Name: Community Risk Assessment of Vitamin A Deficiency (HKI Food Frequency Method).
Background: As USAID has begin to target the reduction of vitamin A deficiency (VAD), particularly through its VITA initiative, it has become increasingly important to find methods for assessing the magnitude of the problem in the community and identifying population groups at risk of deficiency. Country and community assessments for problem identification are needed for program planning. Community assessment tools to identify groups at risk of VAD may be used together with clinical and biochemical evaluations, but these are more complex and expensive, and often not affordable. Since VAD is often the result of inadequate dietary intake of vitamin A, habitual low consumption of the vitamin is recognized as one of the most important risk factors. Although vitamin A consumption can be quantitatively measured by conventional dietary intake assessment methods, these tend to be relatively complex, expensive, tedious and time consuming. A prototype method and instrument such as the tool reviewed here, once adapted locally, allows for a semi-quantitative assessment of vitamin A intake and a rapid assessment of community risk of VAD.
Origin: Helen Keller International developed, field tested, and validated the tool in fifteen communities, and have extensively used and disseminated the manual: Food Frequency Method for Community Assessment of the Risk of VAD. OMNI further tested and validated the HKI method as part of a national vitamin A survey in Morocco in 1997.
Source: Helen Keller International
Basic Description: The Food Frequency Manual forms the second of a two-part series on assessment. (Part One is: Conducting a Qualitative Assessment of Vitamin A Deficiency: A Field Guide for Program Managers.) The Food Frequency Manual describes the steps for using the HKI Food Frequency Method for three purposes: to identify communities where vitamin A deficiency is a problem of public health importance; to provide baseline and end-line data which can be used to evaluate changes in frequency of intake of vitamin A-rich foods as a result of project interventions in communities; and to provide guidance on discontinuing mass distribution of high dose vitamin A supplements when vitamin A consumption in the community may be sufficient.
The method is essentially a one-question survey: "How many days, in the past seven days, did (child's name) eat (a specified food item)?" This food frequency question is repeatedly asked by the survey interviewers for up to 28 food items. In order to determine whether vitamin A deficiency is a public health problem in a survey area, 15 communities should be surveyed. In each community, 50 mothers or primary caretakers of children 1-5 years of age (12-71 months) must be successfully interviewed, for a total of 750. The method provides a ready-made questionnaire with specific food items that have already been carefully selected and tested. These food items include: a staple food that is consumed by most children on a daily basis; a food that is almost never consumed by young children in the survey area; major food sources of vitamin A, (foods that contain at least 100 retinol equivalents (RE) of vitamin A per 100 grams of food); and major sources of fat, oil, and protein. The questionnaire is always adapted to local dietary practices, and certain food items can be replaced with ones which are more locally appropriate. The data from the survey are analyzed to identify whether vitamin A deficiency is a problem of public health importance in each community and in the entire survey area.
Country Applications: HKI has used the tool in a large number of countries, including Tanzania, Guatemala, and Philippines. OMNI further field tested and validated it in Morocco, as part of a national vitamin A survey.
Languages Available: English.
Technical Scope: The method establishes whether vitamin A deficiency is a problem of public health significance in a community or population by assessing the frequency of consumption (on a week-period basis) of certain food items.
The information is collected through survey interviews of mothers or caretakers of children by using a standard food frequency question on 28 specific food items. Data analysis, easily calculated by hand, allows one to establish whether or not a community has a vitamin A deficiency problem based on the frequency of consumption of animal sources of vitamin A or total consumption of animal and plant sources of vitamin A (weighted by the source).
Purpose: Problem identification/needs assessment, and impact evaluation.
Type of Methods: Semi-quantitative through household interviews of mothers/caretakers.
Design: Descriptive and cross-sectional. Random sample of 50 mothers or primary caretakers of children one to five years of age from each of 15 communities.
Frequency of Administration: Likely to be repeated as end-line for program evaluation purposes.
Key Users of Information
Primary users: The method was designed to be a simple and rapid assessment tool for the staff of community-based health, agricultural, and development programs, as a foundation for planning nutrition or other food-based interventions to prevent and control vitamin A deficiency.
Secondary users: USAID missions, Cooperating Agencies (CAs), other international donors, PVOs and NGOs.
Objectives and Scope of Tool
The main objective of the tool is to establish whether vitamin A deficiency is a problem of public health significance in a community or program area.The tool provides a simple means for gather information on the frequency of consumption of cert ain food items by the target groups of children. On the basis of this information, judgements are made as to the potential public health significance of vitamin A deficiency in the community or area. These data also allow for identification and documentation of local dietary practices. Additional data for program planning and evaluation purposes may be included, e.g. a question regarding the recent (within past six months) receipt of vitamin A syrup or capsules by the child for estimating current coverage of vitamin A supplementation.
Key Monitoring Needs and Evaluation Questions Tool Seeks to Address
Is vitamin A deficiency a problem of public health significance in a given community or survey area ?
Have changes in intake of vitamin A occurred since a baseline survey as a result of project interventions in communities?, and
Has vitamin A consumption in the community reached sufficient levels to allow for discontinuation of mass distribution of high dose vitamin A supplements?
Key Indicators
Two key indicators are easily calculated by hand by calculating the animal and weighted total scores on each questionnaire:
To determine whether community level vitamin A deficiency is a problem of public health significance, two threshold values are used:
Design
For the method and tool to be able to determine whether vitamin A deficiency is a public health problem in a survey area, 15 communities should be surveyed. In each community, 50 randomly selected mothers or primary caretakers with at least one child one to five years of age must be successfully interviewed. After random selection of 50 households with children within the specified age range, one respondent is randomly selected per household and, for each mother/caretaker, one of her children is selected at random. A one-question survey is carried out on those mothers regarding frequency of consumption of 28 specific food items by the selected child over the past seven days.
Implementation
A full survey using the HKI frequency method in 15 communities (750 mothers) would take from 14-24 days, as follows: one day for developing the sampling plan, one day for conducting a group discussion, half a day for conducting a shop survey, half a day for modifying the questionnaire, two to three days for training the interviewers, one day for field testing the questionnaire, 5-14 days for conducting the survey, and three days for data analysis. The required expertise and experience include some sampling experience or technical assistance in epidemiology, basic expertise in nutrition and food groups, experience leading groups, ability to read food labels, leadership and training skills, and prior experience in conducting surveys and non-biased interviewing. Prior experience in data analysis is helpful. Ideally, interviewers should be high school graduates and the supervisors have leadership skills. Costs vary by local settings; special expenses include salaries and per-diem for local personnel, transportation, supplies (flip chart paper, pens, markers) and photocopy costs. The costs can be minimized by linking the survey to ongoing data collection efforts.
Analysis
Data analysis can be easily made by hand. The above described threshold values are used to determine whether or not a community has a vitamin A deficiency problem. If at least 70% of the communities surveyed (11 of the 15) have a vitamin A deficiency problem, vitamin A deficiency is likely to be a public health problem in the entire survey area. The questionnaire does not provide the information necessary to determine whether an individual child is vitamin A deficient.
Reporting
Reporting the results of the survey is a simple matter that is facilitated by specific directions and a prototype report format included in the manual.
Dissemination of Results
The users of the method are encouraged to shared the results with others (co-workers, colleagues, partners, and communities in the survey area, as well as with other health, agriculture, education and development professionals). HKI maintains a computerized collection of survey results.
Manuals and Guidelines
A comprehensive step-by-step manual for using the food frequency method and for carrying out a community survey is available from HKI. The Manual provides clear, practical and easy to understand guidelines for implementation following 11 steps: define survey area; select season and time of day for survey; developing sampling plan; determine locally available foods; modify food frequency questionnaire; select and train interviewers; translate questionnaire; field test, refine and finalize questionnaire; conduct survey; analyzed survey data; and interpret and use the data. In addition, as an example, the manual provides the results of a case study in India, as well as guidelines on: planning for the HKI food frequency method; how to select a random sample; and a proposed format for sharing results.
References
Rosen DS, Haselow NJ, Sloan NL. How to Use the HKI Food Frequency Method to Assess Community Risk of Vitamin A Deficiency. Helen Keller International Vitamin A Technical Assistance Program. New York, NY 1993.
Underwood B. et al. Guidelines for the Development of a Simplified Dietary Assessment to Identify Groups at Risk of Inadequate Intake of Vitamin A. IVACG. Washington, D.C., 1989.
Other
The tool and method are widely used by PVOs, NGOs and other groups working in nutrition, micronutrients, vitamin A and community development projects in developing countries. IVACG developed a similar tool and method for a simplified dietary assessment to identify groups at risk of inadequate intake of vitamin A, which combines both 24-recall and food frequency approaches to provide more quantitative information by allowing to calculate scores of risk for inadequate intake of vitamin A (a proxy for the likelihood of a problem of public health significance) for communities and population groups.