Monthly Archives: July 2012

Anthropometry: Height and Weight

Module 8 takes note of other measurements as well. These include height or length (if a child is < 85 cm, measuring their length provides a more accurate measurement) and weight. Since the focus of FoF is to eliminate “hidden hunger”, these measurements provide us with a lot of information about the nutritional status of the women and children we’re meeting. A woman or child may look healthy enough – their bones won’t be visible, or their bellies won’t be swollen (indicators of Marasmus and Kwashiorkor, both of which are types of severe acute malnutrition, or SAM). However, when we have their height/length, weight and age, we can use this information to compare them to healthy individuals of the same age and gender to get a better picture of their health.

There are three indicators that we use:

  1. Height/length for age – when we know a person’s height and their age, we can compare them to the average height for a healthy individual of the same age and gender. If the person is significantly short for his or her age, we call this stunting. It is a sign of chronic malnutrition.
  2. Weight for height – we can use an adult’s weight and height to calculate their body mass index, or BMI. A healthy BMI is anywhere from 18.5-24.9. Anything below 18.5 means a person is malnourished. In children, we compare their weight to the weight of a healthy reference child of the same height. If the child is significantly lighter than the reference child, we call this wasting, which indicates acute malnutrition.
  3. Weight for age – when we know a person’s weight and their age, we can compare them to the average weight for their age and gender group. If the person is light for his or her age, he/she is considered to be underweight.

Here are some pictures from the field.

 

Anthropometry: MUAC

Module 8 of the survey is Anthropometry and Hemoglobin. One of the measurements we take is the mid-upper arm circumference (aka the MUAC). The MUAC is generally regarded as an accurate assessment of nutritional status in adults and children. Also, it’s easy to do in the field.

There are two steps to taking a MUAC measurement. The first involves measuring the length of the upper arm to determine the mid-point of the upper arm. The second is to wrap a band around that point to measure the circumference.

The band tells us two things:

  1. The MUAC in centimetres, and
  2. What degree of malnutrition an individual has, if any. This is possible because the band is divided into three coloured segments that indicate whether an individual is well-nourished (green), suffering from moderate acute malnutrition (MAM) (yellow), or suffering from severe acute malnutrition (SAM) (red).  In children, these divisions are based on how many standard deviations a person’s MUAC is from the mean, which is 13.0 cm. In adults, the cutoffs are 18.5 cm for moderate undernutrition, and < 16.5 cm for severe undernutrition.

Here are some pictures that demonstrate the process. Enjoy!

 

Baseline: Day 16

Our last day of baseline has come and gone. Given how smoothly every day had gone, it was surprising that we had a few minor problems on our last day. The village we were going to had the same name as a village in another district, so we got lost. Then we had to track some mothers down in the rice fields, which set us back a few hours. Of all the days to run into problems, Day 16 was probably the best because we weren’t rushing to get anywhere in the afternoon.

Leaving the field was bittersweet for me. I truly enjoyed being immersed in a culture and lifestyle so completely different from my own. The stories I heard were incredible, and I can’t wait to see how FoF impacts the lives of the people we met. However, I’m happy to be back in Phnom Penh, where my food options are more diverse.

I’m taking this weekend off, but check back Monday for a new post and some videos.

Baseline: Day 15

My how baseline has flown! Tonight is our last night in Prey Veng. Tomorrow morning we will go to one more village and then head back to Phnom Penh. I managed to get some videos of women and children at the anthropometry station today, but I’m far too exhausted to edit and post them tonight. They should be up by the weekend. For now I’ll leave you with a picture of a treat we had yesterday.

Fresh coconut water!

Baseline: Day 14 (VMF)

This afternoon our anthropometry and hemoglobin analysis stations were set up at the home of a Village Model Farm (VMF). I was really excited because I hadn’t seen a VMF yet, AND because our VMF concept just received press as of yesterday! (Click here to read an article about FoF in the New Agriculturalist) I had the chance to speak with the VMF representative in the village of Svay Trai, and thought I would share what I learned on the blog.

The backstory: Sophal Eab used to be a wedding stylist, but when her children were old enough to attend school, she needed a job that required less travel. When the opportunity to have the VMF in her village arose, she took it. Until her farm is up and running, she sells corn for income. She purchases 500 ears of corn for $40 USD from her local market (160,000 Riel at 320 Riel/ear). She then boils all of the corn and sells it from a stand in front of her house for 500 Riel per ear (sometimes she has to sell it for less if it’s not good quality corn). Taking the cost of fuel into account, she makes roughly 100 Riel per ear, leaving her with a profit margin of anywhere from  50,000 Riel ($12.5 USD) per day to 100,000 Riel ($25 USD) per day depending on the quality of the corn available at the market.

Sophal's corn stand.

A happy customer!

Making the most of leftovers.

Sophal has already impressed FoF with her dedication. Within one month she has raised the height of the land on her property to better support the beds needed to grow fruit and vegetables. She purchased wire and sourced local bamboo to make a fence to keep animals off of her farm. She also bought mango seeds so she could start growing mangoes. Luckily, she already had a fishpond, but she is considering expanding it. FoF will provide her with other seeds for her farm and fingerlings (small fish) for her pond. For now, all she knows is that she has to grow a variety of fruit and vegetables and follow the guidelines given to her by HKI and FoF, but she is looking forward to her training. She hopes to grow enough of her own corn so that she can increase the profit margin of her corn stand by not having to purchase corn from the market.

The back of Sophal's farm.

Facing Sophal's house from the back of the farm.

The fishpond that was already at Sophal's house.

The new fence is working out quite well!

The VMF will play a very important role in FoF. Each village will have a VMF, and the VMFs in the aquaculture villages will also have a fishpond. The VMF representative will be a woman who receives training and inputs as part of our intervention. She will learn about homestead food production (HFP), aquaculture, and sustainable agricultural practices. There will be a marketing component to her training that will include information on how to plan the planting and harvesting of crops according to the seasons (of which there are 2 here – wet and dry), how to price crops, how to pick a good market to sell her produce, and how to form a marketing group to share information with VMF representatives from other villages. For instance, the marketing group may discourage women from growing morning glory (a common leafy green vegetable here) because it can be grown anywhere and with little input, so it doesn’t fetch a good price at the market. There will also be gender-specific training, as one of our goals is to empower women by improving both their health and their opportunities for income. The VMF representative will teach the FoF households in her village how to use their new farms and fishponds. Her knowledge will be e a local resource for other households in the village. She will be monitored every 4 months by FoF to see how her farm, her fishpond, and her “students” (the other FoF households in her village) are doing.

There is also a nutrition education component of our project that is being carried out by Village Health Volunteers (VHVs). The details, however, are another story for another day.

Baseline: The Survey

My apologies for not posting over the past few days. The posts I’ve planned for the next week take longer to write as they involve some research.

Anyways, to recap: I’ve discussed how we picked the households for FoF and what it’s like to be out in the field. I’ve also briefly mentioned what the purpose of our project is: to improve household food security and the nutritional status of women and children in rural Cambodia by combining HFP and aquaculture (it says so on the site’s banner). The word baseline keeps popping up – in post titles, categories, my writing. But what IS baseline? What are we trying to measure, and how are we measuring it? These are the questions I’ll be answering in my next few posts.

All 900 houses are completing a one-hour survey during baseline. The enumerators have a set of questions they work through, as well as a guide that explains how to record answers. When all of the questions have been answers, the women and any of their children under the age of 5 make their way to the anthropometry station to be measured and pricked. This process will be repeated after the intervention (ie after the farms and fish ponds have been established) during what is called the endline survey.

Half of the women are also completing 24-hour recalls and providing blood samples. I’ll discuss this another day.

Going back to the survey – what are we asking the women? What information do we hope to obtain from their answers?

The survey is divided into 8 modules: Household Information, Water and Sanitation, Homestead Food Production (subcategory: animal raising), Food Consumption, Mother’s Nutrition and Health, Knowledge and Attitudes, Household Food Security, and Measurements and Hemoglobin. The first 7 modules contain questions asked during the interview, and the last module is filled in by the enumerators trained in anthropometry and hemoglobin analysis.

Module 1: Household information

Here we try to ascertain the main characteristics of the household. We want to know how many people live in the house, the highest level of education obtained by the mother and father, annual income, who makes decisions about income, health care, and other important issues (mother, father, both?), what material goods the house has, and what materials the house is made out of. These questions provide a detailed picture of the family’s socioeconomic status.

Module 2: Water and Sanitation

We want to learn about the family’s hygiene (how often they use soap, where they go to the bathroom), and whether or not they have decent access to clean water.

Module 3: Homestead Food Production

We are trying to establish what kind of food, if any, people grow for their own use and to sell. This includes gardens, fishponds, and animal raising. This helps us gain insight into a variety of things, such as what food is available in a household, how familiar people are with HFP and aquaculture, what kind of income they make.

Module 4: Food Consumption

The most direct way of assessing nutritional status. We want to know what people eat, and how often. Because of our interest in aquaculture, we want to get as specific as possible when discussing fish. Therefore we ask people if they consume 10 common species of fish (5 big, 5 small), and we also leave room for any species not on the list. To help with this section, all enumerators carry a fish atlas with them, which has pictures of 36 fish common in Cambodia for easy identification of species consumed. We also want to know what nutrients they are or aren’t getting. Our questions specifically ask about dark, leafy greens (iron), fruit and vegetables with orange insides (vitamin A), grains (carbohydrates), organ meats (iron, protein), animal protein and oil, fat, and butter (dietary fat). Finally, we want to know where their food comes from (home, market, gift).

Module 5: Mother’s Nutrition and Health

The purpose of this section is to look at anemia and pregnancy. We ask if/when women have taken iron tablets, and we write down their current pregnancy status (not pregnant, or pregnant and how many months along they are). We also have a question about night blindness during pregnancy, as night blindness is a strong indicator of vitamin A deficiency.

Module 6: Knowledge and Attitudes – This is where we assess what women know about proper nutrition for themselves and their children. We ask how much they think they should feed their children, when they should introduce solid food, and if they can identify which foods are good sources of certain nutrients such as vitamin A and iron.

Module 7: Household Food Security – The last module in our survey tries to determine how food secure a household is by asking women if they worry about getting enough food for their family, or the right kinds of food, and whether or not they sometimes have to skip meals or eat famine foods (foods that make you feel full but don’t provide a decent amount of nutrients).

Hopefully this provides some insight into the kind of data we are collecting during baseline and why we care about this information. I’m going to try to film videos in the field tomorrow. Between my iPhone, laptop, and camera, I should be able to get some footage. Wish me luck!

Baseline: A Day in the Life

5:45 am: Alarm goes off. Hit snooze for 15 minutes.

6:00 am: Wake up, put on sunscreen, bug spray, and clothes. Grab name tag, water, field bags (a small one with camera and notebook, bigger one with laptop, sunscreen, first aid kit, and hat), and food box with snacks.

6:15 am: In the truck, ready to go.

6:40 am: Stop for breakfast with the team. This is usually soup with noodles and meat. A bowl of vegetarian noodles (my order) costs 3,000 Riel ( $0.75 USD). We also get Vietnamese coffee, which is iced coffee with condensed milk. It tastes more like chocolate milk, but I’m not one to refuse caffeine. Total cost: 2,000 Riel ($0.50 USD).

Breakfast!

7:00 am: Back on the road.

8:15 am (sometimes earlier, sometimes later depending on the day’s destination): Stop at house of village chief to announce our arrival and assign houses to each enumerator. This is also usually where we set up the anthropometry and hemoglobin analysis stations.

Assigning houses to the enumerators.

8:30 am: Walk to houses to begin survey. Each survey lasts about an hour, and each 24 hour recall lasts roughly 30 minutes (it varies depending on how far away the house is and how varied the woman’s diet was the day before). At this point I either follow an enumerator to observe, or hang out in the car getting work done on my laptop/reading from the Kindle app on my phone. As the first surveys go on, issues can arise that field supervisors must troubleshoot. This part of the day can be really exciting or really boring.

Chris, getting work done from the field.

9:45 am: The first mothers to finish their survey arrive at the village chief’s house with their child to be measured and pricked.

11:45 am: Pack up and leave first village.

12:00 pm: Lunch break. Depending on where we are, we can drive out of the village to a restaurant or we eat in the field. If we go to a restaurant, lunch is usually rice and meat. Also on the menu: a second coffee. Total cost: 7,000 Riel ($1.75 USD).

12:45 pm: Set out for the next village

1:45 pm: Arrive at village chief’s house. Set up anthropometry and hemoglobin analysis stations. Enumerators set off to survey or conduct the 24 hour recall.

Getting everything ready at the anthropometry station.

2:00 pm: The afternoon is the same as the morning – surveys, 24 hour recalls, measurements, finger pricks, work in the car, reading, maybe even a nap in the car (the heat makes everyone a little drowsy).

4:30-5:30 pm: Pack up and head home. We end at a different time every day, and our travel time back to the guesthouse varies.

6:00 pm: Downtime in our rooms. Usually a good time for a shower, uploading pictures, or a nap. If we get back on the early side, maybe some wine and card games.

7:15 pm: Head to dinner (there are maybe 6 restaurants to choose from in the provincial capital, where we’re staying). It usually costs 12,000 Riel ($3.00 USD).

8:30 pm: Home from dinner. Do some computer work – fill out reports, work on the blog.

10:00 pm: Bedtime. Sleep comes easily after a long day.

Our Website has Launched!

…and it looks great! Check it out at fishonfarms.landfood.ubc.ca

You can find: an overview of FoF, profiles of our people, reports, media, pictures, and links to our partners.

Baseline: Day 7

I‘ll confess, I made a rookie mistake – I forgot to charge my camera battery. The only picture I managed to take before my battery ran out was of a recently slaughtered chicken next to a bowl of its own blood.

Ingredients for today's lunch.

I didn’t get to ask the cook what they intended to do with the blood, but since they went to great lengths to collect it in a bowl post-slaughter, I assume it was incorporated into the meal in some way. While this may sound unappetizing to a lot of readers (especially those in North America), it’s pretty common in other parts of the world — even in Western countries. The Brits are known for their blood sausage and blood pudding. For centuries the Maasai warriors of Kenya have consumed the blood of cows. In Cambodia, where so many are anemic, adding animal blood to the diet makes sense as it’s an excellent source of iron.

I’m spending the 8th day of baseline at a health center to watch the NIPH (National Institute of Public Health) technicians collect more blood samples, but I’m saving the details for a post on the blood collection process. So instead of a recap, check back tomorrow for another special feature!

Sampling Methodology

One of the issues that we have encountered during the first week of baseline is that some of the houses that were originally selected to be part of the study are no longer eligible.

In some instances, the mother went to Phnom Penh or the Thai border to seek work. The purpose of our study is to show the effects of HFP and aquaculture on household food security and the nutritional status of women and children. As such, the woman of the house must be present year-round to reap the benefits of these interventions. By migrating for work, a woman’s nutritional status at the end of the study would not reflect the addition of HFP and aquaculture in her life. Therefore, her household is now ineligible for participation in FoF.

In other instances, when we arrived at the house we found out that the children were over the cutoff age of 5 years old. This happened for a variety of reasons: some women couldn’t accurately remember the date of birth (the Khmer calendar is different from ours), the selection team didn’t check the proper documents to verify the child’s age, or the age on the village chief’s list was incorrect. It’s also possible that some women provided false ages for their children because they wanted to be part of a study that provides the expensive inputs needed for HFP and aquaculture.

In any event, our team has been scrambling to fill their spots so that we have the right sample size for the study. We’ve accounted for a possible 15% of houses lost due to follow up, but we want to start with the biggest sample possible to minimize that loss given how expensive and time-consuming the project is. 

This seems like a good opportunity to discuss the methodology behind household selection. In an earlier post (Household Selection), I briefly outlined the criteria that households needed to meet to be part of FoF. However, meeting the selection criteria does not mean a household is automatically enrolled in FoF. This is, after all, a scientific experiment; certain research principles must be upheld.

In order for this to be a valid and reliable scientific experiment, we need our sample to represent our target population as closely as possible while eliminating any potential biases or confounders. We achieve this by picking the proper sampling method. FoF is using a multi-stage sampling strategy. The first stage is cluster sampling, which is a form of probability sampling that examines naturally occurring groups such as villages. The second stage is systematic sampling, which is used to select the houses in the villages by picking a random point to start (eg the fourth house on the list) and continuing through the list in a systematic fashion (eg every fourth house on the list). A few key definitions are needed at this point:

  • Valid – we are measuring what we say we are going to measure
  • Reliable – our measurements are as accurate as possible
  • Probability sampling – the entire target population is known, and thus everyone in that population has an equal chance of being selected
  • Randomization – picking units (in our case, villages) at random to ensure the sample is representative of the target population
  • Target Population – the population we want to study, as defined by certain parameters (eg location, age, SES)

First, we looked at all of the villages in the province of Prey Veng on a list from the most recent census conducted by the Ministry of Planning in 2008. We excluded the villages that had already been part of a HFP program by HKI that was funded by the EU, the villages that are part of the ongoing ODOV (Organization for Development of Our Villages – one of our partner NGOs) food security project, and the villages that are taking part in other Cambodian NGO projects. This left us with 164 villages in 4 districts: Ba Phnum, Kamchay Mear, Me Sung, and Svay Antor. Then the villages were randomized, resulting in 120 villages with 40 villages per group (HFP, HFP + aquaculture, or comparison) being selected.  Finally, 30 out of 40 villages were selected after further randomization.

Workers from the ODOV went into the field and met with the village chiefs (and in some instances, a village council) to divide the households with children under the age of five into 3 categories: poorest, poor, and medium wealth. They wrote their wealth ranking assessment for each household on a slip of paper that was placed into a box to maintain anonymity. This was done because it was our intention to try to help those most in need.

The ODOV and the village chiefs met with the households categorized as poorest or poor to explain the project to them and to ask if they were interested in joining. If they responded “yes”, field staff went to the house to make sure it met the selection criteria. They made sure that each house had enough land to support HFP farms and fish ponds, and they assessed whether or not the house would be able to maintain these projects during the course of our study. They also inquired about the ages of the children, most often by looking at the village chief’s list of villagers, but as we’ve discovered this list isn’t always correct.

A list of all eligible households was sent back to HKI. The houses categorized as poor or poorest were listed, and from that list we began with the 4th house and picked every 4th house after that. We were able to find 10 eligible houses in each village by using this method. The ODOV received a list of selected households and went to the village chief to inform him of the date and time of the survey.

In the field, each supervisor brings his or her list of 10 households per village that have been selected for the study. Sometimes, something goes amiss and the household is no longer eligible (for all of the reasons I listed above). Then we have 2 options: 1, we pick another house categorized as poor on the ODOV list that wasn’t originally selected during the systematic sampling; or 2, we go back to the very first list that the ODOV produced (the one that listed all the households in the village before the wealth ranking) and we discuss with the chief whether or not picking a new house from that list is a good idea. This means that sometimes we will get houses that vary in socioeconomic status (SES). Ideally, we’d like to control for SES before we collect data, but our survey includes a module about household income and wealth that will allow us to control for SES after the data has been collected.

Once we have our 10 houses picked in the village, we hold a lottery to randomly select 5 houses to participate in the 24-hour recall and blood analysis components of our study. Slips of paper with the numbers 1 through 10 are placed faced down, and 5 slips are drawn. Those houses are highlighted on the list. If, for some reason, we have to replace a house that has been highlighted, the replacement house is automatically assigned to be part of the 24-hour recall and blood draw. The enumerator goes to the house to conduct the 24-hour recall and to obtain consent (very important) for the blood draw. The woman is given a slip of paper that has her unique identifier and the time and location of the blood draw. We are only conducting recalls and collecting samples from 450 women (half of the women in the study) because the recalls are time-consuming and the blood collection is invasive and expensive.

Households selected by lottery for the 24-hour recall and blood draw

And that is the method we used to recruit 900 households for FoF while adhering to the principles of sound research as best as we possibly can.

I’d like to give a special thank you to Sokhoing Ly from HKI for explaining all of this to me with great patience.