Appendix B

Recommendations for the Survey-Surveillance Activities Reviewed by the Committee

◆ ◆ ◆ ◆ ◆

The committee offers the following recommendations for improving the study methods of each of the five nutrition survey-surveillance activities that the committee reviewed.

RUSSIAN LONGITUDINAL MONITORING SURVEY

With the wealth of information collected in this multilevel survey, it is frustrating that very little could be said about the effects of macroeconomic reforms, based on the available data. The surveys as designed were intended to provide a rapid-response monitoring system that could provide critical data for policy formulation. What became clear from the documents provided was that local-level collaborators did not have the capacity to implement such a complicated and extensive survey and still provide the rapid analysis and interpretation of data. Therefore the review team felt strongly that there were four steps that should be taken to ensure that the current data, and any data collected in the future, are more useful for decision making. Specifically:

  1. The CIN perceives that more information has been collected in the RLMS than is essential to monitor macroeconomic reform in Russia. The utility of the various parts of the massive sets of questions for a monitoring system cannot be determined without some articulation of the policy questions that are meant to be addressed. Therefore, the first recommendation is that the RLMS research team identify the series of policy questions that the current survey is meant to address.



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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Appendix B Recommendations for the Survey-Surveillance Activities Reviewed by the Committee ◆ ◆ ◆ ◆ ◆ The committee offers the following recommendations for improving the study methods of each of the five nutrition survey-surveillance activities that the committee reviewed. RUSSIAN LONGITUDINAL MONITORING SURVEY With the wealth of information collected in this multilevel survey, it is frustrating that very little could be said about the effects of macroeconomic reforms, based on the available data. The surveys as designed were intended to provide a rapid-response monitoring system that could provide critical data for policy formulation. What became clear from the documents provided was that local-level collaborators did not have the capacity to implement such a complicated and extensive survey and still provide the rapid analysis and interpretation of data. Therefore the review team felt strongly that there were four steps that should be taken to ensure that the current data, and any data collected in the future, are more useful for decision making. Specifically: The CIN perceives that more information has been collected in the RLMS than is essential to monitor macroeconomic reform in Russia. The utility of the various parts of the massive sets of questions for a monitoring system cannot be determined without some articulation of the policy questions that are meant to be addressed. Therefore, the first recommendation is that the RLMS research team identify the series of policy questions that the current survey is meant to address.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Based on this series of focused policy questions, dummy tables should be developed that indicate how the data from the various parts of the questionnaire will be analyzed and presented. This step is critical because as the CIN observed from the extensive number of tables already presented, few if any were presented in a way that is useful for decision makers. The CIN believes that adoption of Recommendations 1 and 2 will result in a more focused study. A direct result will be the identification of a core group of essential indicators for monitoring the ongoing effects of economic reforms in Russia. The resulting set of essential indicators will in most likelihood be sustainable within the current institutional infrastructure in Russia. There may be longer-term goals for which a more detailed survey protocol can be justified. Again, however, they are not clear from the current survey. Therefore, the CIN suggests that the RLMS research team articulate a potentially larger set of research-policy questions that justify additional data collection procedures above and beyond the essential set of indicators identified. The CIN does not believe that more data are necessarily more policy relevant. Indeed, considerable time was spent discussing the enormous respondent burden that is inherent in the current multitiered survey. The CIN decided against identifying specific sections of the questionnaires that could be eliminated or specific questions that seemed superfluous. However, the relevance of many of the detailed questions on tangential issues was questioned. Ideally, each of the individual questions should be linked to a policy question and a specific analysis plan. CARE PENSIONER SURVEYS In future studies, weight and height should be measured, not self-reported. It is also important to identify where and with whom pensioners live in order to determine what kind of social support system they have (e.g., a family-based support system). Other questions to consider are the following: Are there intrinsic issues or characteristics about the pensioners that prevent them from using these social support systems? How serious is the food shortage among pensioners, and what is the situation of their personal food stock? What are some coping strategies by which pensioners can maintain their health and diet in light of these shortages? How do pensioners supplement their income? How much international food aid has been delivered, and what are the most useful forms of food aid to pensioners? Surveys of pensioners living in rural areas should be undertaken to determine the extent of their well-being. Contrary to the usual presumption, other data available to the CIN appear to show that pensioners in small communities tended to live alone more.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Social welfare programs should be monitored directly, particularly in Armenia where the health status of pensioners appears to be more grave. CARE UNDER-TWO-YEARS-OF-AGE SURVEY The committee hopes that the full data set will be analyzed and that possible risk factors for perceived changes in food consumption will be studied. Additional attention should be given to the analysis of food intake data, as the analyses provided were not easily interpretable. In addition, the purpose for which the food intake data will be used needs to be made clear. Questions on perceived changes in food availability-accessibility should be validated and related to other objective measures of nutritional status. It is conceivable that these subjective responses may indicate some breakdown in food production, distribution, or accessibility that could be a forerunner of a larger food problem. Additional information on the rates and etiology of anemia is needed, although this is probably a chronic, rather than emergent, problem —except if there is a current problem with availability of iron supplements. Other longer-term issues that need attention are availability of modern family planning services and promotion of optimal infant feeding practices. Whether any changes in maternal employment patterns have been a recent factor undermining optimal breast-feeding practices should be explored. ANEMIA PREVALENCE SURVEY IN UZBEKISTAN Although there appear to be extremely high rates of anemia in all age groups, the application of appropriate age group-specific and physiologic group-specific definitions of anemia must be confirmed. These observations should be followed up with investigation of the etiology of anemia in each age group. Available serum plasma samples should be analyzed for iron, total iron binding capacity, and ferritin as well as other micronutrients (and toxins) such as retinol, folate, vitamin B12, riboflavin, zinc, and possibly others including lead and other heavy metals. The etiology of the anemia and growth stunting is not yet understood, but poor diet seems unlikely to be the only cause, although this was difficult to discern based on the information provided to the committee. More analysis is needed on relationships such as that between anemia and tea drinking or between anemia and the use of iron pots. It is also conceivable that the observed age-related differences in rates of stunting are due to methodological problems, such as failure to control for removal of shoes and inconsistent measurement of recumbent length versus stature. These alternative explanations could possibly be explored by examining age-related patterns of stunting in historical data, if available, and by examining

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities distributions of weight-for-height separately for children of different age groups in the current study population. HEALTH/NUTRITION EARLY WARNING SYSTEM Because data were not presented to the committee, no review could be performed. However, the committee feels that the use of the existing medical facilities and data collection systems appears to be an efficient and effective way of monitoring the health situation. The system also assists in institution building. As in all surveys, the data to be collected need to be clearly linked to possible interventions. The committee could not ascertain what specific data would be available on a routine basis regarding the food and nutrition situation in the NIS apart from infant feeding practices (where the reliability of the data is doubtful) and anemia (which may increase due to lack of supplements rather than poor diet). In Armenia during January through April 1992, the EPHISS collected, jointly with the Red Cross, food security data on refugees. In a follow-on survey of a former CARE Pensioner Survey of April 1992, 347 pensioners were surveyed in August 1992 for assessment of nutritional risk based on food security. The monthly public health bulletins provided a much-needed way to improve communication both within the NIS as well as between the NIS and international agencies involved in assistance for health and nutrition surveillance. This activity should be continued.