Methodological aspects of assessing nutrition security

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Anne Hatløy

Methodological aspects of assessing nutrition security Examples from Mali

Doctoral dissertation

Methodological aspects of assessing nutrition security

Institute for Applied Social Science P.O.Box 2947 Tøyen

To be able to assess food and nutrition security, good tools are needed. For the youngest children, breastmilk is the most important source for covering nutrition requirement. In this report the manner in which the economic value of the breastmilk can be calculated is demonstrated. A common form for assessing the nutritional situation is the comparison of the height and the weight of children with their age. However, mistakes made estimating age can lead to incorrect evaluations of nutritional status. In addition, simple indicators for food security have been developed in this report. The number of food items and the number of food groups are shown to give fairly good indication of the nutritional adequacy of the diet and were also related to the nutritional status of the children.

Fafo-report 323 ISBN 82-7422-300-4

Methodological aspects of assessing nutrition securityAnne HatløyFafo

Institute for Nutrition Research University of Oslo, Norway

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Anne Hatløy

Methodological aspects of assessing nutrition security Examples from Mali

Doctoral dissertation

Fafo-report 323

Institute for Nutrition Research

University of Oslo, Norway

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Cover page: Jon S. Lahlum Cover photos: Anne Hatløy

Printed in Norway by: Centraltrykkeriet AS

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Acknowledgement

The present work was carried out during the years 1990 to 1999, from 1995 to 1998 as a research fellow, at the Institute for Nutrition Research, University of Oslo. The work was supported by grants from the Norwegian Research Council (NFR), and carried out as part of the SSE (Sahel, Sudan, Ethiopia) Research Program in Mali, a multidisciplinary research program funded by the Norwegian Ministry of Foreign Affairs and the Norwegian Universities’ Committee for Development and Research (NUFU). I appreciated the close collaboration both with the CNRST/SSE head- quarter in Bamako and with the National Institute for Research on Public Health (INRSP) in Bamako.

A special thanks goes to all the people responding to our questionnaires both in the Gourma in 1990 and in Koutiala in 1994 and 1995. Without their willing- ness to let us come into their homes, there would not have been any surveys.

I would like to express my sincere gratitude to all the Malian and Norwe- gian colleagues and friends within the Mali Program. First to my supervisor Arne Oshaug who introduced me to the field of food and nutrition security in Mali 11 years ago. He provided me with new challenges, and supported me throughout the process. Then to my close collaborator through all these years, Modibo M. Diarra, whose social intelligence has been invaluable both for contact with the people in the villages and at the administrative level. All the fieldworkers and others involved in the surveys did a formidable job. Not least, the drivers for the SSE-program worked strenuously throughout the rainy season – thank you! Special thanks to Mohamed Ag Bendech, Moro Diakité and Ibrahim Cissé for valuable discussions and social life both in the field and in Bamako.

Thank you to Jon Pedersen for opening the mysteries of computers and data- analysis for me. I want to thank Marit Beseth Nordeide for several years of sharing office as well as experiences in Mali. Alida Boye made efforts to try to co-ordinate us within the project, thank you for your never-ending enthusiasm for Mali. To Liv Elin Torheim and Ingrid Barikmo, it has been very inspiring both to be your supervisor, and after that to be colleagues on the Mali-project. I’m glad you both will continue to work in Mali.

I want to thank all friends and former colleagues at the Institute for nutrition research for friendliness and for willingly sharing knowledge and skills. To Siri

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Damman and Lene Frost Andersen, I want to give special thanks, for many stimu- lating discussions about all aspects of life. Thanks also to Wenche Barth Eide, for everlasting inspiration. During my fieldwork, I found the best place of recreation in the world in Bafoulabé – thanks to Bodil Tveit and all others at the Strømme Foundation and the Norwegian Santal Mission for hospitality and friendship. Last, but not least, I want to thank my family and all my friends for all their moral sup- port during these years!

Anne Hatløy Oslo, May 1999

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List of abbreviations

CNRST Centre National de la Recherche Scientifique et Technologique (The National Centre for Scientific and Technological Research, Bama- ko, Mali)

DDS Dietary Diversity Score, number of food groups FVS Food Variety Score, number of food items

INRSP Institute National de la Rescherche en Santé Publique (The National Institute for Research on Public Health, Bamako, Mali)

H/A Height-for-Age, low height or length for age, an indicator for short- ness or stunting

HAZ Height-for-age in z-score (standardised standard deviation), -2 used as a cut-off for malnutrition

HFS Household Food Security (for definition see Chapter 3.2)

MAR Mean Adequacy Ratio, indicator for nutritional adequacy of the diet MUAC Mid-upper-arm circumference, an indicator for thinness or wasting

SES Socio Economic Score

SSE-program Sahel-Sudan-Ethiopia program¹

W/A Weight-for-age, low bodyweight for age, an indicator for lightness or underweight

WAZ Weight-for-age in z-score (standardised standard deviation), -2 used as a cut-off for malnutrition

W/H Weight-for-age, low bodyweight for height, an indicator for thinness or wasting

WHZ Weight-for-height in z-scores (standardised standard deviation), -2 used as a cut-off for malnutrition

1 The SSE-program was funded in 1986 by the Norwegian Ministry of Foreign Affairs. Funds for the Program were channelled through multilateral organisations, non-governmental organisations and research institutions. The research component within the SSE-program in Mali was a collaboration between the University of Oslo and Malian research institutions co- ordinated by CNRST.

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1 About the study

The level of malnutrition, both in the children and the adult population in Mali is very high (Unicef, 1998; ACC/SCN, 1997; Dettwyler, 1992; Castle, 1995; Couli- baly et al., 1996). Malnutrition is a sign of nutrition insecurity, and is caused by food insecurity, insufficient care and inadequate health services. To be able to assess the nutrition security situation in a community, there is a need for proper tools for different levels of analysis. Such tools are not adequately developed today. This study is a contribution to the development of some tools necessary for assessing nutrition security.

The work has been carried out as a part of the nutrition component of the interdisciplinary SSE Research Project in Mali involving researchers both from the National Institute for Research on Public Health (INRSP) in Bamako and from the

Figure 1 Map of Mali (the square indicates Figure 2)

Algeria

Mauritania

Burkina Faso

Niger

Côte dIvoire Guinea

Senegal ^Niger

Kidal

Gao Tombouctou

Taoudenni

Mopti Kayes

Koulikoro Bamako

Sikasso Ségou 0

200 400 km 400 ml 0

200

Koutiala

Gourma

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University of Oslo. The main study-area in the period 1989-92 was the Gourma, in the Northern Sahel, bordering the Sahara in northeastern Mali. The area had a population of both nomads and sedentary people who had suffered in the drought in 1983/84. Comparative studies were carried out in Koutiala (southeastern Mali).

Koutiala is assumed to be one of the richest areas in Mali concerning agricultural production. The Gourma on the other hand is situated in a zone with very low annual rainfall and a low level of food production. The assumption was that there would be a much higher level of malnutrition in the Gourma than in Koutiala; the results showed, however, no differences between the areas (Ag Bendech et al., 1994).

The studies in the Gourma had a longer time perspective than those in Koutiala.

However, due to a rebellion that affected the situation, the project group had to leave the Gourma in 1992 for security reasons, before sufficient data had been collected and the results have therefore remained preliminary. The Koutiala part of the project continued, however. Most of the results in this thesis are based on data collected in Koutiala.

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2 Aims of the study

The aims of this thesis were to identify indicators and develop tools for assessing nutrition security, by:

1) Assessing the effect of age-estimation on age-based anthropometric indicators (Paper I).

2) Assessing quantity and economic value of human milk, as an indicator for nutrition security for infants (Paper II).

3) Assessing nutritional quality of foods for development of a food composition table as a tool for estimating nutrient adequacy of the diet (Paper III).

4) Developing scores of food variety and dietary diversity as simple indicators of nutritional adequacy of the diet (Paper IV and Paper V).

The thesis is composed of a short introduction to the area and the nutritional con- ditions in Koutiala. Then the concepts food security and nutrition security are clari- fied. This is followed by a description of the methods. Summaries of the results from the articles with some complementary results are then presented. Finally, the results are discussed in relation to the framework of nutrition security.

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3 Background

3.1 Description of the area

The cotton zone

Most of the data presented in this thesis were collected in Koutiala Cercle. Koutiala Cercle is situated in the Sudanian zone with an average annual rainfall of 900 mm (Jonckers, 1987). Moreover, Koutiala is one out of seven Cercles in Sikasso, that again is one of the eight regions in Mali (Traoré, 1980). Koutiala Cercle is divided into seven arrondissements, of which one is a town, Koutiala town, with about 49,000 inhabitants (Bureau Central de Recensement, 1990). The other arrondissements are defined as rural areas, with 234,000 inhabitants according to the census in 1987 (ibid.). The sampling area was six out of the seven arrondissements, including the urban area, with a total population of 247,000 inhabitants.

Figure 2 Map of Koutiala and surrounding areas

Koulikoro

Sikasso Ségou

Bobo-Dioulasso Koutiala

Bougoni

Kinian Mena Beléko

Fana Mpessoba

San

Bla

Yangasso

Sangasso

Karangana Yorosso Kouniana

0

50 km 0

50 ml

Burkina Faso

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2 The second ethnic group in Koutiala town was Bambara (20%). In addition, there were Fulani, Dogon, Sarakolé and other ethnic groups.

Mali is the second main cotton-producing country in West and Central Africa (Fok, 1994), with Koutiala as the core area of the cotton zone. The relatively developed infrastructure of the region is due to the cotton production and Koutiala town serves as a junction between Mali and the neighbouring countries Burkina Faso and the Ivory Coast. All cotton exported from Mali is produced in the region (Benjamin- sen, 1998b). A cotton factory dominates the economy in Koutiala town. In addition to cotton, the area produces maize, sorghum and millet. The cotton zone in southern Mali is today a net exporter of grain to other parts of the country (Ben- jaminsen, 1998a). The cultivated area of food crops has increased in Koutiala during the last decades, while the area under cotton has remained more or less stable (Bade et al., 1996). Cotton production seems to have a positive impact on food production, because of the introduction of modern agricultural practices (Raymond and Fok, 1995).

The main ethnic group in the zone is Minyanka (Jonckers, 1987). In our sample from 1994/95, 81% of the rural household leaders (n=488 households) were Minyanka. In the urban area, however, the population is much more heterogene- ous, only 35% out of the 329 household leaders were Minyanka². In the urban area, 95% of the household leaders were Muslims and the remaining 5% were Christian.

In the rural areas, 68% reported that they where Muslims, 26% animists and 6%

Christian. Both the Muslims and the animists men are allowed to marry up to four women. The households³ consist of a household leader, which we found to be a man in 97% of the rural households and 94% of the urban households, his wives, children, other relatives and people working in the household. The mean household- size in the urban area was 9 members, in the rural areas they had a double size, namely 18 members. In both the urban and the rural areas, extended households with more than 70 members were found.

Nutritional status in Koutiala

Given the favourable conditions in Koutiala, one would have thought that nutrition status would be better there than in other parts of the country. This, however, is not the case. The level of stunting in rural areas in Koutiala has been found to be at the same level as in the Gourma, and somewhat worse than in Western Mali (Ouassala/Oussoubidiania) (Diallo et al., 1998). This is shown in Table 1, which is ranged by the level of stunting, the highest first and the lowest last. Both our data

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and other data from the area (Table 1) indicate that the nutritional situation is better in urban than in rural areas. The only rural group where the children showed a better nutritional situation than the urban ones were the nomads in Fintrou (Ag Bendech et al., 1994).

The situation is similar when considering the nutritional status for children less than 3 years of age. The level of stunting was higher in rural than in urban areas also for younger children. Our data showed that 35-39% of the rural children

Table 1 Comparison of nutritional status in Koutiala with other parts of Mali for children less than 6 years of age, percentage less than –2 z-score

e g A

) h t n o m (

n o s a e

S Year N Stunted ) A / H (

d e t s a W

) H / W (

- r e d n U

t h g i e w

) A / W (

f e R

r e v i R : a m r u o

G Rural 6–59 Nov 1990 403 44,

a 15 47,

a 4

l a r t n e C : a m r u o

G Rural 6–59 Nov 1990 376 43,

a 9 39,

a 4

a l a i t u o

K Rural 6–59 Sep 1994 879 42 12 40 a

l a i t u o

K Rural 6–59 Jan 1991 484 41 10 35 ⁴

a l a i t u o

K Rural 6–59 Aug 1990 333 38 10 36 ⁴

r e v i R : a m r u o

G Rural 6–59 May 1990 284 37,

a 19 46,

a 4

a l a i t u o

K Rural 6–59 Mar 1995 910 36 13 36 i

r o b m o H : a m r u o

G Rural 6–59 Nov 1990 428 36,

a 13 39,

a 4

l a r t n e C : a m r u o

G Rural 6–59 May 1990 293 33,

a 20 38,

a 4

a l a s s a u

O Rural 6–59 Dec 1997 205 32 9 31 ¹

a i n a i d i b u o s s u

O Rural 6–59 Nov 1997 396 31 14 31 ¹

i r o b m o H : a m r u o

G Rural 6–59 May 1990 284 31,

a 11 34,

a 4

o s s a k i

S Urban 0–59 - 1988 578 27 7 21 ²

o s s a k i

S Urban 0–71 - 1989 707 26 5 20 ²

o s s a k i

S Urban 0–71 - 1991 571 25 18 31 ²

a l a i t u o

K Urban 6–59 Sep 1994 264 25 13 29 o

s s a k i

S Urban 0–71 - 1990 650 25 12 25 ²

o s s a k i

S Urban 0–71 - 1993 517 24 13 28 ²

a l a i t u o

K Urban 6–59 Mar 1995 262 24 9 24 u

o r t n i F : a m r u o

G ^b Rural 12–59 May 1992 146 18 4 20 ⁴

u o t c u o b m u o

T ^b Rural 0–59 Drought 1985 240 - 43 - ³ u

o t c u o b m u o

T ^c Rural 0–59 Drought 1985 1558 - 20 - ³

1(Diallo et al., 1998) ^aUnpublished

2(Bouvier et al., 1995) ^bNomads

3(Carnell and Guyon, 1990) ^cSedentary

4(Ag Bendech et al., 1994)

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in this age group were stunted, compared to 13-17% of the urban children. Fur- ther, our data from the rural areas showed an even higher level of stunting than the level found in the national Demographic and Health Survey (DHS). The DHS data from the region showed that 33% of the children in Sikasso were stunted (Couli- baly et al., 1996).

The data from three areas in the Gourma, along the river, Central Gourma and Hombori, on the age-based nutritional indicators have not been published before due to uncertainty of the validity of the age-estimation (Paper I). As argued in the paper, the age is probably underestimated, this means that the true values of underweight and stunting were even higher than shown in Table 1.

3.2 Defining food and nutrition security

The roots of concern with food security can be traced back to the world food crisis of 1972-74, and before that, at least to the Universal Declaration of Human Rights in 1948, which recognised the right to food as a core element for an adequate stand- ard of living (Maxwell and Smith, 1992). In the Declaration on the Eradication of Hunger and Malnutrition from the World Food Conference in Rome in 1974, world food and nutrition security was declared a task of highest priority for the world (Beissner and Schleich, 1982). Both food and nutrition security are used to cover many different circumstances at various levels. In 1992 nearly 200 different defini- tions of food security were identified (Smith et al., 1992). As for food security, dif- ferent definitions of the term nutrition security have been suggested. Nutrition security was seen as directly concerned with the consumer, as opposed to food security that refers primarily to the supply of food before reaching the consumer (ibid.).

Nutrition security aims at guaranteeing that those persons identified as members of a target group in fact receive the food. The present aim is not to give a new definition of the two security concepts but rather to clarify their use in this thesis.

At the beginning of the 1970s, the concept food security was strongly asso- ciated with food production and food supply on regional or national levels. In the World Food Conference in 1974, food security was defined as:

… availability at all times of adequate world supplies of basic food-stuffs … to sustain a steady expansion of food consumption … and to offset fluctu- ations in production and prices. Resolution XVII (United Nations, 1975).

One thought that increased food production would lead to food security and a reduction of hunger. Despite an increased food production, food insecurity continued to be a problem of massive proportions in the 1980s and 1990s (ACC/SCN, 1997).

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The thinking shifted from an assumption that an increased food production would solve the world food problem, to a focus on food access. The question was whether individuals and households were able to acquire sufficient food (Maxwell and Smith, 1992). In 1981 the economist and later Nobel price winner Amartya Sen introduced the concept food entitlement (Sen, 1981). The problem, he said, is not with availa- bility of food per se but with the failure of vulnerable groups and individuals to gain entitlement to it. His ideas had already been commonplace in nutrition planning and had been demonstrated in field studies (Joy, 1973). As a result of these efforts, it has been impossible since the early 1980s to speak credibly of food security as being a problem of food supply, without at least making reference to the importance of access and entitlement

In the second half of the 1980s, food security became an important organ- ising principle in development projects (Maxwell and Smith, 1992). Furthermore, the focus shifted from food production policies to income-generating policies. It was also thought that eliminating hunger would eliminate malnutrition. However, results from various studies showed that an increase in household income did not automatically decrease child illness and did not have any dramatic effect on the nutritional status of pre-school children (Kennedy and Haddad, 1992). It was therefore proposed that in order to achieve food security and nutrition goals, control of resources and intra-household issues should also be addressed (ibid.). They further proposed that the major positive effect of policies and programs on household food security (HFS) and nutrition would come through an improvement in women’s nutritional status (ibid.). Another point that was emphasised was that food and nutrition security needed to be broadened to include micronutrients.

Some definitions that have been used on HFS include the aspects of adequate and safe food, and that the food should be acquired in social acceptable ways

Figure 3 A normative basis for food security Food security

Stability of the food supply and access

Nutritional adequacy

Food safety

Cultural

acceptability Environmental

sustainability Social sustainability Adequacy of the food supply

Oshaug et al. 1994b

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(e.g., without resorting to emergency food supplies, scavenging and stealing) (An- derson, 1990; Campbell, 1991; Fitz, 1998; Armar-Klemesu et al., 1995; Fitz, 1998;

Armar-Klemesu et al., 1995). These definitions are, however, not very specific in the sustainability or the time-perspective of the food security.

During the last two decades, Oshaug, Eide and others have developed a framework for food security (Figure 3) (Oshaug et al., 1994; Oshaug, 1985; Eide et al., 1985). In this framework, both the adequacy of the food supply as well as the stability of food supplies and access are taken into consideration. This definition of food security fits well with the poverty reduction thinking in the 1990s. There are clear parallels in the poverty reduction thinking to the nutrition and food security where concepts of cultural acceptability, autonomy and self-reliance have been common currency (Maxwell, 1998; Maxwell, 1996; Oshaug, 1985).

A definition of household food security that covers the aspects mentioned in Figure 3, may be the definition from ACC/SCN:

A household is food secure when it has access to the food needed for a healthy life for all its members (adequate in terms of quality, quantity, safety and culturally acceptable), and when it is not at undue risk of losing such access.

(Gillespie and Mason, 1991).

During the 1980s, a conceptual framework for analysing the causes of malnutrition was developed by Unicef (Figure 4). The framework was developed as part of the Unicef nutrition strategy, and further developed through the 1990s (Unicef, 1990; Unicef, 1998). The framework focuses on different levels of causes for nutritional problems, and it is used at national, district and local levels, to help in the planning of effective actions to improve nutrition. This was used as a basis for analysing the nutrition security situation in Norway as a preparation for the FAO/

WHO International Conference on Nutrition (ICN) in Rome 1992. To achieve and maintain nutrition security three conditions must be present: food security, adequate care and sufficient health services (Oshaug, 1994). At the ICN, consen- sus was obtained that the cornerstone of nutrition security comprises those three areas: food, health and care (ICN, 1992). The nutrition security concept provides the link between the household food security and the nutritional outcome explained as nutritional status, morbidity and mortality.

Based on past thinking and frameworks, a definition of nutrition security was recently suggested:

A person is nutrition secure when she or he has a nutritionally adequate diet, and the food consumed is biologically utilised such that adequate performance is maintained in physical growth and in mental development and

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capacity, in resisting and recovering from disease, and in pregnancy, lacta- tion and physical work. (Frankenberger et al., 1997)

The aims of the present work, as described in Chapter 2, are defined into a nutrition security framework as presented in Figure 5. In this figure, the upper part of the causal model of malnutrition (Figure 4) has been changed to a normative model of nutrition security. The main goal is to achieve nutrition security. To obtain that, some sub-goals have to be achieved namely an adequate dietary intake and adequate disease control for each individual. To achieve those again, there are some clusters of sub-goals at household level, namely food security, adequate care and adequate prevention and control of diseases that must be fulfilled. To be able to judge

Figure 4 Conceptual framework of causes of malnutrition

Inadequate

dietary intake Inadequate

disease control

Inadequate and/or inappropriate knowledge and discriminatory attitudes limit household access to actual resources

Political, cultural, religious, economic and social systems, including womens status, limit the utilisation of potential resources

Community level Individual level

Household level

Potential resources;

environment, technology, people

Quantity and quality of actual resources human, economic and organisational and the way they are controlled Malnutrition, death and disability

Poor water/

sanitation and inadequate health

services Inadequate

maternal and child care practices Household

food insecurity

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if those goals and sub-goals have been achieved, there is a need for appropriate tools of assessment. The aims of this study as described in Chapter 2 are to identify tools for assessing parts of this framework. In Figure 5 the parts covered by this study are highlighted and references are given to the aims in Chapter 2 and to the papers.

Figure 5 Theoretical framework for this thesis work

Adequate

dietary intake Adequate

disease control Nutrition security

Paper I (objective 1)

Paper V (objective 4)

Paper IV (objective 4)

Paper II (objective 2) Adequate prevention and control of diseases

Foodsafety Cultural acceptability

Main goal

Sub-goal (individual level)

Sub-goal (household level)

Paper III (objective 3) Nutritional adequacy

Household food security Adequate care

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4 Methods

The data were collected in two cross-sectional surveys based on questionnaires. The first survey was carried out in the rainy season, August/September 1994 and the second after the harvest in March 1995 (Table 2). Data on both a household and an individual level were collected, and the questionnaires included assessment of nutritional status on children and women, health parameters, food frequency and socio-economic variables. As a preparation for this, a qualitative study was conducted in April-May 1994 in urban and rural areas in Koutiala.

For a better understanding of the food consumption pattern, an in-depth study of the food intake of 76 children was carried out in the urban area from April to July 1995. To deal with food intake data, there is a need for valid food databases and food composition tables. As there was no such database in Mali, except the old FAO-table for all of Africa (FAO, 1968), work was started to develop such a database for Mali. Food items were collected for chemical analysis, a work that started in the Gourma in 1992 (Nordeide et al., 1994), and continued in Koutiala in May 1994. To get a better understanding of the importance of green leaves and gath- ered foods in the diet, focus group discussions were carried out in April 1995 (Ta- ble 2).

Data for age-estimation were collected in the Gourma during surveys in May and November 1990. The development of event history calendars and a lunar

Table 2 Data-collection in Koutiala s

e i t i v i t c

A Responsible 1994 1995

A M J J A S O N D J F M A M J J A y

d u t s e v i t a t i l a u

Q AH,MMD,MD,AO²

y d u t s e v i t a t i t n a u

Q AH,MMD,MD¹,AO² s

m e t i d o o f f o n o i t c e l l o

C AH,MBN²

s d o o f d l i w s p u o r g s u c o

F MBN,AH³

e k a t n i d o o

F LET,AH³,AO²

AH = Anne Hatløy, MMD = Modibo M Diarra, MD = Moro Diakité, MBN = Marit Beseth Nor- deide, LET = Liv Elin Torheim, AO = Arne Oshaug. ¹Did not participate in 1995. ²Included in the planning and follow up, but not in the field. ³Included in the planning and initiation in the field.

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calendar started during my fieldwork in the Gourma for a Master thesis in the period February-July 1990.

4.1 Qualitative study

The qualitative study was carried out in order to identify the most important factors in the food and nutrition situation in Koutiala. This study formed the background for the development of questionnaires for the two cross-sectional surveys.

Table 3 Matrix to analyse nutrition insecurity

a. Description b. Problems c. Strategies and activities d. Actors e. Vulnerable group f. Favourable elements g. Unfavourable elements h. Indicators i. Type of survey j. Methods Hypotheses

I. Household food insecurity

II. Inadequate care

III. Inadequate health system

Was completed in the households

Was completed in the households and by professionals at the health centres Was completed by the research team

2. Inadequate recourses 1. Groups with particular needs 2. Inadequate breast-feeding

and weaning practises 3. Heavy work-load for the adults 4. Inadequacy in the care concerning

household size and structure 1. Nutritional inadequacy

(quantity and quality) 2. Unsafe foods (pesticides,

toxicity, water pollution 3. Cultural unacceptability 4. Ecological, economic

and social instability

1. Inadequate performance

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The nutrition security in the area was analysed through in-depth interviews. Based on the theoretical framework presented in Chapter 3.2, a matrix like the one in Table 3 was developed to identify the causes and extent of nutritional insecurity in Koutiala.

Each of the cells in the matrix represented a new questionnaire. For example, the cell I.1.a describes nutritional inadequacy in the household. Separate interviews were carried out with women and men by using an interview-guide. Fur- thermore, the interviewees were asked to identify what were the main problems with the nutritional inadequacy (cell I.1.b in Table 3), and what strategies and activities were used to overcome those problems (cell I.1.c in Table 3). Then they were asked to identify the actors in those strategies and activities (cell I.1.d in Table 3) and at last, to describe the most vulnerable groups suffering from the problems (cell I.1.e in Table 3). The same system was followed for the subjects linked to household food security, inadequate care and inadequate health system. The cells under inadequate health system were in addition completed by information provided by the health centres (cells III.1.a to III.2.e in Table 3). When the interviews were finished, the group of researchers identified favourable and unfavourable elements, and suggested indicators to use. One completed example of the responses from the urban households to the food insecurity part of the matrix is given in Appendix 1.

For the qualitative study, twelve households in Koutiala Cercle were inter- viewed. Those households were chosen according to a criterion of including a het- erogeneous group of households. In the urban area, four households were chosen:

one urban farmer, one governmental employee and two from the commercial/trans- port sector. As nearly all the households in the rural area had agriculture as their principal activity, the households were chosen from two villages in different zones.

In one zone, Sangasso, the cotton production had stagnated, and in the other, Molobala, the cotton production had had a positive development (CMDT/PGT, 1993). In each of the villages, the village leader and his village-council were asked to choose four households with different socio-economic status.

In each of the twelve households, the team used 2-4 hours to complete the matrices as described. These matrices formed the basis of the selection of the indicators.

The result from this study gave a rather broad picture of food-items available in Koutiala. During discussions of the quality and quantity of the diet, detailed information on recipes used throughout the year was given. This gave the basis for an extensive list of food-items available in Koutiala. Some of the problems identified in the area, were the monotonous diet for the children and the low food production due to low rainfall. Children and women were identified as the most vulnerable groups in the area.

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Based on this study, types of methods were selected and the questionnaires for two cross-sectional studies developed. We selected children and women to be investi- gated more thoroughly as they were identified as the most vulnerable groups.

4.2 Cross-sectional surveys

The main method for collecting quantitative data in this study was using pre-cod- ed questionnaires in cross-sectional surveys. In the two surveys in Koutiala, 12 fieldworkers with a least high school education carried out the interviews. The fieldworkers worked in pairs of one female and one male. In each pair, at least one was from Koutiala with knowledge of Minyanka, the local language. All the fieldworkers spoke French and Bambara, the main languages in Mali. The interviews were carried out in Minyanka or Bambara. Every two pairs had one supervisor present in the field during the interviews. The sampling method was a modified 30-cluster sampling scheme, as recommended by Unicef (Henderson and Sundaresan, 1982) (described in Paper V). The questionnaires were divided into three parts. One part concerned information on a household level, and included socio-economic conditions, demog- raphy and a simplified food frequency (Appendix 2). This part was directed partly to the head of the household and partly to the women that had prepared the food in the household the previous day. Another questionnaire was directed to all women in the household in the age-group 15-45 years, and included anthropometric measures, health conditions and birth history. The third questionnaire was used to obtain health and anthropometric measures on all children 6-59 months of age in the households.

4.3 Anthropometry

As presented in Chapter 3.2, the level of malnutrition is seen as an indicator of nutrition insecurity. Anthropometry is the single most universally applicable, inexpen- sive, and non-invasive method available to assess the size, proportions and composition of the human body. Moreover, since growth in children and body dimension at all ages reflect the overall health and welfare of individuals and populations, anthropometry may also be used to predict performance, health, and survival (WHO, 1995). Poor feeding practices and infections, are major factors that affect physical growth and mental development in children (de Onis and Blössner, 1998). The most

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A) and weight-for-age (W/A) (WHO, 1995). Other studies have shown a relation- ship between all these indices and mortality when applied to young children (Pel- letier et al., 1994; Vella et al., 1992a; Vella et al., 1992b).

Stunting (H/A < -2 z-score) is the recommended indicator that best reflects the process of failure to reach linear growth potential as a result of sub-optimal health and nutrition conditions (de Onis and Blössner, 1998). As stunting is indicated by height measures and age, the age-estimation becomes crucial in areas where age is unknown by the family, which is a major problem in this part of Africa. For estimation of age in the surveys in Koutiala, the experiences from the surveys in the Gourma were used (described in Paper I). A lunar calendar and an event history calendar, in addition to a local agricultural calendar was developed. In the cases were the children had a birth certificate the given date was controlled against the calendars mentioned. In cases were family-members had a knowledge of the age of the child, that age was controlled against the calendars. Also the age-span between children in a household where asked for if there were problems in the determination of the age by the other methods.

In this study, z-scores, standardised standard deviations, for W/H, H/A and W/A were used as indicators of nutritional status. Weight was measured using manual scales with a maximum capacity of 25 kg and with 100 g accuracy. In order to measure height, specially prepared height boards were used, measuring ver- tical height for children 2 years of age and older and measuring length for children less than 2 years of age. The measures were taken with 0.1 cm accuracy.

The calculations of WHZ, HAZ and WAZ are based on the international reference data (CDC/WHO, 1989). These references have been widely used (John- ston and Ouyang, 1991) and are so far the most useful, in the absence of a new international reference to come (de Onis et al., 1997). The nutritional status data have been treated both as continuous variables and as discrete variables with –2 z- scores as cut-off-point for malnutrition (WHO, 1983). In other words, children with value 2 standard deviations below the mean of the reference population were recognised as malnourished.

4.4 Assessing quantity and economic value of human milk

An estimate of the human milk production was calculated based on the survey data from Koutiala and Demographic and Health Survey (DHS) data from Mali, Ni- geria, Senegal and Zimbabwe (Traoré et al., 1989; DHS, 1992; Ndiaye et al., 1994;

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Central Statistical Office (Zimbabwe) and Macro International Inc, 1995). The estimation of the human milk production were based on the ages of the children, breastfeeding frequency, the distribution of children over each age group, and the amount of human milk consumed by children of each age group as reported in scientific articles (WHO, 1985; Prentice et al., 1995; Jelliffe and Jelliffe, 1978). The method was developed from a method used in the Norwegian food statistics (Os- haug and Botten, 1994). A detailed description of the method is given in Paper II.

4.5 Dietary assessment

To achieve food security, nutritional adequacy of the diet must be fulfilled. A challenge is to find methods for assessing the food intake that are reliable and valid for the area of interest. First, one has to decide on which levels the data are required, i.e. if they should be on household or individual level. Secondly, if there is a need for calculation of nutrient intake, or if the food pattern or intake of special food items will be sufficient. In this study, food consumption data were collected both at an individual level and at a household level. The individual data were collected to determine the nutrient content of the diet, while the household data were collected to give information of the food pattern.

Extra challenges are added when dealing with cross-cultural communities.

Western researchers may ask for too accurate measures or using tools not under- stood by the interviewees. Some of the commonly used methods in one part of the world are not suitable in other parts of the world (Coates et al., 1995). Because most rural people in developing countries are illiterate or semiliterate, one cannot use self- administrated food questionnaires (FAO/WHO, 1998). Only face-to-face interviews or techniques that rely on observed records are appropriate in such societies (Kigutha, 1997). It is important to choose dietary assessment methods using culture-specific technology for food achievement, storage, exchange, processing, and preparation.

In addition, the cultural rules on food distribution and food consumption in the family must be taken into consideration (Jerome, 1997).

Assessing food intake and nutrient adequacy of the diet

In Koutiala, people normally eat from a shared bowl. This is a situation that has been considered impossible or very difficult for measurement of food intake on individual level (Hudson, 1995; Bingham et al., 1988; Ag Bendech et al., 1998).

Nevertheless, fairly accurate individual assessment of food intake was carried out in Koutiala town. The situation required active participation from fieldworkers, who

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had to be present at each meal. Three days observed-weighed records were chosen as method for 76 children 13-58 months of age (description of the method in Pa- per IV). The food to those children was served on separate plates, a method that has been used in former studies (Dop et al., 1994). From those data, an index for the nutrient adequacy (MAR) of the diet was created. This index was calculated from the content of ten nutrients and energy intake for each child (a full description of the method in Paper IV).

Assessing food variety and dietary diversity

In addition to the calculations of the nutrient adequacy of the diet, two other indices were created, Food Variety Score (FVS) and Dietary Diversity Score (DDS). FVS and DDS were generated from two different data sets. In Paper IV they were calculated based on the data collected through the three days observed-weighed records on an individual level. FVS and DDS were in addition used for assessment of food use at a household level, as described in Paper V. Here the scores were calculated based on data from the surveys. The women who had prepared the food the previous day responded to a list of food items that had been used in the household the previous day.

FVS was defined as a count of food items eaten during the registration period. All items were given the same weight, a full list of food items included is found in Appendix 2. A similar score has been used in former studies (Krebs-Smith et al., 1987; Drewnowski et al., 1997).

DDS is in the present study defined as a count of the food groups used during the registration period. There have been different suggestions for defining DDS during the recent years. The definitions differ in the number of food groups included, their composition and the use of dietary assessment methods (Guthrie and Scheer, 1981; Schuette et al., 1996; Franceschi et al., 1995; Krebs-Smith et al., 1987;

Drewnowski et al., 1996). In Paper IV, the DDS were defined to include eight food groups. Arguments were given in the article to include a separate group for high- energy foods as oils and sugar. In Paper V, a high-energy group was included and in addition, the staple group was divided into staples (grains and tubers) and nuts/

pulses.

Methods for assessing nutritional quality of food

To assess the nutritional quality of foods, different methods were used. Focus group discussions with younger and older women in villages in Sangasso and M’Pessoba, two arrondissements in Koutiala in addition to groups in Koutiala town, were or- ganised as described in Paper III. Information about seasonality, availability and

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preparation of various foods were collected from those groups. Food frequency data were collected in the two cross-sectional surveys already described, but calculated in Paper III only for Koutiala town and the two arrondissements where the focus groups where conducted. Selected food samples were collected for chemical analysis of nutrient composition. The choices of foods were based on information from key-informants and those available at the marked in the study period (April-May 1994). The food samples of green leaves (baobab, amaranth, onion and tamarind), tamarind fruit, and seeds and flour from African locust bean were analysed for water, energy, fat, protein, minerals, amino acids and carotenoids.

The FAO table for Africa (FAO, 1968) did not cover all the food items utilised in Koutiala. To be able to calculate the nutrient content of the diet, the work with a new Malian food composition table (Nordeide, 1997) was initiated. The numerical data in the table were based on the new analyses from Paper III, analyses of some food items from the Gourma (Nordeide et al., 1994) and a collection of analyses of foods from other parts of Africa.

4.6 Statistical analysis

The choice of statistical methods was done based on the research questions linked up to each of the aims. Thus, several statistical methods were used. Most of the statistical work was done by using the statistical program package SPSS for Windows.

The statistical analyses are fully described in the Papers I-V.

One important challenge was the decision of unit of analysis. Data were collected both in the entire household and for separate children within the household. Data from the different questionnaires were mainly analysed separately, apart from the data in Paper V, where food variety and dietary diversity data collected in the household questionnaire were analysed together with the nutritional status collected in the child questionnaire. To assess whether the choice of unit (index child of the household or all children) of analyses had any influence on the results, one index-child was randomly chosen from each household, and characteristics of those index-children were compared with the characteristics of all the children collected in the child questionnaire.

Table 4 shows only minor differences in the results whether using an indexchild or using all the children. The file with all the children included was also weight- ed by relative weight due to the unequal sampling probabilities, but this did not influence the results either (data not shown). As the main purpose with the analyses in Paper V was to identify the associations between variables, not to generalise about the conditions in Koutiala, the analyses including all the children were chosen.

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As the results in Table 4 show, the situation in urban and rural area in Koutiala was quite different concerning both food habits and nutritional status. Separate analyses for urban and rural areas were therefore conducted.

Table 4 Comparison of food variety scores, socio-economic status and nutritional status with different sampling for analyses

n a b r

U Rural

n e r d l i h

C ^a Indexchild^b Children^a Indexchild^b

=

N 526 328 1789 488

S V F n a e

M ^c 20 20 15 14

S D D n a e

M ^d 6.1 6.0 5.5 5.4

Z H W n a e

M -0.6 -0.6 -0.8 -0.8

Z A H n a e

M -1.1 -1.1 -1.6 -1.6

Z A W n a e

M -1.2 -1.2 -1.7 -1.7

e r o c s - z 2 -

<

Z H

W 11% 9% 13% 12%

e r o c s - z 2 -

<

Z A

H 25% 24% 39% 39%

e r o c s - z 2 -

<

Z A

W 27% 27% 38% 38%

a Individual file with children in the age-group 6-59 months.

b One child between 6 and 59 months of age was randomly chosen from each household

c Food Variety Score, number of food items

d Dietary Diversity Score, number of food groups

Methodological aspects of assessing nutrition security

Anne Hatløy

Methodological aspects of assessing nutrition security Examples from Mali

Doctoral dissertation

Methodological aspects of assessing nutrition security

Anne Hatløy

Methodological aspects of assessing nutrition security Examples from Mali

Doctoral dissertation

Institute for Nutrition Research

University of Oslo, Norway

Contents

Acknowledgement

List of abbreviations

1 About the study

2 Aims of the study

3 Background

3.1 Description of the area

3.2 Defining food and nutrition security

4 Methods

4.1 Qualitative study

4.2 Cross-sectional surveys

4.3 Anthropometry

4.4 Assessing quantity and economic value of human milk

4.5 Dietary assessment

4.6 Statistical analysis