Now we're going to talk about data sources and measurement options for nutrition impact measures. So the common nutritional data sources or some you've seen obviously before, we've talked about DHS and MICS, that DHS looks at women 15 to 49 in children under 5. There have indicators related to growth anemia and intervention coverage. And it's normally done every three to five years in countries, as we mentioned earlier, is a few countries that do continuous surveys and so they measure yearly. MICS generally does the same thing, but focuses on children under five less on the mother. They get growth and intervention coverage is again three to five years. Now, specific to nutrition, there's different surveys, SMART and micronutrient surveys. SMART's an interesting process that it was set up for basically measuring, focusing on anthropometry in kids under five. They also try to track mortality and some ideas of food security, where they really try to focus on the idea of the differential between populations, their food secure and food insecure. This is not a standard program like DHS and MICS that it's funded and run consistently, but rather they kind of work on the idea that all of their survey tools and things are available on the website. It's often run by UNICEF, for example, ran this for years in Nigeria at state levels where they would use the SMART survey to get additional information in between the standard DHS and MICS. It allows for adoption and many people use it as kind of the basis if they're focusing in their evaluation of nutrition of their data collection instrument micronutrients surveys or a similar thing that people use. It focuses on women and children. There, you really have to draw blood. I'd assault, you can actually do by just saying, is it in the house? But in most of these surveys, you're going to draw blood and test for different things. In some countries, micronutrients surveys or SMART surveys or run quite frequently, for example, Indonesia. A lot of east Asian countries run these yearly or every other year. Indonesia has been doing a national nutrition survey yearly for the last ten years. So now let's look at nutrition data sources in core DHS and MICS. Now when I say core, both of these things can be altered. You can add additional pieces. But you see the DHS provides more information, especially about nutrition, especially related to mothers and interventions. So these, you look down at the bottom supplementation powders, things like this, iron supplementation, these aren't really impact measures, but their coverage of interventions that relate to your impact measures of anemia or growth and could be used in later modeling and might be important. MICS doesn't collect all of those in their standard, MICS survey, but they do have additional modules that can be added on that collects all of that information. SMART surveys, let's go through what they have. Is that really nutritional status? So they're doing anthropometry. They also track mortality though. Let me give my opinion on that. They don't measure it. Well, it's as nonstandard approach and most people don't use the mortality. Their original goal here was for emergency refugee situations. They could see if mortality suddenly gone up 50% or something like that. But it's not a standard approach to under five mortality and that they sometimes add, given that the whole program is to let you add modules, they'll have situation specific coverage indicators that are added. So for example, in Nigeria that I mentioned earlier was running this, UNICEF also had some core coverage indicators that weren't related nutrition that they added. It's really designed to be an emergency rapid assessment. It can be used to generate national or sub national prevalence assessments of stunning and wasting and that many places will use a smart survey and refer to it as a national nutrition survey. This is also for you as an evaluator. If you go and try to collect all the information related to nutrition from a MICS or a DHS, it's much more complex than simply grabbing the standard SMART survey, especially if you're focusing on anthropometry and use that as the basis of your tool in your evaluation. Another thing that's kind of grown over the last 10 or 15 years is anemia measurement. USAID, which funds the DHS surveys, has started training standard test for an email, drawing blood. It's a fairly good system. They've shown it's been very reliable and accurate measure. It's fairly low cost, but again, it's always an additional cost in doing collecting samples within household surveys. So the key is if you're going to collect your own data. So if you're doing an evaluation and there's a big national survey that you can link to for baseline and in line, that's great. But often, you're going to have to do your own surveys to collect this information. So one of the things we talked about earlier is you gotta think about timing that that's really critical if you're going to run baseline and in line surveys to make sure that timing is captured correctly. So you don't kind of measure during the kind of post harvest season where lots of fuel available and then the other sir value measure at a period before harvest. So there's less food availability. So that's a critical component. Second, you have to worry about the effects your programs can have. You've got to be measuring. And if you're looking at stunting, what's the age of the population, the two-year program, you should only be looking at changes in growth and the kids under two. For sampling, the idea is one of the nice things about these surveys is compared to measuring mortality. You're probably going to need a more smaller sample simply because you're measuring all children. You're not looking at death and it's not stunting and wasting is not near rare event is under five mortality. As for example, lots of African countries over 30 of kids are stunted, even at the early age is you may be talking 15 or 20 versus under 5 mortality rates of 60. So a much more frequent outcome. So a smaller survey would be able to accurately measure it. And for implementation, the key is anthropometry. If you're measuring anthropometry, every household is going to ave to have at least two data collectors to do the measurements and record it. You can't go out with a household with a single person, go in and do it. You're going to have to have two that makes it more expensive and time consuming to do it. And if you're doing blood sampling, even dried blood spots, very resource intensive, extra logistics to protect samples. And there's going to be additional ethical concerns that you don't have in most household surveys. So and kind of summarize about nutrition as an impact measure. It's an important contributor population health and it should be included in the program impact of all feasible. Even if you're only looking at under five mortality, knowing information about growth in this population is quite important. The primary indicators for nutrition or growth in anemia, that these are really the things growth primarily in children anemia in women of reproductive age. Growth is relatively as we've talked about Eastern measure compared to anemia. So you're using anthropometry for growth and then biomarkers for anemia. Including an assessment of nutritional status will certainly increase the cost of your household survey. But if it's really your only outcome, you may save money because you will require a smaller sample size to get a reliable measure of nutritional impact than you would have mortality.
