Monitoring at the Household Level Methods, Problems, and Use of Critical Information

A Simplified Conceptual Outline: Where does this information fit? Provision of services: Adequately iodized salt must be available in the marketplace Utilization of services: Consumers must be aware of the importance, and use iodized salt Coverage: An adequate proportion of the population must consistently use iodized salt Impact: Periodic measurement should show adequate iodine intake as measured by urinary iodine

Salt Production, Importation, and Distribution Is iodized salt available? Does it meet the iodine needs of the population? Does it consistently meet standards? ? ? ? Internal and External Monitoring Provision of services

Salt Production, Importation, and Distribution Insures that salt available to population meets government legal requirements regarding iodine content Internal and External Monitoring

Use of Iodized Salt, Awareness, Cost And Cultural Habits Is iodized salt being used? Does the population recognize the importance? ? ? ? KAP studies, IEC evaluations, price and consumption surveys Utilization of services

Use of Iodized Salt, Awareness, Cost And Cultural Habits KAP studies, IEC evaluations, price and consumption surveys Provides an understanding of constraints to use of iodized salt that may ultimately affect coverage

Household Use of Iodized Salt Do the majority of households use iodized salt? Are some groups missed? ? ? ? Household coverage surveys, sentinel site coverage assessment Coverage

Household Use of Iodized Salt Household coverage surveys, sentinel site coverage assessment Provides a quantitative measure of household use, and can confirm adequacy of iodine content throughout distribution

Iodine Status of The Population Has iodine deficiency been eliminated? Are any groups still deficient? ? ? ? Urinary Iodine Assessment in different population groups Impact

Iodine Status of The Population Urinary Iodine Assessment in different population groups Confirms elimination of iodine deficiency at the population level, or among different high risk target groups

Household level monitoring includes understanding purchasing patterns using qualitative techniques, and estimating coverage Coverage may be single most important indicator

Assessing Purchasing Habits and Preferences KAP surveys, focus group discussions, key informant interviews and other qualitative techniques are used Helps with initial program development, in understand key issues influencing decision to use iodized salt, including price, mis-perceptions or concerns about safety and usage, cultural habits Usually do not need to assess quantity of salt consumed: varies from 5-15 gms/person/day on average

Assessing Coverage Can use sentinel models to assess specific geographic areas Ideally population-based, representative sampling at a national level, on a periodic basis

Salt testing in schools can provide coverage estimate, while building awareness Developed as part of science curriculum Uses salt test kits to demonstrate presence of iodine Provides a rough coverage estimate among households with children attending the school

Questions raised : Coverage within sentinel sites (schools, clinics) Is the figure representative of all endemic areas? Is there bias due to the special attention given sentinel sites? ?

Population-based Coverage Estimation Should be easily included in periodic national surveys (DHS, MICS, Food/Agricultural Surveys, Employment Surveys) Can be done using classic immunization (EPI) cluster survey method

Cluster Survey Coverage Protocol Developed in response to need for simple immunization coverage figure Addresses sampling issues to insure representativeness Based on a random selection of households from weighted selection of villages or other administrative units

Survey Coverage Protocol Describes: Selection of the geographic area or other administrative unit that the population sampled will represent (usually a district or region) Selection of areas or sub-units from which to select households Selection of households within sub-units Collecting data from individuals

Coverage Survey Provides a statistically valid estimate of the proportion of households with iodized salt present, and/or stating use of iodized salt Provides an opportunity to test salt at the household level in a representative sample of households A sample size of 900 is adequate regardless of total population sampled Is usually accurate to within + or – 10% of the estimate

Questions raised : Coverage surveys Is there bias in household selection? Is the salt tested the salt usually used? Does the geographic area sampled adequately reflect the national population? ?

Interpretation of Low Coverage: Does it reflect poor or inconsistent production level quality assurance? Does it reflect the specifics of the geographic area selected? Does it reflect consumer concerns about iodized salt? ? Availability / Supply Issues Technical Sampling Issues Demand Issues

Actions To Be Taken Review total tonnage of iodized salt imported: Is it adequate to meet needs? Increase external monitoring and enforcement (monitoring at import sites) Investigate coverage further Review educational activities: Are IEC efforts effective? Addresses supply issue Ensures adequate quality entering the country Addresses demand issues Resolves sampling or geographic representation concerns