Disease surveillance

24 November 2014

Indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition
If a strategy of fortifying a vector food with iron is adopted, in view of the extent and homogeneity of the phenomenon in the population, regardless of age or sex, repeatedly measuring the same indicators and comparing them to previous values or to an international reference, will allow evaluating the effectiveness of the strategy. It may be exacerbated by high rates of infection, especially diarrhoea and measles. Landscape Analysis more information: No public health problem. The rationale behind the low-income food-deficit classification is that being both food deficit and having a low income at the same time means that the country lacks the resources not only to import food but also to produce sufficient amounts domestically.

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Dietetics and Nutrition

Therefore, serum retinol is best used for the assessment of subclinical vitamin A deficiency in a population not an individual. Blood concentrations of retinol the chemical name for vitamin A in plasma or serum are used to assess subclinical vitamin A deficiency. Night blindness is one of the first signs of vitamin A deficiency. In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry and damaging the retina and cornea.

An estimated — vitamin A-deficient children become blind every year, and half of them die within 12 months of losing their sight. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation.

Furthermore, it diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, as it may increase children's risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.

Serum or plasma retinol. Night blindness XN in pregnant women. Micronutrients Database [online database]. The new database is not yet publically available and the NLIS country profiles have not yet been updated.

Global prevalence of vitamin A deficiency in populations at risk — Serum retinol concentrations for determining the prevalence of vitamin A deficiency in populations. Xerophthalmia and night blindness for the assessment of clinical vitamin A deficiency in individuals and populations. Vitamin A deficiency, list of publications.

Trends and mortality effects of vitamin A deficiency in children in low-income and middle-income countries between and This indicator allows an assessment of iodine deficiency at the population level.

Iodine is an essential trace element that is present on the thyroid hormones, thyroxine and triiodotyronine. It occurs most frequently in areas where there is little iodine in the diet—typically remote inland areas where no marine foods are eaten.

Although goitre assessment by palpation or ultrasound may be useful for assessing thyroid function, results are difficult to interpret once salt iodization programmes have started. The median urinary iodine concentration is considered the main indicator of iodine status for all age groups, because its measurement is relatively non-invasive, cost-efficient and easy to perform. Since the majority of iodine absorbed by the body is excreted in the urine, it is considered a sensitive marker of current iodine intake and can reflect recent changes in iodine status.

Median urinary iodine concentrations have been most commonly measured in school children aged 6—12 years due to their easy access. During the neonatal period, childhood and adolescence, iodine deficiency disorders can lead to hypo- and hyperthyroidism.

Serious iodine deficiency during pregnancy can result in stillbirth, spontaneous abortion and congenital abnormalities such as cretinism, a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia.

Of even greater significance is the less visible, yet pervasive, mental impairment that reduces intellectual capacity at home, in school and at work. Cut-off values for public health significance in different target groups. Concentration cut-off values for public health significance. May pose a slight risk of more than adequate iodine intake in these populations.

Risk of adverse health consequences iodine-induced hyperthyroidism, autoimmune thyroid disease. Urinary iodine concentrations for determining iodine status deficiency in populations. Goitre as a determinant of the prevalence and severity of iodine deficiency disorders in populations. Iodine deficiency, list of publications. Global iodine status in and trends over the past decade. In NLIS, it is used as a proxy for access to health services and maternal care.

The indicator gives the percentage of live births attended by skilled health personnel in a given period. A skilled birth attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of women and newborns for complications.

In developed countries and in many urban areas in developing countries, skilled care at delivery is usually provided in health facilities. Births do, however, take place in various other appropriate places, from home to tertiary referral centres, depending on availability and need.

WHO does not recommend a particular setting for giving birth. Home delivery may be appropriate for normal births, provided that the person attending the delivery is suitably trained and equipped and that referral to a higher level of care is an option, however this may lead to an overestimation of births attended by skilled personal as infants delivered outside of a health facility may not have their birth method recorded.

All women should have access to skilled care during pregnancy and at delivery to ensure the detection and management of complications. One woman dies needlessly of pregnancy-related causes every minute, representing more than half a million mothers lost each year, a figure that has improved little over the past few decades. Another 8 million or more suffer life-long health consequences from the complications of pregnancy.

The lack of progress in reducing maternal mortality in many countries often reflects the low value placed on the lives of women and their limited role in setting public priorities.

The lives of many women in developing countries could be saved by reproductive health interventions that people in rich countries take for granted, such as the presence of skilled health personnel at delivery. Improved sanitation facilit ies and drinking-water sources. What do these indicators tell us? These indicators are the percentage of population with access to an improved drinking-water source and improved sanitation facilities.

How are they defined? Improved drinking-water sources are defined in terms of the types of technology and levels of services that are likely to provide safe water. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources are unprotected wells, unprotected springs, vendor-provided water, bottled water unless water for other uses is available from an improved source and tanker truck-provided water.

Improved sanitation facilities are defined in terms of the types of technology and levels of services that are likely to be sanitary. Improved sanitation includes connection to a public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines.

Service or bucket latrines from which excreta are removed manually , public latrines and open latrines are not considered to be improved sanitation. Access to safe drinking-water and improved sanitation are fundamental needs and human rights vital for the dignity and health of all people.

The health and economic benefits of a safe water supply to households and individuals especially children are well documented. Both indicators are used to monitor progress towards the Millennium Development Goals. Water, Sanitation and Hygiene. World Health Statistics, Children aged 1 y ear immunized against measles. Estimates of vaccination coverage of children aged 1 year are used to monitor vaccination services, to guide disease eradication and elimination programmes and as indicators of health system performance.

Measles vaccination coverage is defined as the percentage of 1-year-olds who have received at least one dose of measles-containing vaccine in a given year. In countries that recommend that the first dose be given to children over 12 months of age, the indicator is calculated as the proportion of children under 24 months of age receiving one dose of measles-containing vaccine. Measles is a leading cause of vaccine-preventable childhood deaths, and unvaccinated populations are at risk for the disease.

Measles is a significant infectious disease because it is so contagious that the number of people who would suffer complications after an outbreak among nonimmune people would quickly overwhelm available hospital resources. When vaccination rates fall, the number of nonimmune persons in the community rises, and the risk for an outbreak of measles consequently rises.

Millennium Development Goals indicators database. This indicator reflects the percentage of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. It provides information about the quality and coverage of perinatal medical services. Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency.

However, despite its proven efficacy and wide inclusion in antenatal care programmes, its use has been limited in programme settings, possibly due to a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level.

This indicator is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. The indicator is defined as the proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years.

Data can be reported on any iron-containing supplement including iron and folic acid tablets IFA , multiple micronutrient tablets or powders, or iron-only tablets which will vary by country policy.

Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes and enhance maternal and infant health. Iron and folic acid supplementation improve iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective.

Folic acid supplementation with or without iron provided before pregnancy and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects. Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality and also increases the risks for perinatal mortality, premature birth and low birth weight.

Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, because of the adverse effect of iron deficiency on the immune system. Iron deficiency is also associated with reduced work capacity and with reduced neurocognitive development. Demographic and Health Surveys. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for Children with diarrhoea receiving oral rehydration therapy.

This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy. It is the proportion of children aged 0—59 months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution.

The terms used for diarrhoea should cover the expressions used for all forms of diarrhoea, including bloody stools consistent with dysentery and watery stools, and should encompasses mothers' definitions as well as local terms. Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost—effective intervention indicates progress on an intermediate outcome indicator of the Global Nutrition Targets, prevalence of diarrhoea in children under 5 years of age.

Children with diarrhoea receiving zinc. This indicator reflects the prevalence of children who were given zinc as part of treatment for acute diarrhoea. Unfortunately, there are no readily available data on this indicator, which is maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity. Measures to prevent childhood diarrhoeal episodes include promoting zinc intake. Diarrhoeal diseases account for nearly 2 million deaths a year among children under 5, making them the second most-common cause of child death worldwide.

The greater the prevalence of zinc supplementation during diarrhoea treatment, the better the outcome of treatment for diarrhoea. WHO and the United Nations Children's Fund UNICEF recommend exclusive breastfeeding, vitamin A supplementation, improved hygiene, better access to cleaner sources of drinking-water and sanitation facilities and vaccination against rotavirus in the clinical management of acute diarrhoea and also the use of zinc, which is safe and effective.

Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for days lowers the incidence of diarrhoea in the following months.

Currently no data are available. The impact of zinc supplementation on childhood mortality and severe morbidity. Report of a workshop to review the results of three large studies.

Geneva , World Health Organization, Children aged months receiving v itamin A supplements. These indicators are the proportion of children aged months who received one and two doses of vitamin A supplements, respectively.

The indicators are defined as the proportion of children aged months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every months for all children between the ages of 6 and 59 months living in affected areas. The recommended doses are IU for month-old children and IU for those aged months. Programmes to control vitamin A deficiency enhance children's chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities.

The World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival and therefore of the achievement of the fourth Millennium Development Goal, a two-thirds reduction in mortality of children under 5 by the year As there is strong evidence that supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals.

Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival. Immunization, Vaccines and Biologicals. These indicators are the proportion of children aged months who received one or two doses of vitamin A supplements.

The indicator reflects the proportion of babies born in facilities that have been designated as Baby-friendly. Proportion of births in Baby-friendly facilities is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. This indicator is defined as the proportion of babies born in facilities designated as Baby-friendly in a calendar year.

To be counted as currently Baby-friendly, the facility must have been designated within the last five years or been reassessed within that timeframe. Facilities may be designed as Baby-friendly if they meet the minimum Global Criteria, which includes adherence to the Ten Steps for Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes.

The Ten steps include having a breastfeeding policy that is routinely communicated to staff, having staff trained on policy implementation, informing pregnant women on the benefits and management of breastfeeding, promoting early initiation of breastfeeding, among others. The International Code of Marketing of Breast-milk Substitutes restricts the distribution of free infant formula and promotional materials from infant formula companies.

The more of the Steps that the mother experiences, the better her success with breastfeeding. Improved breastfeeding practices worldwide could save the lives of over children every year. National implementation of the Baby-friendly Hospital Initiative. Implementation of the Baby-friendly Hospital Initiative. Mothers of children months receiving counselling, support or messages on optimal breastfeeding.

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. Optimal practices include early initiation of breastfeeding within 1 hour, exclusive breastfeeding for 6 months followed by appropriate complementary with continued breastfeeding for 2 years or beyond.

Even though it is a natural act, breastfeeding is also a learned behaviour. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. This indicator has been established to measure the proportion of mothers receiving breastfeeding counselling, support or messages. The proportion of mothers of children months who have received counselling, support or messages on optimal breastfeeding at least once in the previous 12 months is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

The indicator gives the percentage of mothers of children aged months who have received counselling, support or messages on optimal breastfeeding at least once in the last year. Counseling and informational support on optimal breastfeeding practices for mothers has been demonstrated to improve initiation and duration of breastfeeding, which in has many health benefits for both the mother and infant.

Breast milk contains all the nutrients an infant needs in the first six months of life. Breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence. Breastfeeding has also been associated with higher intelligence quotient IQ in children. Salt iodization has been adopted as the main strategy for eliminating iodine-deficiency disorders as a public health problem, and the aim is to achieve universal salt iodization.

While other foodstuffs can be iodized, salt has the advantage of being widely consumed and inexpensive. Salt has been iodized routinely in some industrialized countries since the s. This indicator is a measure of whether a fortification programme is reaching the target population adequately. The indicator is a measure of the percentage of households consuming iodized salt, defined as salt containing parts per million of iodine.

Iodine deficiency is most commonly and visibly associated with thyroid problems e. Consumption of iodized salt increased in the developing world during the past decade: This means that about 84 million newborns are now being protected from learning disabilities due to iodine-deficiency disorders.

Monitoring the situation of women and children. Sustainable elimination of iodine deficiency disorders by Micronutrient deficiencies, iodine deficiency disorders.

Population with less than the minimum dietary energy consumption. This indicator is the percentage of the population whose food intake falls below the minimum level of dietary energy requirements, and who therefore are undernourished or food-deprived. The estimates of the Food and Agriculture Organization of the United Nations FAO of the prevalence of undernourishment are essentially measures of food deprivation based on calculations of three parameters for each country: The average amount of food available for human consumption is derived from national 'food balance sheets' compiled by FAO each year, which show how much of each food commodity a country produces, imports and withdraws from stocks for other, non-food purposes.

FAO then divides the energy equivalent of all the food available for human consumption by the total population, to derive average daily energy consumption. Data from household surveys are used to derive a coefficient of variation to account for the degree of inequality in access to food. Similarly, because a large adult needs almost twice as much dietary energy as a 3-year-old child, the minimum energy requirement per person in each country is based on age, gender and body sizes in that country.

The average energy requirement is the amount of food energy needed to balance energy expenditure in order to maintain body weight, body composition and levels of necessary and desirable physical activity consistent with long-term good health. It includes the energy needed for the optimal growth and development of children, for the deposition of tissues during pregnancy and for the secretion of milk during lactation consistent with the good health of the mother and child.

The recommended level of dietary energy intake for a population group is the mean energy requirement of the healthy, well-nourished individuals who constitute that group. FAO reports the proportion of the population whose daily food intake falls below that minimum energy requirement as 'undernourished'. Trends in undernourishment are due mainly to: The indicator is a measure of an important aspect of food insecurity in a population.

Sustainable development requires a concerted effort to reduce poverty, including solutions to hunger and malnutrition. Alleviating hunger is a prerequisite for sustainable poverty reduction, as undernourishment seriously affects labour productivity and earning capacity.

Malnutrition can be the outcome of a range of circumstances. In order for poverty reduction strategies to be effective, they must address food access, availability and safety. Rome, October The State of Food Insecurity in the World Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition. FAO methodology to estimate the prevalence of undernourishment.

FAO, Rome, 9 October This indicator gives the prevalence of people living in extreme poverty, as measured by their daily income, and allows comparisons and aggregation of data on the progress of countries in reducing extreme poverty and allows monitoring of global trends.

As this poverty line has fixed purchasing power across countries or areas, it is often called the 'absolute poverty line'. Measures of poverty in countries are generally based on national poverty lines. Comparisons of poverty measures within countries are also difficult, especially for urban-rural differences. As the cost of living is typically higher in urban than in rural areas, the urban monetary poverty line should be higher than that for rural areas. The difference between the two in practice, however, may not properly reflect the difference in cost of living.

Mal nutrition is the single one of the most important risk factor for disease. When poverty is added, it results in a downward spiral that may end in death. Turning the tide of mal nutrition. Responding to the challenge of the 21st century. Washington DC, World Bank. Millennium Development Goals indicators series metadata. Indicators for monitoring the Millennium Development Goals. New York , United Nations, Infant and young child feeding.

The recommendations for feeding infants and young children 6—23 months include: The caring practice indicators for infant and young child feeding available on the NLIS country profiles include: Early initiation of breastfeeding. This indicator is the percentage of infants who are put to the breast within 1 hour of birth. Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed. This indicator is the percentage of infants aged 0—5 months who are exclusively breastfed. It is the proportion of infants aged 0—5 months who are fed exclusively on breast milk and no other food or drink, including water.

The infant is however, allowed to receive ORS and drops and syrups containing vitamins, minerals and medicine. Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important implications for the health of mothers.

An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants. Breast milk is the natural first food for infants.

It provides all the energy and nutrients that the infant needs for the first months of life. Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment. It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long. Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them.

These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample. Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available. These data are often kept together in national statistical offices.

They consist of a regular collection of information based on a small number of selected indicators. The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism.

They can represent a sound basis for central monitoring. A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.

Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status. They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention.

These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities.

They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis. They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration. They are generally grouped together at the central administrations of regions or administrative centres.

The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.

They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes. If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets.

Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends. Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices.

They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc. Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators.

Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators. A sound knowledge of local records and their quality is needed to avoid wasting time.

New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work. Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced. In general, they offer an integrated view of the issues concerned.

They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions. The participatory aspect should be emphasized rather than the precision or sophistication of data.

An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.

Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources. To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system.

The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state.

The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office. The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity.

The usefulness of such data varies depending on information needs and thus on the quality of the data required. Data concentrated at the central level are probably useful primarily for analysing trends. On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation.

We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints. Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners. This implies that a method is needed for guiding the choice. The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation.

A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners. However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context.

The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined.

For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators.

The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects. The concept of food security is generally perceived as that of sufficient availability of food for all.

However, several dozen different definitions have been proposed over these last 15 years! This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet. This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc.

It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact. Obviously it is not so much the final diagram which is of importance as the process through which it was developed. Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational.

Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified. The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team.

Let us again take the example of a problem of food security. It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets. A certain number of macro-economic or specific policies will affect one or all the elements in this block. Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C.

The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact. This will be the basis for an information system reflecting the overall framework of the programme and how it should work.

Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al. Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators.

It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration.

The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders. The way it is built tends to favour a clear, "vertical" visualization of series of causal relationships, eliminating the lateral links or loops that are often the source of confusion in other representations. In a second phase, a framework is developed linking the human or material resources available at the onset inputs , the procedures envisaged activities , the corresponding results of implementation outputs , and the anticipated intermediate outcomes or final impact of each activity or of the programme.

This tool is very useful for defining all the necessary indicators. This represents the formalisation of a real conceptual scheme. While many representations of conceptual models comprise comparable elements, it is essential that a model should never be considered as directly transposable, since it must absolutely apply to the local context.

A direct transposition would therefore be totally counter-productive. While it is obvious that the conceptual analysis must ideally be carried out before the programmes are launched, it can be done or updated at any time, leading to greater coherence and a consensus on current and anticipated actions; this applies even more in a long-term perspective of sustainability.

In operational terms, establishment of a conceptual framework allows to define in a coherent way the various types of indicators to be used at each level. After defining the activities to be undertaken, status indicators referring to the target group will be identified, as well as indicators of causes that will or will not be modified by these activities, and indicators that will reflect the level or quality of the activities performed.

Lastly, indicators will be chosen to reflect the changes obtained, whether or not these are a result of the programme.

Identification of precise objectives makes it possible to monitor changes in impact indicators not only vis-à-vis the original situation but also in terms of fulfilment of the objectives adopted.

During this initial phase, existing indicators are assessed, as well as those that will be taken from records or collected through specific surveys. It should be specified who needs this information, as well as who collects the data. In fact, it is important that this choice should be demand-driven, in order to be sure that the information selected is then actually used.

One might be dealing with several groups of users who do not exactly have the same needs: In this way, foundations can be laid for an information system essential for monitoring and evaluation. A proximate, often indirect, indicator will have to be sought and limitations to its validity in the context considered will have to be verified carefully which will depend on the precise objective. For example, can a measurement of food stocks at a given moment be validly replaced in the context under consideration with a measurement of food consumption in order to assess the food insecurity situation of a target group?

Is a measurement of food diversity a good proximate indicator for micronutrient intake? Does it at least consistently classify consumers into strong and weak consumers?

Does it allow defining an acceptable level of consumption vis-à-vis recommendations? Will it allow children to be classified correctly vis-à-vis a goal of improved growth? Validity studies are sometimes available locally, otherwise specific studies can be carried out; hence the usefulness of collaborating with research groups - for example from universities - who will be able to carry out this type of validation study under good conditions.

The relationship between two variables, making them interchangeable for defining an indicator, may vary over time as a result of implementation of a programme, and this must be taken into account. For example, if there is a clear link between family size and food insecurity in a given context, the criterion of family size can simply be taken as a basis for identifying families at risk.

However, if a specific programme has been successfully carried out among these families, this indicator could lose its validity. The ideal would be to use the same indicators in all places and at all times in order to have the benefit of common experience regarding collection and analysis, so that direct comparisons can be made. In practice, however, concepts on indicators evolve steadily with the progress of knowledge, leading to the dilemma of being unable to carry out comparisons either with older series of indicators or with what is being done elsewhere.

Comparability within time is obviously a priority in the case of monitoring. Preference will thus be given to indicators that, although not necessarily identical, are comparable, in other words give a similar type of information. The issue of the comparability of data from different sources has been the subject of studies especially in the field of health indicators. Whenever traditional indicators seem inadequate or insufficient in capturing the phenomenon or situation under consideration, the value of "innovative" and potentially promising indicators with excellent basic characteristics should not be neglected - although it is important to make sure that they have been validated for circumstances similar to those under study.

Since such innovative indicators usually have to be collected "actively", especially at the community level, the decision often depends on their technical feasibility as a guarantee of the sustainability of collection.

In a context of dietary transition, an indicator expressing the structure of food consumption for example the percent of energy from fat is more subject to major changes than the average consumption level expressed in calories, while also providing important information on the future health of the population considered. In contrast, data on food habits tend not to change rapidly, unless an education programme is specifically developed for this purpose; the repeated collection of the corresponding indicators is thus of little use for purposes of short- or medium-term monitoring of the situation.

Slowness in collection and in getting the data back to user level are key factors to be considered, for many information systems are paralyzed by this problem, while timely information is often needed for decision-making or for adjusting the programme or the intervention e. From this point of view, the nature of potential sources of data for these indicators or the direct availability of these indicators at the level where they are needed can be decisive for their selection.

In practice, data collected to produce indicators need to be compared to a reference or to a "cut-off value". Verify the license status and disciplinary history of a healthcare professional or facility license in the State of Florida. Apply for a License. The Dietetics and Nutrition Practice Council is an advisory council under the supervision of the Board of Medicine and was legislatively established to ensure that every dietitian, nutritionist or nutrition counselor practicing in this state meets minimum requirements for safe practice.

The Dietetics and Nutrition Practice Council is responsible for licensing, monitoring and educating dietitians, nutritionists, and nutrition counselors to assure competency and safety to practice in Florida.

The Board of Medicine is responsible for any required disciplinary action. Applicants from Puerto Rico often apply by Endorsement of Another license where the territory laws and rules must be provided to perform a law to law Comparison. One option for applicants who are unable to provide a copy of the law would be to allow them to submit written authorization for the Council to review a copy of the laws that had been provided by previous applicants.

When you use the new MQA Online Services Portal for the first time, you will be required to register for a new user account and link your existing health care licenses or previously submitted applications to your account. This is a one-time process that takes approximately minutes. Just follow these five easy steps:. Once you have registered and linked your health care practitioner license s or application s to your user account, you will have a streamlined, more user-friendly online services experience.

The new portal provides access to updated features such as requesting a name change or status change online, adding a secondary practice location, changing a password without having to call and submitting all of the required documentation for your license online rather than having to send it by mail. For more information, detailed guides and frequently asked questions, please visit www.

Not knowing does not alleviate accountability. Become familiar with the Grounds for Discipline found in Section Notice to Licensees About Fraudulent Documents. The Florida Department of Health DOH is aware that documents purportedly originating from DOH requesting information of a sensitive nature have been received by members of the public.

These documents request licensees share information that may be used to commit fraud against a licensee or patient.

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