Measuring the coverage of nutrition interventions along the continuum of care: time to act at scale

The global community is committed to addressing malnutrition. And yet, coverage data for high-impact interventions along the continuum of care remain scarce due to several measurement and data collection challenges. In this analysis paper, we identify 24 nutrition interventions that should be tracked by all countries, and determine if their coverage is currently measured by major household nutrition and health surveys. We then present three case studies, using published literature and empirical data from large-scale initiatives, to illustrate the kind of data collection innovations that are feasible. We find that data are not routinely collected in a standardised way across countries for most of the core set of interventions. Case studies—of growth monitoring and screening for acute malnutrition, infant and young child feeding counselling, and nutrition monitoring in India—highlight both challenges and potential solutions. Advancing the nutrition intervention coverage measurement agenda is essential for sustained progress in driving down rates of malnutrition. It will require (1) global consensus on a core set of validated coverage indicators on proven, high-impact nutrition-specific interventions; (2) the inclusion of coverage measurement and indicator guidance in WHO intervention recommendations; (3) the incorporation of these indicators into data collection mechanisms and relevant intervention delivery platforms; and (4) an agenda for continuous measurement improvement.

Yes, DHS7. Questions do not distinguish composition of supplement beyond "iron containing". Long period for maternal recall is a concern for validity.
Percentage of women who received any IFA during pregnancy  Determine if IFA or "iron-containing" supplement  Decide whether to include questions on quantity of pills/syrup received  Consider additional indicators to capture consumption of pills/tablets received (e.g., for X days or more)  Define recall period (e.g., most recent pregnancy within last X years) Multiple micronutrient supplementation (L)

No
They may qualify as "ironcontaining" supplement in DHS7 but there is no way to distinguish it was a MMN supplement.
Percentage of women who received any multiple micronutrient supplements (MMS) during pregnancy  Confirm minimum definition of MMS (e.g., 3 or more plus iron) and whether multiple micronutrient powders are included  Decide whether to include questions on quantity of pills received  Consider additional indicators to capture consumption of pills received (e.g., for X days or more)  Define recall period (e.g., most recent pregnancy within last X years) Percentage of women whose cord was clamped at 2 minutes after birth  Difficult to capture through HH surveys and at the individual level (because difficult for women to recall the 2minute interval immediately after childbirth).  Assessments can be made among service providers (as part of supervision) and as part of national policy reviews Support for early initiation of breastfeeding (L, W) Yes, DHS-7 and MICS 6. Survey questions are included in the post-natal care module so time period is limited to any Percentage of women who were assisted by a provider to put the infant to the breast in the first hour after childbirth.

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Can be problematic for women to determine the 1-hour cut-off.
time in the first 2 days after childbirth. Iron supplementation (lactating women) (W)

No
Percentage of lactating women who received any ironcontaining supplement within 6 months after childbirth. Percentage of women with a child 0-6 months of age who received advice/information from a health care provider or community worker within 1 month after childbirth; and/or Percentage of women with a child 0-6 months of age who were observed BF by a health provider or community. Additional time periods after childbirth may be added depending on country/contextspecific services.

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Need to define time frame for when the observation occurred (e.g., within a month of birth)  Should this only be asked for women with children 0-6 months old? (focus on exclusive BF as key indicator)  For observation/ support requires that woman is still lactating but all women should receive information  Assess whether lactation support should be asked about and if so, how Counseling for exclusive and continued breastfeeding (L, W) Yes, DHS 7 and MICS 6 Survey questions are included in the post-natal care module so time period is limited to any time in the first 2 days after childbirth. Information/counseling may be needed later on during infancy.
Percentage of women with a child 0-6 months of age who received information/counseling about exclusive breastfeeding from a health provider or community worker in the last 6 months.

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Define the time frame from childbirth (e.g., within 1 month, within the first 6 months, etc)  Define the age range of the child (e.g, women with a child 0-6 months of age)  Define list of health care providers Percentage of children 6-23 months of age from food insecure populations who received any food supplements in the last X months  Determine which children live in a food insecure population (define food insecurity at a population level)  Decide if additional questions/indicators are needed that capture information about consumption of food supplements, and the frequency of consumption o Decide if a minimum duration of receipt/consumption should be set (i.e., consuming any complementary food may not be a meaningful indicator, but data on frequency may be informative)  Define types of food/macronutrient supplement  Age group and recall period need to align with local program recommendations Iron supplementation in a population where children of 6-59 mo have 20% or higher prevalence of anemia (W)

No
Percentage of children (6-59 months) in a selected population who received any iron supplements in the X days before the survey.
Percentage of children (6-59 months) in a selected population who received at least X doses of iron supplements in the X days before the survey The preconception phase" includes interventions delivered during the time period prior to a first pregnancy and interpregnancy intervals as well as interventions provided to women of reproductive age and adolescent girls (ages 10-14) who do not eventually or ever become pregnant. *** UNICEF includes in its databases the following indicator which is based upon a combination of survey and administrative data: Percentage of children ages 6-59 months who received two doses of vitamin A during the calendar year. Yes, DHS 7 and MICS 6. Both survey programs use an aided recall of receipt of zinc.
Percentage of children who received zinc and ORS for an episode of diarrhea in the 2 weeks before the survey  Age group needs to be determined, based on national policy