Friday, 30 October 2015

Quality Measures

by Sidra Mazhar

Photo Credit: Collective for Social Science Research 

Stunting and wasting, which measure respectively, height-for-age and weight-for-height shortfalls among children are well-established indicators of nutritional status of a population. These statistics, part of a branch of measurement known as anthropometrics (literally, the measurement of people), are widely used to reflect on progress and direct policies. We know, for example, that the rates of stunting and wasting in Pakistan are recognized as being above UNICEF’s emergency threshold levels. While there have been many debates about what these statistics signify and how they might improve, how we actually arrive at the numbers is often taken for granted.

Researchers of the Collective were fortunate to learn more about measuring stunting and wasting from Dr Elaine Ferguson who visited us to help organize a survey in rural communities. The survey is part of a study for the research consortium Leveraging Agriculture for Nutrition in South Asia (LANSA) and seeks to examine the relationship between women’s agricultural work and nutritional outcomes such as stunting and wasting. Elaine who teaches at the London School of Hygiene and Tropical Medicine (LSHTM) is also part of LANSA through the Leverhulme Centre for Integrated Research on Agriculture and Health (LCIRAH). She is not only a renowned expert on food and nutrition, but is also a trained anthropometrist with extensive research networks in Asia and sub-Saharan Africa and close links with the World Health Organization and the Food and Nutrition Technical Assistance III Project (FANTA).

Our team’s training with Elaine began with the basic premise of child anthropometrics that there are three key variables involved: age, weight and length/height. Stunting means that a child is too short for her or his age compared to a healthy child. This might be due to the inadequate intake or absorption of important micronutrients such as zinc over a period of time. Stunting, or below par growth, in the first two years of a child’s life is usually irreversible, thus making it chronic in nature. Wasting means a child is too thin, or that she or he weighs much less than a healthy child of the same length/height. Wasting, in most cases, can be attributed to acute current starvation, lack of sufficient food and energy and/or severe disease and thus can be classified as acute in nature.

Both stunting and wasting, therefore, are reported in relation to established international standards of good health. This often raises a number of questions. What are the standards based on? Is it not true that even within the well-nourished populations, the height and weight vary over a considerable range, and these ranges are related to age, sex, region and other factors? Aren’t some people naturally taller than others? An important study conducted by the World Health Organization (WHO) in countries from different parts of the world showed that for children under-five years of age living in healthy conditions, this natural variation is the same across all populations of the world. The survey showed that children who were brought up in clean, safe environments, with an adequate diet, and under prescribed care practices (such as exclusive breastfeeding in the first six months of life) had identical growth across countries as diverse as India, Ghana, Norway, Brazil, Oman and the US. So these WHO standards can and should be used in Pakistan.

The key thing, as Elaine pointed out during the course of the training, was to capture the data correctly using methods which follow the WHO standards. It is notoriously difficult to get accurate age data in countries such as Pakistan where birth registration is partial. But even physical measurement is often prone to error. In particular, it takes skill, patience and attention to detail to get a child’s height or length right. Measuring length can provoke anxiety and fear in children making it difficult to record accurate measurements. Children’s heads and feet must be positioned just right for an accurate reading. With newborns, it is not possible to straighten their knees as they are very fragile and can easily be injured if too much pressure is applied to their legs. It is not easy to get a child to lay straight along the board and not change his or her posture or position while taking measurements.

Elaine spent a week with us, training surveyors who already had considerable fieldwork experience in anthropometric measurement. “The researchers are already trained, so our training should last for about a day or two” was the initial thought after her ice-breaking session with the team. But as the training got underway, it became obvious that even those who had worked on major surveys in the past needed to be retrained into international procedures and protocols. And the key to the training was practice, assessment and more practice, day after day. Several mother-infant pairs (or dyads) came to the training venue every day so that the surveyors could hone their skills and iron out any difficulties before going out into the field. Arranging adequate numbers of dyads every day was a challenge in itself, because the infants are very sensitive to a change in their environment. The training schedule often had to be altered according to the everyday ‘moods’ of the infants.

Another challenge was to get some of the experienced team members to accept suggestions to improve their skills without offending and demotivating them. Through her calm and supportive manner Elaine managed to overcome this challenge and inspired the surveyors to take pride in what they learnt. It was a tough week for all of us, and one when we learnt that behind the anthropometric statistics, which are invaluable for making sound policies, there is so much hard work, patience and care to detail.