity Experience Scale (FIES) is a standard measure of moderate and severe food insecurity. It is an indicator that countries use to measure their progress towards the Sustainable Development Goal of ending hunger (Target 2.1). There are plans to add the FIES as an optional module that countries can include in a DHS survey.

Growth monitoring for children is the second most common nutrition intervention reported by WHO member states. The Woman’s Questionnaire will now collect this information for comparable data at the national and sub-national levels.

Anthropometry measurement (height and weight) is a core component of DHS surveys that is used to generate indicators on nutritional status. The Biomarker Questionnaire now includes questions on clothing and hairstyle interference on measurements for both women and children for improved interpretation.