UNICEF/WHO Invited Commentary on ‘Infant and young child feeding assessment with small sample surveys: a proposal for a simplified and structured approach’
Contact persons at UNICEF New York Headquarters: Diane Holland, Nutrition Section, Programme Division and Julia Krasevec, Data and Analytics Section, Division of Policy and Statistics.
Contact persons at WHO: Dr Bernadette Daelmans, Department of Maternal, Newborn, Child and Adolescent Health; Dr Carmen Casanovas or Zita Weise Prinzo, Department of Nutrition for Health and Development.
The global indicators for assessing infant and young child feeding (IYCF) practices, developed through a comprehensive collaborative review process between WHO, UNICEF, Food Policy Research Institute (IFPRI),USAID, Food and Nutrition Technical Assistance (FANTA) project and other agencies, were designed to track progress in IYCF within and across countries1. These global IYCF indicators were proposed for use in large-scale surveys with the caveat that some could be imprecise in monitoring change due to sample size. The article by Guevara et al. in this issue of Field Exchange2 proposes a new set of IYCF indicators to fill the gap of programme monitoring on a smaller scale, and highlights the need for better communication about the appropriate uses and limitations of current global IYCF indicators. While the sharing of field experience is acknowledged as a key reason for publishing these new indicators, the authors present these proposed indicators as viable options without full disclosure of the limitations; this may lead to confusion among the general nutrition community, particularly programme managers. We present here below the limitations that merit consideration as we move forward and are built upon our involvement in the validation and consensus processes followed for the 2008 release of the global IYCF indicators and extensive use of these indicators in the field.
The authors state that their indicators are a development of earlier work undertaken by IFPRI and the FANTA project. However, they fail to mention more recent publications by many of the original researchers, which support the fact that they themselves have moved towards more comprehensive and validated methods for the assessment of appropriate IYCF practices through which shortfalls of their earlier work have been addressed. Key examples include improvements in the assessment of micronutrient intakes (using diet diversity as proxy) and energy intake (using inclusion of milk feeding frequency for non-breastfed children as proxy)3,4,5
While the authors do assert the need to finesse their newly proposed indicators, for example, through improving the infant and child feeding index(ICFI) scoring algorithm, even more important limitations for these proposed methods should be at least mentioned, if not further elucidated, such as:
- The simplified data collection instrument has not been validated in terms of improving data quality nor in relation to a standard methodology. While the data collection instrument appears to have been modified to simplify data collection and analysis, the modifications have not taken into account the main purpose of the questionnaire, which should be to facilitate complete and correct answers from the respondents. The simplified data collection tool presented in the paper will likely lead to overestimation of exclusive breastfeeding, underestimation of diet diversity, as well as similar problems for other dimensions of IYCF practices.
- Lack of precision: for example, with regard to diet diversity.
- Key dimensions of appropriate IYCF practices are missing: for example, milk feeds for non-breastfed children.
The paper also makes confusing assertions with regard to sample sizes. Nine of the fifteen global IYCF indicators have the same age ranges and thus potential for sample size limitations as those newly proposed in the article by Guevara et al. While the authors specifically criticize the global indicators that have a very small sample size (e.g. Introduction to solid, semi-solid and soft foods for 6-8 month olds), they do not propose any other indicators to replace these and instead only mimic some of the global indicators with larger age ranges and thus sample sizes. It is therefore unclear how the proposed indicators have overcome the sample size limitations being criticized.
The authors argue that a single structured indicator they have proposed aids in decision-making by focusing on the overall IYCF programme. However, it is impossible to identify which programmatic actions require correction, without also using the newly proposed “diagnostic” indicators. This is because the single indicator approach combines both exclusive breastfeeding (0-5 month olds) and appropriate feeding for 6-23 month olds, thereby making it unclear which practices contribute most to the final score. For example, the interventions required to make changes in the exclusive breastfeeding practices in working mothers, are different from those to help ensure diet diversity among older children of these same mothers. If the diagnostic indicators are used in order to balance the single composite indicator, it must be noted that they will suffer the same sample size issues as many of the global indicators, which therefore leaves this sample size issue unresolved.
The current article in Field Exchange wrongly asserts that the entire set of global IYCF indicators are not appropriate for assessment at the sub-national (regional, district and sub-district) level. While the 2008 WHO indicator document acknowledges ‘small-scale programmes’ as being out of the realm of application, when sample sizes have permitted, many of the WHO indicators have been successfully applied to generate estimates at the sub-national level as evidenced through survey reports.6,7
We are concerned by the authors’ conclusions that the global IYCF indicators have limited value in planning, monitoring, and evaluating IYCF programmes as no evidence is provided as to how they do not function in this capacity. In fact, UNICEF and other stakeholders have been effectively using these indicators in numerous countries, for just these purposes.
We acknowledge that the international nutrition community has not yet filled the gap that the paper by Guevara et al. proposes to fill. There is a need for developing simple and user-friendly technical documents for monitoring of small scale IYCF programmes. However, what is offered seems to be a simplification of the WHO 2008 global IYCF indicators. An appropriate approach for assessing changes in small- scale programmes would require (i) alternative, yet valid, survey design and sampling methods appropriate for small area programmes such as a longitudinal design which could allow for use of the global indicators in their current from despite small age ranges; as well as (ii) development of context-specific indicators most likely on a case-by-case basis to best reflect specific interventions of these small-scale programmes. We are eager to see that this specific article helps to mobilize our collective action to address shortfalls in indicators for monitoring IYCF programmes and practices as part of our collective contribution to improving infant and young child survival, health and development.
For more details, contact: Diane Holland, UNICEF, email: dholland@unicef.org
1WHO, IFRI, UC Davis, FANTA, USAID, UNICEF et al. (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions.
2Guevara E., et al. IYCF Assessment with small-sample surveys: a proposal for a simplified approach. Field Exchange Issue???
3Ruel MT, Brown KH, and Caulfield LE. Moving forward with complementary feeding: indicators and research priorities. Food and Nutrition Bulletin 24, 2003, 3:289–90 and IFPRI/FCND Discussion Paper, April 2003.
4Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality and energy intake of infants and young children in developing countries: Summary of findings from analysis of 10 data sets. Report submitted to: the Food and Nutrition Technical Assistance (FANTA) Project/Academy for Educational Development (AED), August 2006.
5Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality of infants and young children in developing countries: Additional analysis of 10 data sets. Report submitted to: the Food and Nutrition Technical Assistance (FANTA) Project/Academy for Educational Development (AED), July 2007.
6Lao Ministry of Health and Lao Statistics Bureau (2012). Lao Social Indicator Survey 2011-12.
7Instituto Nacional de Estadística e Informática Peru (2012). Encuesta Demográfica y de Salud Familiar 2012.