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Administering the Module

Part 1: 24-Hour Recall

Interviewing for dietary intake should be done with women directly, not from a second party. For children six years of age and under, you will need to interview the primary caretaker, usually the mother.

This module should take approximately thirty minutes.

i. Explain to the respondent that you are interested in learning what foods were recently eaten in their home, particularly by the young children and women living there. Start by asking the primary caretaker how many children six years of age or under live in the household. Gather the background information listed on the top of Form 8.1 (one form per child) including each child's name, sex, age, whether they are currently or were previously breastfed, and if they have received vitamin A supplements. Record the responses on separate copies of Form 8.1 for each child.
ii. Continue by asking how many woman of reproductive age live in the household. Record each woman's name on a separate form, if the woman is pregnant or lactating, and whether the woman has received a vitamin A supplement(s).
iii. Begin with the oldest child under six. You may start by saying, "Now I would like you to tell me about all the food and beverages that (name of child) had in the last twenty-four hours. We will begin with the most recent food or drink that (name of child) had and work back to this time yesterday. Can you tell me what he or she last ate or drank?"
iv. Record the respondents answer on Form 8.1.
v. Continue by saying, "What was the food or drink before that?"

Be sure to ask about additions to beverages, such as sugar or milk and what type these were. For example, you may say, "Do you add anything to your coffee?" You could continue by asking, "Is that white sugar or...?" Or, depending upon the respondents response, "Is that condensed milk or skimmed milk?"

When probing for additions to food items the interviewer could ask questions such as, "Do you put sauce on or add condiments to your rice?" followed by, "Could you describe the way in which the sauce is prepared? What are the ingredients you include in the sauce?" If the individual named a complicated dish you will want to record the ingredients and approximate the amounts of the portions eaten at the bottom of Form 8.1. During the study, you will want to collect information on ingredients and the quantities frequently used for sauces.

Be sure to use probing techniques to get detailed and accurate information. In the case of children, between meal snacks, such as fruits, may be a particularly important source of vitamin A. Therefore you will want to probe the caretaker to gather information on ways in which the child acquires food outside of the household, what food is obtained, and the quantity of between meal snacks the child consumes. When eliciting information on snack foods you may try to interview some of the older children (five- to six year olds) to confirm that the responses are accurate and consistent. If alcoholic beverages are commonly consumed in the area, additional probing may also be necessary when carrying out intakes for women.
vi. Continue to question the respondent, gathering information on all foods consumed over the past twenty-four hours by each child (age six months to six years) and woman of reproductive age living in the household.
vii. Record the answers on Form 8.1 as the information is collected. When recording the data it is important to be as detailed and precise as possible.

Part II: Food Frequency

This module makes use of structured questions, that are directed to the primary caretaker/food preparer of the household. The amount of time it will take to go through the food frequency list will obviously depend upon the number of children living in the household. Carrying out this module for an individual child should take about fifteen minutes.

i. Begin with Form 8.2 by entering the list of key foods in the left hand column. If a photocopy machine is available it will save time if you can make copies of this master form.
ii. Fill out the appropriate information at the top of Form 8.2 for each child (age six months to six years) and woman of reproductive age living in the household. You should be gathering information on the same individuals with whom you carried out the 24-hour recalls.
iii. Explain to the respondent that you now want to find out how often the foods you have just been discussing are eaten by the same household members.
iv. With Form 8.2, begin with the oldest child under six and the first item on the list. You may say "During the last week, how many days did you serve (child's name) (food item)?" To ensure that the question "how many days per week..." is understood and to give the respondent confidence in her responses, start with the staple foods or the foods which are most commonly eaten.
v. Record the number in the appropriate box.
vi. Continue by saying, "How many times was (food item) served?"

You should also inquire whether somebody else feeds the child occasionally. You may say, "Are there times when the child is not with you? Do you know what he or she eats then?"

If the child in question is old enough, you may want to speak to him or her directly.

vii. Record the answer in the appropriate box on Form 8.2.
viii. Next, ask how much of that food item was actually consumed and record the response in the right hand column under quantity.
ix. Then, ask about the consumption of the same food item by the next oldest child (if there is more than one child under six in the household) and fill in the responses on a separate form. Going item-by-item, continue the series of questions with all of the children under six years of age in the household and complete the interviews by administering the questions to the children's mother, recording the responses in the appropriate boxes as the interview is being carried out.

FORM 8.1 24-Hour Recall by Individual (M5)

Respondent No:_____________________________________________________________
___________________________________________________________________________
Name of Child: __________________________Child's Age: __________________Sex: M F
Breastfed Current: Yes No Breastfed Previous: Yes No Number of Months Breastfed: __________________________________________________________________
Vitamin A Supplement: Yes No If Yes, Type of Supplement:________________________
Number of Supplements Received: __________Date of Last Dose:___________________

Name of Woman of Reproductive Age:__________________________________________
(circle one): Lactating Pregnant Neither
Vitamin A Supplement: Yes No If Yes, Type of Supplement:________________________
Number of Supplements Received: _______________Date of Last Dose:______________

FORM 8.2 Food Frequency for Individuals (M5)

Respondent No: ________________________
____________________________________________________________________________
Name of Child: ____________________Child s Age: _________________________Sex: M F

Name of Woman of Reproductive Age: ____________________________________________
(circle one): Lactating Pregnant Neither

Analysis

The main purpose of the analysis is to describe the consumption of individual food items by categories among individuals at risk of deficiency and to identify patterns of use. An estimate of vitamin A intake will be made by calculating the number of times vitamin

A-rich foods are consumed on a weekly basis for each child multiplied by the content rating you have assigned that food. You should use a five point scale rating where (0) no vitamin A content, (1) a trace of vitamin A, (2) a small amount of vitamin A, (3) a medium amount of vitamin A and (4) a large amount of vitamin A. (See Appendix 8 for rating vitamin A-rich foods). The final rating should be based on the frequency and quantity of the particular food item consumed, and the vitamin A content rating of the item found in your source table.

i. Estimating Vitamin A Intake

a. For each food item, multiply the number of days the food is eaten per week by the number of times the food is eaten each day. For example, if rice was eaten six times during the week, two times per day, you would multiple six by two to get a total of twelve times during the week. Since rice does not contain any vitamin A, you would multiply this figure by the content rating zero and get an individual rating of zero.
b. The total for each food item, in this case zero, should be recorded in the right hand column marked rating on Form 8.2. Remember that you are interested in the number of times that vitamin A-rich foods are consumed per week, as well as the vitamin A content. You should also take into account the quantity of the food item consumed when determining the vitamin A rating. c. Go through the entire list calculating the totals for each food item, and record the answers in the appropriate boxes.

In summary, the scoring will depend upon the availability of vitamin A-rich food items in the region/community, the frequency each is consumed, the vitamin A content, and the quantity consumed.

ii. Patterns of Use

a. This module is constructed to give you a better idea which groups under six years of age are at greater risk for developing vitamin A deficiency. Divide preschool aged children into three groups: (1) infants or zero to eleven months, (2) one to three years, and (3) four to six years. Also include a separate analysis of the intake of women of reproductive age, according to whether the woman is pregnant, lactating, or neither.
b. Take the responses from Form 8.2 and separate the forms according to the age groups listed above. Using Form 8.3 record the responses for each age group. Determine the median (see Glossary) for each food item.
c. Find the medians by subgroup for each food item. Once you have determined all of the medians, rank order them as you did in the free list module. (The highest ranked food will have a #1 in the ranking column). Place the food items from the highest to the lowest median on Form 8.4. Find the vitamin A food rating (using the five-point scale) and place the corresponding number in the second column. Remember that the list will range from food item #1 (ranked one in Form 8.3) to the number corresponding to the number of foods that you have on Form 8.1. You should be generating six different lists, one for each subgroup of the population at risk for developing vitamin A deficiency.
d. At the top of the same form, include the attributes/concepts that were rated in Module 3. Do a cross-tabulation comparison between the rank order of median vitamin A scores and the way that the foods were rated in Module 3. In the appropriate box, include the rating (most, between most and intermediate, intermediate, between intermediate and least, and least) that best characterizes each of the food items listed in the left hand column.

Combining vitamin A scores and ratings of food attributes are important data for developing intervention strategies and designing nutrition education messages.

M6. Hypothetical Health Case Scenarios

Purpose

This module is Intended to get information from the mother or the primary caretaker in the household on:

i. Whether the primary caretaker recognizes signs and symptoms of vitamin A deficiency?
ii. How she would respond if a child showed signs and symptoms of vitamin A deficiency, including whether she would administer care in the home or seek help elsewhere?
iii. How she would respond if this applied to herself; in other words, if she showed signs and symptoms of vitamin A deficiency?
iv. At what stage would care be administered?
v. What would be the sequence of action in providing homecare, or seeking care outside of the home?
vi. What factors would determine her decision to seek care?

It should provide an understanding of the preferred choices for healthcare for signs and symptoms of vitamin A deficiency. This task is a means to examine beliefs in the area related to health-seeking behavior for eye problems and some of the diseases associated with vitamin A deficiency.

After you have asked the respondent to identify the healthcare provider(s) that she would seek, have the respondent explain the reason for each choice. This format should enable you to find out about health practitioners, such as traditional healers, which mothers may normally be reluctant to discuss or admit using. It also permits identification of both negative and positive attitudes on the various health resources available, and the locally-perceived ability of health practitioners to administer treatment for signs and symptoms of xerophthalmia.

In some communities, especially in rural areas, the population may not have health resource choices available to them or there may be only one option, such as a traditional birth attendant, in the area. If this is the case, you may want to adapt the module to include resources outside the community. Try to determine when the respondent would travel outside of the community to seek help, and where and to whom they would go.

The case scenarios are presented to the respondent, followed by a series of questions to elicit the information mentioned above. The first question asks the respondent what is wrong with the child. The respondent should then be asked for other information she may want to ask of the sick child's mother, other signs to look for in the child, and advice she may want to give regarding what should be done for the child who has shown signs of vitamin A deficiency. Additional questions should be asked to discover what subsequent steps the mother, primary caretaker, would take in providing for this child and at what stage these actions would be initiated. It is important that the interviewer record on the form whether the respondent would initially react by administering a home remedy or by seeking an outside source for treatment.

FORM 8.3 Summary of Calculated Food Medians by Age Subgroup (M5)

Continued

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