Iraq National Micronutrient Survey 2007
IRAQ National Micronutrient Survey 2007
Contents
ACRONYMS AND ABBREVIATIONS ............................................................................ 4
MAP OF IRAQ ................................................................................................................ 4
INVESTIGATORS AND COLLABORATORS ................................................................. 5
1. INTRODUCTION ......................................................................................................... 7
1.1 BACKGROUND ......................................................................................................... 8
1.2 OBJECTIVES ............................................................................................................ 9
2. PLANNING AND PREPARATION .............................................................................. 9
2.1 STUDY COORDINATION ............................................................................................. 9
2.2 COMPONENTS OF THE SURVEY .............................................................................. 11
2.3 TARGET POPULATIONS ........................................................................................... 12
2.4 SURVEY TEAMS AND MANAGEMENT ........................................................................ 12
2.5 COMMUNITY MOBILIZATION .................................................................................... 13
: ................................................................................................................................. 14
3. SAMPLING ............................................................................................................... 14
3.1 STRATIFICATION .................................................................................................... 14
3.2 SAMPLE SIZE DETERMINATION ................................................................................ 14
3.3 FIRST STAGE SAMPLING ......................................................................................... 16
3.4 SECOND STAGE OF SAMPLING ................................................................................ 16
4. DATA COLLECTION ................................................................................................ 17
4.1 INCLUSION AND EXCLUSION PROCEDURES ............................................................... 17
4.2 ENROLLMENT PROCEDURES AND CONSENT ............................................................. 17
Unavailable and absent eligible survey participants ............................................... 17
4.3 DATA COLLECTION AT THE HOUSEHOLD ................................................................... 18
Interview procedures and salt collection ................................................................ 18
Anthropometry ....................................................................................................... 18
Collection of biological specimens ......................................................................... 18
Procedures for blood collection.............................................................................. 19
Completion of data collection process in the household......................................... 19
5. SURVEY INSTRUMENTS AND OUTCOMES ........................................................... 19
5.1 GENERAL QUESTIONNAIRES ................................................................................... 19
Target group .......................................................................................................... 19
5.2 ANTHROPOMETRY ................................................................................................. 20
a) Length/height .................................................................................................... 20
b) Body weight ....................................................................................................... 21
c) Data Quality ....................................................................................................... 21
5.3 ANEMIA ................................................................................................................. 21
5.4 IRON STATUS AND IRON DEFICIENCY ANEMIA ........................................................... 22
5.5 VITAMIN A STATUS ................................................................................................. 22
5.6 IODINE STATUS ...................................................................................................... 22
6. SPECIMEN PROCESSING ....................................................................................... 23
6.1 HEMOGLOBIN CUVETTES ........................................................................................ 23
2
IRAQ National Micronutrient Survey 2007
6.2 VENOUS AND CAPILLARY BLOOD ............................................................................. 23
6.3 URINE ................................................................................................................... 23
6.4 SALT .................................................................................................................... 23
7. LABORATORY PROCEDURES ............................................................................... 23
7.1 SERUM FERRITIN, RETINOL, VITAMIN D, FOLATE AND CRP ........................................ 24
7.2 URINARY IODINE .................................................................................................... 24
7.3 SALT .................................................................................................................... 24
8. DATA ENTRY AND ANALYSIS PLAN ..................................................................... 24
9. DISSEMINATION OF STUDY RESULTS ................................................................. 24
10. TIME FRAME .......................................................................................................... 25
11. BUDGET ................................................................................................................. 25
REFERENCES.............................................................................................................. 26
ANNEX 1: SAMPLE SIZE ............................................................................................ 27
ANNEX 2 – DIFFERENCES THAT CAN BE DETECTED BETWEEN A BASELINE
AND FOLLOW UP SURVEY ........................................................................................ 28
ANNEX 3: EXAMPLE OF A CLUSTER CONTROL FORM .......................................... 29
ANNEX 4: SUPPLEMENTAL INFORMATION FOR PROTECTION OF HUMAN
RESEARCH PARTICIPANTS ....................................................................................... 30
ANNEX 5: IRAQ SURVEY TIMELINE .......................................................................... 32
ANNEX 6: COST OF LABORATORY ANALYSIS OF SPECIMENS, BASED ON USING
DR KHATIB’S LABORATORY ..................................................................................... 35
3
IRAQ National Micronutrient Survey 2007
Acronyms and abbreviations
AGP
CDC
COSIT
CRP
DBS
EMRO
FAO
IMMPaCt
INRAN
IRAQNMS
MoH
MDG
MTSP
NRI
PDS
PSU
UNICEF
WHO
WFP
1-acid glycoprotein
U.S. Centers for Disease Control and Prevention
Central Organization for Statistics and Information
Technology
C - reactive protein
Dried blood spot
Eastern Mediterranean Regional Office
Food and Agricultural Program
International Micronutrient Malnutrition Prevention and
Control Program
Italian National Institute of Food and Nutrition
Iraq Nutrition and Micronutrient Survey
Ministry of Health
Millennium development goals
Mid term strategic plans
National Research Institute
Population Distribution System
Primary sampling unit
United Nations Children’s Fund
World Health Organization
World Food Program
Map of Iraq
4
IRAQ National Micronutrient Survey 2007
Investigators and Collaborators
5
IRAQ National Micronutrient Survey 2007
Support to the Ministry of Health (MoH) for this survey will be provided by several
investigating and collaborating agencies. These include (in alphabetical order):
Jordan University of Science and Technology
UNICEF Iraq
U.S. Centers for Disease Control and Prevention (CDC)
World Health Organization, Eastern Mediterranean Regional Office (WHO EMRO)
The core members of the survey coordinating committee are as follows:
Dr Usama Tawfeeq
??
??
– Overall Survey Coordinator
– Survey manager
– Laboratory coordinator (Iraq)
The core survey coordinating committee will be supported by the following members of
the International Micronutrient Malnutrition Prevention and Control Program (IMMPaCt)
at the U.S. Centers of Disease Control and Prevention (CDC) and UNICEF Iraq.
Katie Tripp (CDC)
Dr Bradley Woodruff (CDC)
Dr Bakary Drammeh (CDC)
Dr Rosemary Schleicher (CDC)
Alexander Malyavin (UNICEF)
6
IRAQ National Micronutrient Survey 2007
1. Introduction
In 2004 a meeting was held in Amman Jordan to plan a national micronutrient survey in
Iraq. Members of the Iraq Ministry of Health (MoH), Nutrition Research Institute (NRI)
and Central Organization for Statistics and Information Technology (COSIT), World
Health Organization, Eastern Mediterranean Regional office (WHO EMRO) and United
Nations Children’s Fund Iraq (UNICEF IRAQ) were in attendance. Researchers from the
National Institute of Food and Nutrition (INRAN) were also at the planning meeting to
offer technical advice and support.
A protocol for the survey was developed but due to concerns about the security situation
the survey was not initiated. However, the need for an assessment of the micronutrient
situation still remained and in September 2006 UNICEF engaged technical experts from
the US Centers of Disease Control and Prevention (CDC) to assist in revisiting the
original proposal and developing a new protocol for undertaking a micronutrient survey
in Iraq in 2007.
In July 2006 a meeting to plan the survey was convened in Amman, Jordan. Two
technical experts from the International Micronutrient Malnutrition Prevention and Control
(IMMPaCt) program at the CDC meet with a delegation from Iraq and advisors from
UNICEF, WHO and the World Food Program (WFP) to plan for the survey. Based on the
very positive outcome of the meeting in Amman, the IMMPaCt program at the CDC
agreed to provide technical assistance for the duration of the planning and
implementation of the Iraq micronutrient survey. UNICEF Iraq also agreed to contribute
funding to assist with planning, implementation and programmatic follow up to the
survey.
Attendees at the meeting included:
Dr Mohammed Abdu Gofoor, MoH
Dr Usama Tawfeeq, MoH
Dr Shahab Shahab, MoH
Laith Abdul Wahid, MoH
Hassan Hashim, MoH
Louay Rashid, COSIT
Thanaa Sallman, COSIT
Dr Kunal Bagchi, WHO
Azhar Alazzawi, WFP
Joan Sherko, WFP
Dr Taha Al-Mulla, UNICEF
Bassam Kanadelchy, UNICEF
Alexander Malyavin, UNICEF
Katie Tripp, IMMPaCt, CDC
Bradley Woodruff, IMMPaCt, CDC
The final plan for the Iraq National Micronutrient Survey (IRAQNMS) was developed
through wide consultations with micronutrient stakeholders and experts both in Iraq,
Jordan, INRAN and CDC.
7
IRAQ National Micronutrient Survey 2007
1.1 Background
Before 1990 Iraq belonged to the group of middle-income countries. Malnutrition was
virtually not seen, as households had easy and affordable access to a balanced diet.
Health care services were guaranteed by an extensive network of well-equipped, wellsupplied and well-staffed health facilities.
Since the 1991 war and, more recently, since the war in 2004, damaged infrastructure,
food shortages, poor environmental sanitation and non-functioning social and economic
sectors have resulted in the deterioration in overall health conditions.
There are no national-level micronutrient data available in Iraq. Primary health care
centers have reported a high prevalence of anemia. Neural tube defects have been
documented but there is no information on folate deficiency. In order to combat iron
deficiency anemia and folate deficiency a wheat fortification program has just been
established (August 2006) and flour is now fortified with iron and folic acid. This flour will
be available for everyone in Iraq through the public distribution system (PDS).
There are no serum retinol data available but a survey of clinical manifestations of
vitamin A deficiencies in 1994 in three governorates of Iraq indicated that 0.5% of
children had Bitot spots, 1.6% had night blindness and 0.05% had xeropthalmia.
Currently vitamin A supplements are available but only half the dose recommended by
WHO is provided.
In 1992 a survey showed that 41.7% of women of children bearing age had an enlarged
thyroid. A survey conducted in 1993 indicated that 44% of primary school children and
51% of women had low urinary iodine levels. Since 1993 a salt iodization program has
been in place. According to MICS 2000, 40% of households in Iraq have iodized salt but
there is some suspicion that this proportion has dropped recently due to the privatization
of salt production.
The report "Assessment of Food & Nutrition Situation in Iraq" of May-June 2000 by the
Food and Agricultural Organization (FAO), WFP, and WHO confirmed that about
800,000 children under 5 years of age are chronically stunted (low height for age). The
report also indicated a high prevalence of anemia in school children and stated that
numerous cases of rickets (vitamin D deficiency) still occur. The report also confirmed
that diarrhea was an important contributing factor to malnutrition in Iraq. Wasting (low
weight for height) in children under 5 was reported to be over 10% in Baghdad, Kerbala
and Diyala governorates. More recently, data from the 2005 WFP food security survey
demonstrated that 25% of children 6-59 months were stunted, 14% were underweight
and 9% were wasted.
Justification for the survey
One of the main justifications for conducting this survey is that while there are some
local data on micronutrient status, there are no nationally representative data that can be
used to plan micronutrient interventions or assess the impact of already established
programs. Various programs have been introduced in Iraq, such as wheat flour
fortification, but there are no data to evaluate the impact of these programs on
micronutrient deficiencies. Vitamin A supplementation is practiced in Iraq, but there are
8
IRAQ National Micronutrient Survey 2007
no data to demonstrate whether or not supplementation with only half of the WHOrecommended dose has had any effect.
While salt iodization is underway, data suggest that Iraq is still far from achieving
universal salt iodization. Data from this proposed survey will help to advocate and plan
for improvements in salt iodization.
1.2 Objectives
The overall goal of the IRAQNMS is to assess the overall micronutrient status of various
population groups and to evaluate current interventions to improve micronutrient status
in Iraq. Additionally the survey will enable the MoH and its partners to more effectively
manage existing interventions and to adequately plan, implement and monitor new
prevention programs and evaluate their impact.
The specific objectives are to obtain regional (Northern, Upper, Central and Southern)
estimates of:

the proportion of households which have adequately iodized salt

the urinary iodine levels among non-pregnant women of child bearing age (15-49
years of age)

the urinary iodine levels among children 6-14 years of age

the prevalence of anemia and iron deficiency in children 24-59 months of age
and non-pregnant women of child bearing age

the prevalence of vitamin A deficiency in children 6-59 months of age

the prevalence of stunting and wasting in children 6-59 months of age

the prevalence of vitamin D deficiency in children 24-59 months

the prevalence of folate deficiency in non-pregnant women of child bearing age

the prevalence of anemia in men 18-50 years, children 6-23 months and children
6-14 years of age
2. Planning and preparation
2.1 Study coordination
The Iraq survey coordinating committee has overall responsibility for the quality of data
collection and analysis and for timely and appropriate reporting and advocacy. Tasks of
this committee include:

On-going planning and implementation of the IRAQNMS

Ensuring adequate financial, human and organizational resources for the
IRAQNMS
9
IRAQ National Micronutrient Survey 2007

Ensuring timely data analysis, report writing and dissemination

Organizing high level meetings to advocate for action based on the results of the
IRAQNMS
The coordinating committee will hold meetings to:






Review and finalize the draft study protocol
Discuss and approve a work plan
Identify and obtain necessary resources
Discuss the draft report presenting the results of the IRAQNMS
Plan the meeting to disseminate the final results
Plan additional activities to implement preventive interventions or further studies
The coordinating committee will also hold monthly meetings to discuss the progress of
the IRAQNMS and any problems that need to be resolved. Members of the committee
include representatives of the Ministry of Health (MoH), NRI and COSIT. CDC and
UNICEF Iraq are to be sent minutes from the meetings every month.
Table 1. Allocation of Roles and Responsibilities by Institution.
Task
Responsible
Finalizing study protocol
CDC, NRI and MoH
Survey Manager

Hiring

Supervising
MoH/NRI/UNICEF
NRI
Procuring supplies
Laboratory:

Collecting and handling of
specimens

Analysis of specimens
Developing a work plan:

Hiring and training interviewers

Transport

Informing/involving district

Payment of staff
Data management:

Data management plan

Data entry

Data analysis
Obtaining research and ethical clearance
Finances:
?
MoH
Dr Khatib at the Jordan University of
Science and Technology and possibly
Dr Juergen Erhardt at the University of
Jakarta, Indonesia
MoH, NRI and CDC
?
?
?
MoH, COSIT, CDC
MoH, COSIT, CDC
MoH, COSIT, CDC
MoH
10
IRAQ National Micronutrient Survey 2007



Arrange funding
Financial management
Accounting and financial reporting
Report writing and dissemination of
results:



Write the survey report
Print the survey report
Organize dissemination and
advocacy events
UNICEF
MoH, UNICEF
MoH, UNICEF
MoH/NRI/ COSIT/UNICEF Iraq
(CDC available for assistance)
A survey manager will be hired and will be responsible for the day-to-day planning and
implementation of the IRAQNMS. The survey manager will report to the overall survey
coordinator, Dr. Usama Tawfeeq, and the survey coordinating committee.
NRI and MoH will be responsible for hiring the survey manager. Qualifications of the
successful applicant should include:

Experience in a medical, nutritional or bio-chemical field (a MSc or PhD would be
an added advantage)

Expertise in and experience with planning and conducting field-based nutrition or
health programs and/or surveys

Experience with coordinating multi-sectoral teams and working to a detailed
timeline

Experience with obtaining government approval for activities and with ordering
supplies and obtaining customs clearance

Some experience with data analysis

Experience with data interpretation and report writing

Availability full time for a period of 1 ½ years

Self motivated and able to work independently and as part of a team
Besides technical assistance for the specific activities of the IRAQNMS (e.g. sampling,
data analysis, and laboratory analysis), CDC will make a person available who will work
closely with the survey manager and coordinator at critical points in the survey, such as
finalizing the protocol, developing the questionnaires, training the survey workers,
supervising field data collection, data analysis and interpretation, and writing the report.
2.2 Components of the Survey
The IRAQNMS will be composed of integrated components that will be used to assess
the nutrition micronutrient status of the target groups. The various methods to be
employed include anthropometric measurements, hematological and biochemical
assessments, salt sample analysis and interview questions.
11
IRAQ National Micronutrient Survey 2007
2.3 Target populations
The table below outlines the indicators that will be assessed by the survey and the target
groups for each indicator.
Table 2 – Indicators to be assessed in survey target groups
Childre
n 6-23
months
Childre
n 24-59
months
Children
6-14
years
Hemoglobin



Iron status


Vitamin A


Indicator
Househol
d
Vitamin D



Urinary Iodine
Anthropometry
Men
18-50
years

Folate
Salt
Women
(nonpregnant)
15-49
years






Men are at substantially lower risk of many nutritional deficiencies and are therefore not
specifically targeted in most micronutrient assessments. Nonetheless, men may be
included in such surveys because they are much less susceptible than women and
children to iron deficiency, but equally susceptible to other causes of anemia. Therefore,
survey findings indicating that anemia is common among women and children but rare
among men provide evidence that iron deficiency is a predominant cause of anemia.
2.4 Survey Teams and management
There will be 5 teams in each region, 20 teams in total. Each team will consist of one
team leader, one interviewer, one lab technician, and one anthropometrist. The
interviewer will also be trained as the anthropometry assistant.
There will be four regional supervisors that will work in close coordination with the survey
manager and survey coordinator. In each governorate there will be one point person
assigned to assist with the survey. There will also be logistics people assigned to each
region to assist with the transportation of the biological specimens to a central point. The
number of logistical people will be decided once the primary sampling units have been
selected.
12
IRAQ National Micronutrient Survey 2007
Organizational structure
Survey coordinator
Survey committee
Survey Manager
4 Regional
Supervisors
18 Governorate
Focal Point
Logistical support personnel
Table 3- Roles and responsibilities of survey team members
Role
Responsibilities
Team Leader
Identify households previously selected by COSIT staff
Maintain records and cluster control sheets,
Check labels and completed data collection forms before
leaving each household
Plan revisits.
Perform finger sticks and phlebotomy
Manage laboratory specimens during data collection
Collect urine specimens
Measure height and weight of children
Laboratory technician
Anthropometrist
Interviewer
Interview respondents
Assist in weighing and measuring children
Collect household salt specimen
2.5 Community Mobilization
Before commencing data collection, officers from COSIT, in coordination with the
regional supervisors and governorate offices, will organize and implement a community
mobilization campaign. These organizations will produce leaflets and radio spots.
Information will be sent to all communities selected to take part in the survey so that
people will know well ahead of time when the data collection for the survey will occur.
2.6 Training
Training of trainers will take place in Amman, Jordan. The regional supervisors, the
survey manager and the survey coordinator must be present at the training. The training
of field staff will take place in Iraq.
13
IRAQ National Micronutrient Survey 2007
All trainers will receive 8 days of instruction regarding the overall survey objectives and
procedures and pilot testing of procedures among Iraqi families living in Amman. Some
components of the training include the following:
Laboratory training
The training of laboratory technicians trainers will be conducted by Dr Khatib and CDC
lab personnel on procedures for performing a finger stick, the collection and processing
of blood into a microtainer, the use of the HemoCue™ photometer (HemoCue AB,
Ångelholm, Sweden) for hemoglobin measurement, the collection and processing of
venous blood and the collection and field processing of urine specimens.
Anthropometry training
Anthropometrists will be trained to measure weight and height or length on children. This
training will include practice on children and a standardization exercise.
Interview techniques training
All interviewers will be trained on how to conduct interviews and complete the
questionnaires. They will also be trained as anthropometry assistants and trained on
collecting salt in the household.
3. Sampling
3.1 Stratification
A two-stage cluster sampling design will be used with stratification to generate national
estimates for the major nutritional outcomes and region-specific estimates for the four
main regions (Northern-Mountain, Upper-Alluvial, Central-Desert and SouthernMarshlands). The stratification by these four regions will be done for the following
reasons:

The diversity of the landscape, agriculture and cultural practices may result in
wide differences in the nutrition outcomes among the regions.

Programs may need to be introduced or targeted regionally and region-specific
estimates could help identify those regions in greatest need of interventions.

The credibility of the survey findings at a local level will be enhanced.
Using the 2006 census projections Iraq currently has a total population of … million
persons with……. (…..%) residing in the Southern region, ………..(……..%)in the
Central region, ……….. (………..%) in the Upper region and …………..(…….%) in the
Northern region. The 2006 census projections will be used to weight the calculation of
nationwide estimates of the nutrition outcomes.
[Please complete COSIT]
3.2 Sample size determination
The sample size for the IRAQNMS was determined using standard statistical
procedures. The anticipated prevalence, desired precision, and assumed design effect
for each outcome in each target group were determined based on the results from
14
IRAQ National Micronutrient Survey 2007
previous surveys and studies related to the outcomes of interest. Sample sizes for each
outcome in each target group were calculated using the standard formula:
N
1.96 2  p  q
 DEFF
d2
Where: N = minimum sample size needed
1.96 = the z value to obtain a 95% confidence interval
p = the assumed prevalence of the nutrition outcome of interest in a target group
q = 1-p
d = the desired precision expressed as a half-confidence interval
DEFF = the design effect to account for the loss of statistical precision from
cluster sampling
For many nutrition outcomes, conservative assumptions were made to intentionally
overestimate the necessary sample size. For example, because the sample size is
maximum if the prevalence is 50%, if the prevalence of a specific outcome was thought
to possibly approach 50%, the sample size calculation assumed 50% as the prevalence.
Similarly, design effects were overestimated to ensure adequate sample sizes.
For example, the calculation of a sample size for anemia in children 6-59 months of age
was based on an estimated anemia prevalence of 50%, a precision of +/-10 percentage
points, and a design effect of 2.3. Using the standard formula above, 221 children would
be needed per region. The nationwide sample would require four times as many children
6-59 months of age because there are four strata, thus resulting in a total of 884
children. But, of course, a certain proportion of selected households will be unavailable
or refuse participation (household non-response) and a certain proportion of children in
consenting households will be absent or their mothers will refuse consent for a finger
stick or phlebotomy (individual non-response). Taking into account an estimated
individual non-response of 10%, a household non-response of 10%, and the average
number of children 6-59 months of age per household in Iraq (0.8 children per
household) the required number of households that need to be selected to obtain finger
stick blood on 884 children is 1,364.
For most of the outcomes and target groups of interest, there are very few data on which
to base the assumptions necessary to calculate sample size. As described above, a
prevalence of 50% was selected for such indicators to provide the largest sample size
for the given target population. (See annex 1 for a detailed description of the
assumptions used to generate the sample sizes for all major outcomes). For a given
target group, sample sizes were calculated separately for each nutrition outcome
measured in that group, and the maximum size was taken for that target group. It was
decided that the number of households for the entire survey should be 2000, as this will
provide at least the desired precision for most of the nutrition outcomes of interest.
Because the average number of individuals per household is higher for children 6-14
years of age, women of child-bearing age, and adult men, the number of households
necessary to select to obtain the minimum sample size for these target groups is much
less. As a result, in only every third selected household will older children, women, and
men be included as survey subjects.
15
IRAQ National Micronutrient Survey 2007
In addition to calculating the sample size needed for a single survey we also calculated
the sample size needed to be able to detect a difference between this time point and
another survey in the future. Outlined in annex 2 is an example of the kind of differences
a follow up survey could expect to detect if a sample of 2000 HHs were selected to look
at the micronutrient status of young children and non-pregnant women of child bearing
age.
Table 4- Number of survey participants from whom biological samples will be obtained
by target group
Target
group
Number of
households (HH)
Household Percent in
response population
Individual
response
Number of
participants
Children 623 months
2000
90%
5.3%
90%
558
Children
24-59
months
2000
90%
9.6%
90%
1011
667
(every 3rd HH)
90%
23.3%
75%
682
667
(every 3rd HH)
90%
23.9%
90%
839
667
(every 3rd HH)
90%
20.6%
75%
603
Children 614 years
Nonpregnant
women 15
-49 years
Adult men
18-50
years
3.3 First stage sampling
The primary sampling unit (PSU) for the IRAQNMS will be the census unit. In each of
the four regions, 50 PSUs will be selected probability proportional to size (200 in total).
These randomly selected PSU will be located in all 18 governorates in Iraq. Although all
the governorates will be included in the survey, it is important to note that the precision
around the estimates of the prevalence of all outcomes will not be sufficient to generate
governorate-specific estimates.
3.4 Second stage of sampling
Several months before data collection begins the survey coordinator and survey manger
will work with officers from COSIT to enumerate all of the PSUs selected to participate in
the survey. Once the maps or household listings are updated in all 200 PSUs,
governorate statistical officers will randomly select 10 households in each selected PSU.
These 10 households then constitute a cluster. COSIT officers at the governorate level
will inform the survey teams which households have been selected in each PSU and
show the team their location. Although the basic sampling unit is the household, the unit
of analysis for most of the nutrition variables is the individual child, woman or man in the
household. In each selected household, all eligible persons in the identified target
groups will be offered participation in the survey. For the IRAQNMS, a household is
16
IRAQ National Micronutrient Survey 2007
defined as a group of people who share a common cooking pot. [What definition would
be appropriate for Iraq?]
4. Data collection
4.1 Inclusion and exclusion procedures
Of the 10 randomly selected households visited in each cluster, households will be
eligible for participation in the nutrition survey providing that the following criteria apply:
1) Someone is present at the time the household is visited. If none of the defined
target groups live in the household selected then only the household checklist
and household data collection form will be completed before the team moves on
to the next household, and
2) Consent is given by the participant or a responsible adult for survey participation.
The survey will enroll only non-pregnant women of child-bearing age. All women childbearing age will be interviewed, but if a women reports that she is pregnant she will not
have any biochemical samples collected.
4.2 Enrollment procedures and consent
On the cluster control form, the 10 households which constitute that cluster will be listed
on lines numbered 1-10 (see annex 3 for a sample of the cluster control form). In every
household visited the interviewer will complete a household data collection form with the
household head or any adult currently residing in that household. In each selected
household, all children 6-59 months of age currently residing in that household will be
eligible for participation in the survey. In three of the 10 households in each cluster
(households listed in lines 3, 6 and 9 of the cluster control form), all children 6-14 years
of age, non-pregnant women of child bearing age and men 18-50 years of age will also
be eligible to participate in the survey.
All household members who fit the criteria for the relevant target groups for each of the
selected households will be included in the survey if verbal consent is received. See
annex 4 for more information on the consent process.
Unavailable and absent eligible survey participants
At the start of the survey team's visit to selected household, household members or
others in the community will be asked, where feasible, to fetch absent household
members who are eligible for survey inclusion. When any of the eligible occupants of a
selected household are not at home, up to three recall visits may be arranged over 2
subsequent days. Selected houses which are either vacant or in which all eligible
occupants are unavailable will not be replaced.
Survey teams will record for each selected household in the survey sample the following
information, 1) whether the house was unoccupied or occupied, 2) whether at least one
member of the target group was present in the household (required target groups will
differ for every third house), 3) how many eligible subjects from each group live in the
household, 4) whether household consent was given, 5) whether consent was given for
each of the individuals selected for the survey in each household, and 6) whether data
collection was completed for each of these individuals. These data will allow calculation
of household weights, response rates and the determination of reasons for nonresponse.
17
IRAQ National Micronutrient Survey 2007
4.3 Data collection at the household
Interview procedures and salt collection
On arrival at the household the team leader will ask to speak with the head of the
household who is currently residing there. The team leader will explain the purpose of
the survey and ask for consent to conduct the survey. If the household head refuses to
participate in the survey, this information will be entered on the household checklist, and
the team will move to the next selected household in the cluster. If consent is granted
then the interviewer will proceed with the household interview. At the end of the
household interview the interviewer will collect 15 grams of salt from the household
provided that salt is available.
Once the household form is completed, consent will be sought from the primary
caretaker(s) of all children 6-59 months of age currently residing in the household.
Consenting caretakers will be interviewed in turn about each eligible child. In every third
household, consent will be sought for survey participation from the primary caretakers of
all children 6-14 years of age currently residing in the household, and consenting
caretakers will be interviewed to gather data on these children. In addition, consent will
be sought from all available non-pregnant women of child-bearing age and all available
men aged 18 -50 years, who will also be interviewed if consent is granted.
Anthropometry
After the interviews have been completed, children 6-59 months of age will be weighed
and their height or length measured by the anthropometrist. These measurements will
be recorded on the data collection forms.
Collection of biological specimens
In those households in which only children 6-59 months are eligible for survey
participation, all participating children 6-23 months will have a heel or finger stick and
have their hemoglobin tested. Blood will be collected in a microtainer which will later be
used to measure serum retinol and CRP. In addition, all children 24-59 months will have
venous blood collected that will be tested for hemoglobin in the household and
processed for later testing for serum retinol, serum ferritin, CRP and vitamin D status.
After anthropometric measurement of young children is completed in those households
in which women, older children, and adult men are eligible for survey participation,
eligible women and children 6-14 years of age will be asked to provide a urine specimen
to assess urinary iodine. The laboratory technician will provide a screw top urine cup and
specific directions regarding the urine collection process. If participants are unable to
provide a urine specimen at that time, they will be asked to drink some water, so that
they might provide a sample before the team leaves the household. If participants are
unable to provide a urine specimen before the survey team completes data collection at
that household, the team will return to the household later to pick up the specimen.
After completion of urine collection in these households, all children 6-14 years will
undergo finger stick to have their hemoglobin tested. All non-pregnant women of child
bearing age will have venous blood collected that will be used to measure hemoglobin in
the household and processed for later testing for serum retinol, serum ferritin, CRP and
folate status. All eligible men 18-50 years of age will have their hemoglobin tested.
18
IRAQ National Micronutrient Survey 2007
Procedures for blood collection
Children 6-23 months - Each eligible child will have their finger or heel pricked and their
blood will be collected in a microtainer. Once the microtainer is filled the HemoCue
cuvette will be filled with blood from the microtainer and their hemoglobin will be read
using the HemoCue machine.
Children 24-59 months – Each eligible child will have venous blood collected. Once the
needle has been withdrawn from the arm at the end of the blood draw, a drop of blood
from the needle will be used to fill the Hemocue cuvette.
Children 6-14 years – Each eligible child will have blood obtained by finger stick to test
for hemoglobin. The first two drops will be wiped away and the third drop will be drawn
into a HemoCue cuvette and tested according to recommended procedures.
Non pregnant women of child bearing age - Each eligible woman will have venous blood
collected. Their hemoglobin will tested in the same way the children’s hemoglobin will be
tested.
Men 18-50 years – Each eligible man will have finger stick blood collected and tested
according to the procedure described above for children 6-14 years of age.
The hemoglobin of all survey participants will be measured in the household. After
collection of blood in the cuvette, the cuvette will immediately be placed in the HemoCue
hemoglobinometer and the measurement will be read from the instrument and recorded
on the data collection form. All people participating in the survey will be told their
hemoglobin value. Anyone with a hemoglobin concentration below the World Health
Organization cutoffs (see section 5.3) will receive a referral to the nearest clinic.
Completion of data collection process in the household
Once the interviews, anthropometry and biological specimen collection are complete the
team will leave the house and move on to the next household on their list, where they
will complete the same procedure. Before leaving the household the team will ensure
that all waste has been put in bio-hazard bags and lancets and needles disposed of in a
sharps container. The team leader will also check the data collection forms to ensure
complete and accurate data recording.
5. Survey Instruments and outcomes
5.1 General Questionnaires
The questionnaires will be in Arabic and translated into translated into Kurdish. Field
workers administering the questionnaires will be hired from the areas where the survey
will be conducted to ensure that they are familiar with the language, culture and security
situation in the area.
Specific areas of interest to be included in the data collection form are summarized in
the table below:
Table 5 – Topics to be included in the data collection forms
Areas of interest to be included in
Target group
19
IRAQ National Micronutrient Survey 2007
data collection form
Children
6-59
months
Demographic
information
Reproductive
status
Household
members
Ages
Educational
level
Socio-economic
status
Complementary
feeding
Nutritional patterns
and practices (e.g.,
tea consumption)
Social and cultural
factors that might
affect micronutrient
status (e.g.,
restricting children’s
exposure to the sun)
Tobacco usage
Food sources
School
enrollment
Employment
Household
income
Types of
complementar
y foods, age
at initiation of
complementar
y feeding
Children
6-14
years
Nonpregnan
t women
15-49
years
Men 1850 years
Household




(of father
and
mother)


(of father
and
mother)

























5.2 Anthropometry
Height and weight measurements will be taken for all children 6-59 months of age
included in the survey. Children’s ages will be determined from a health card or other
documentation, if available. If no such documentation is available the primary caretaker
will be asked the age of the child. Finally if the caretaker is uncertain of the child's date
of birth or age, a local calendar will be used to determine age to the nearest month.
a) Length/height
For children less than 24 months old, recumbent length will be measured to the nearest
0.1 cm using a height board either manufactured by or patterned on height boards made
by Shorr Productions (Olney, Maryland, USA). The same height board will be used to
measure standing height to the nearest 0.l cm for children 24 months of age or older. All
subjects will be measured without shoes or hair accessories which add artificial height.
20
IRAQ National Micronutrient Survey 2007
b) Body weight
UNICEF Seca Uniscales will be used to measure body weight of children 6-59 months.
The weight of the children unable to stand alone will be measured by taring the scale
after the caretaker's weight is recorded and then handing the child to the caretaker.
c) Data Quality
During data cleaning, records with potentially erroneous data will be excluded from
analysis based on the following standard Z-score cutoffs developed by WHO3.
Z-score values excluded
Indicator
from analysis
Height-for-age
< -5.0 and > +3.0
Weight-for-height
< -4.0 and > +5.0
Weight-for-age
< -5.0 and > +5.0
5.3 Anemia
Anemia will be evaluated by photometric method using the HemoCue hemoglobinometer
on small blood samples collected by finger stick or venipuncture. This method has
shown satisfactory accuracy and precision in laboratory evaluations using standard
methods. A major advantage of the battery-operated HemoCue photometer is that it
readily displays hemoglobin levels with a delay of less than one minute.
Cut-offs for anemia depends on the age and sex of the person. Anemia is defined as in
the following table1:
Table 6 – Hemoglobin levels below which anemia is present
Age-sex group
Definition of anemia
Children 0-59 months of age
<11.0 g/dl
Children 6-11 years of age
<11.5 g/dl
Children 12-14
<12.0 g/dl
Non-pregnant women of child-bearing age
<12.0 g/dl
Adult Men
<13.0 g/dl
For prevalence estimates of anemia based on hemoglobin, the hemoglobin values will
need to be adjusted for altitude and tobacco usage using the WHO 2001
recommendations1. The adjustment for altitude is shown below.
Table 7 - Adjustments for hemoglobin values related to long-term altitude exposure
Increase in cut-off
Altitude (meters)
point defining anemia (g/dl)
< 1000
0
1000-1499
+0.2
1500-1999
+0.5
2000-2499
+0.8
2500-2999
+1.3
21
IRAQ National Micronutrient Survey 2007
Table 8 - Adjustments for hemoglobin values for smokers
Increase in cut-off
Tobacco usage
point defining anemia (g/dl)
Non-smoker
0
Smoker (all)
+ 0.3
½ - 1 packet per day
+ 0.3
1-2 packets per day
+ 0.5
2+ packets per day
+ 0.7
5.4 Iron status and Iron deficiency anemia
Iron deficiency will be defined using serum ferritin. Iron deficiency anemia will be defined
as depleted ferritin together with hemoglobin value below the appropriate group-specific
cut-off for anemia.
Table 9 - Relative extent of iron stores based on serum ferritin concentrations1
Iron stores
Serum Ferritin
(g/l)
Less than 5 years of age
More than 5 years of age
Male
Female
Male
Female
Depleted iron stores
<12
<12
<15
<15
Depleted iron stores in the
<30
<30
-
-
presence of infection
5.5 Vitamin A status
A serum retinol concentration less than 0.70 µmol/L defines subnormal retinol levels.
Serum retinol levels of 0.35 – 0.69 mol/L (10-19 ug/dl) indicate low vitamin A status 2.
Levels less than 0.35 mol/l indicates vitamin A deficiency.2
Vitamin A levels may be affected by infection. When analyzing the retinol data, CRP
results can be used to either exclude the retinol values of individuals with a high CRP or
to make an adjustment of the serum retinol level. For the Iraq survey we will present the
retinol data without any exclusion or adjustments, with adjustments and with exclusions
of individuals with high CRPs.
5.6 Iodine status
Urinary iodine values are expressed as micrograms per liter (g/l). Levels of urinary
iodine within an individual vary from day to day and even during a given day.
Consequently, classification of iodine deficiency as a public health problem is done on
the basis of median values in population groups rather than as a prevalence rate. A
median urinary iodine value of less than 100 g/l defines iodine deficiency as a problem
in a population.
22
IRAQ National Micronutrient Survey 2007
Table 10 - Epidemiological criteria for assessing iodine nutrition based on median
urinary iodine levels in school aged children.1
Level of importance as a public health problem
Excessive iodine (risk of adverse health consequences)
More than adequate (risk of iodine-induced hyperthyroidism within 510 years after introduction of iodized salt in susceptible groups)
Adequate (optimal)
Insufficient (Mild iodine deficiency)
Insufficient (Moderate iodine deficiency)
Insufficient (Severe iodine deficiency)
Median value (g/l)
> 300
200-299
100 – 199
50 – 99
20 – 49
< 20
6. Specimen Processing
6.1 Hemoglobin cuvettes
Hemoglobin will be assessed in the household using the HemoCue photometer. Quality
control of the HemoCue instrument will be ensured by using both liquid controls and the
control cuvette at the beginning and end of each day to ensure the quality of HemoCue
readings. Log sheets of all the quality control measurements will be kept.
6.2 Venous and capillary blood
At each household, venous blood will be collected in vacutainers and capillary blood will
be collected in microtainers and placed in a cool box containing ice packs. The samples
must be transported to some central location within 8-10 hours so that they can be
centrifuged. Once the whole blood has been centrifuged and the serum separated,
aliquoted, and frozen, the serum specimens will be shipped to the laboratories in Irbid,
Jordan where they will be analyzed.
6.3 Urine
Urine samples will be collected in screw top urine collection cups. Each evening, survey
team members will transfer at least 1.5 ml urine sample to each of the 2 pre-labeled
cryovials using disposable pipettes. Do not overfill the cryovials (no more than 1.8 ml)
and seal by screwing the caps on tightly. The pipette and urine collection cups will be
discarded in the biohazard bag. Once the urine specimens in cryovials have been sent
to the regional central point they will be frozen before being sent to Bagdad for analysis.
6.4 Salt
Fifteen grams of salt will be collected from the house. The household salt should be well
mixed prior to collecting the sample. The salt should be put in a pre-labeled plastic bag.
7. Laboratory Procedures
1
The values in the table are for school aged children. A forthcoming WHO consultation
will hopefully give more guidance as to how to interpret values in women.
23
IRAQ National Micronutrient Survey 2007
7.1 Serum ferritin, retinol, vitamin D, folate and CRP
Serum ferritin, retinol, vitamin D, folate and CRP will be analyzed by the staff at Jordan
University of Science and Technology in Irbid, Jordan. Laboratory technicians from Iraq
will go to Irbid to assist with the analysis of the samples. Standard methods will be used.
Ferritin, folate, and CRP are tested by commercial enzyme immunoassay kits. Retinol
will be measured using high performance liquid chromatography (HPLC). Vitamin D will
be tested using radio immunoassay. Prior to laboratory testing, the laboratory will enroll
and pass the quality assurance program VITAL/EQA for these analytes.
7.2 Urinary iodine
Urine samples will be analyzed for urinary iodine at NRI using the ammonium persulfate
digestion with spectrophotometric detection of the Sandell-Kolthoff reaction. In order to
assure the quality of the method to assess urinary iodine levels the laboratory, NRI will
enroll in CDC’s quality assurance program EQUIP and in the Institute of Clinical
Pathology and Medical Research (ICPMR)’s Urinary Iodine Quality Assurance Program.
[Dr Usama is this method available in Iraq? If not then we will have to send the urine to
another lab in the region]
7.3 Salt
Samples will be collected and transported to Bagdad to NRI for salt iodine analysis using
the WYD Iodine Checker, which quantitatively measures the salt iodine content on the
basis of a colorimetric method. Adequately iodized salt at the household level must
contain >15 ppm iodine (ICCIDD, UNICEF, and WHO, 2001)4. [What do Iraqi regulations
require?]
Prior to analysis of survey salt samples, NRI will establish an internal QC program for
salt iodine testing and also participate in CDC’s EQUIP program.
8. Data entry and analysis plan
Any errors in completing questionnaires will be corrected in the field when possible. The
team leader will be responsible for checking the data collection forms before leaving the
household. Completed and checked questionnaires will be sent to a central office in
Baghdad where the data will be double entered using Access. To reduce computer data
entry error, the entry screen will be programmed to accept only codes within a
predetermined range for most variables. All data will also be double entered and verified
at the central location.
Once the data is entered and the data sets are clean, the analysis of the data will be
done by the survey manager and COSIT staff. CDC staff will be available if assistance in
data analysis is needed. Results of the biochemical indicators will be added to the data
set once the results have been provided from the various laboratories.
Please see annex 4 for a description of the provisions for protecting the privacy and
confidentiality of participants.
9. Dissemination of study results
24
IRAQ National Micronutrient Survey 2007
Dissemination of study results will take place in three ways:
1) Detailed study report: for professionals working in the field of nutrition and health at
the academic and policy levels. This report will include all the details of the study,
including background, methodology, results and interpretation of the results. This
report will be needed for a better understanding of the prevalence and causes of
micronutrient deficiencies in Iraq and will be used for the development of adequate
national policies and programs.
2) Easy to read summaries: for people interested in nutrition and health at
international, national and governorate level. These summaries will mainly focus on
the results and interpretation of the results and will be available as national and
regional analyses. The summaries will provide a better understanding of the causes
and consequences of micronutrient deficiencies in Iraq. To increase readability, this
document will convey the results of the IRAQNMS using mainly graphs and other
visuals with minimal text
3) High level advocacy meeting: for major policy makers. The objectives of this
meeting are to disseminate the results and to create awareness on micronutrient
deficiencies, its causes and required programmatic responses among those that are
responsible for planning programs. Examples of such persons include high-ranking
government officials, management personnel of companies producing fortifiable
foods, and representatives of major donor organizations and countries. This one day
meeting should be followed by an inter-sectoral program planning meeting to work
out the recommendations made at the advocacy meeting and plan the programmatic
follow up (supplementation, fortification, dietary diversification and health
interventions).
10. Time frame
A detailed breakdown of the survey timeline can be found in annex 5.
11. Budget
The overall budget will need to be determined by MoH, NRI, COSIT and UNICEF.
Based on the indicators selected the CDC have estimated that laboratory supplies will
cost approximately $39,032. This does not include the costs of laboratory reagents. See
attached equipment and supplies spreadsheet.
See annex 6 for an estimate of laboratory costs for the analysis of blood specimens.
25
IRAQ National Micronutrient Survey 2007
References
1) Iron Deficiency Anemia: Assessment, prevention and Control: A guide for program
managers – WHO, 2001.
2) WHO. Indicators for assessing vitamin A deficiency and their application in
monitoring and evaluating intervention programmes. 1996
3) WHO Anthro 2005 for personal computers manual, WHO, 2006.
4) Assessment of iodine deficiency disorders and monitoring their elimination, ICCDD,
WHO, UNICEF 2001.
26
Annex 1: Sample Size
SAMPLE SIZE CALCULATIONS FOR A SINGLE SURVEY WITH MULTIPLE OUTCOMES
NUMBER OF STRATA OR DOMAINS:
4
[Enter 1 if no stratification]
To calculate sample size of individuals
To calculate sample size of households
(fill in values in blue columns)
(fill in values in blue columns)
Design
Average
effect
StratumTotal
Sample
size
number
of
Target
Sample size
(If NOT
Estimated specific
Individuals individuals Individual
of
individuals
Average
group as Household
of
cluster
prevprecision sampling,
in each
(ALL
nonindividuals
per
household
% of
nonhouseholds
enter 1)
alence
(± X%)
stratum
strata)
response (ALL strata) household
size
popul.
response (ALL strata)
Target
group
Indicator
Household
Iodized salt
Other
50%
10%
3.0
Anemia
Vit A def
Wasting
Stunting
Underweight
Other
50%
10%
9%
26%
16%
10.0%
4%
5.5%
6.0%
5.0%
2.3
1.5
1.8
1.2
1.3
50%
10%
10.0%
5.0%
2.3
1.5
Anemia
Iron def
Iodine def
Folate def
Other
Other
50%
70%
50%
50%
10%
10%
10%
10%
1.6
1.6
1.5
1.5
Anemia
Other
20%
10%
1.5
50%
50%
10%
10%
Complete column J OR columns L and M for children:
Children
6-59
months
(fingerstick)
Children
24-59 m Iron def
(venous) Vit D def
221
324
184
250
273
884
1,297
736
1,002
1,090
10%
10%
10%
10%
10%
884
830
10%
10%
Men
18-50
years
155
130
144
144
618
520
576
576
10%
10%
10%
10%
Children
Anemia
6-14 yrs
Iodine def
369
25%
192
144
768
576
25%
25%
or
6.5
or
6.5
1,024
768
or
6.5
10%
10%
10%
10%
10%
1,364
2,002
1,137
1,547
1,684
10%
10%
2,022
1,899
10%
10%
10%
10%
494
415
460
460
10%
359
10%
10%
752
564
8.3%
23.8%
23.4%
492
Complete column J OR columns L and M for this target group:
2.0
1.5
6.5
687
577
640
640
Complete column J OR columns L and M for men:
92
or
1,281
12.3%
982
922
Complete column J OR columns L and M for non-pregnant women:
Nonpregnant
women
15-49
years
6.5
982
1,441
818
1,113
1,212
Complete column J OR columns L and M for children:
221
207
or
10%
23.3%
IRAQ National Micronutrient Survey 2007
Annex 2 – Differences that can be detected between a baseline and follow up survey using assumptions made in annex 1
SAMPLE SIZE CALCULATIONS TO COMPARE 2 EQUAL-SIZED SURVEYS WITH MULTIPLE OUTCOMES
NUMBER OF STRATA OR DOMAINS:
Target
group
Indicator
Household
Iodized salt
Other
1
NOTE: Sample sizes indicated are FOR EACH SURVEY
To calculate sample size of individuals
To calculate sample size of households
(fill in values in blue columns)
(fill in values in blue columns)
Design
Average
effect
Total
Sample size number of
Target
Sample size
(If NOT
Estimated Estimated
Individuals individuals Individual
of
individuals
Average group as Household
of
cluster
prev-alence prev-alence Diffin each
(ALL
nonindividuals
per
house% of
nonhouseholds
sampling,
enter 1)
Survey 1
Survey 2
erence
stratum
strata)
response (ALL strata) household
hold size popul.
response (ALL strata)
50%
60%
10.0%
3.0
Anemia
Iron def
Vit A def
Children
Wasting
6-59
Stunting
months
Underweight
Vitamin D
Other
50%
70%
10%
9%
26%
16%
10%
42.0%
62.0%
6.0%
5.0%
21.0%
12.0%
6.5%
8.0%
8.0%
4.0%
4.0%
5.0%
4.0%
3.5%
2.3
2.3
1.5
1.8
1.2
1.3
1.5
Anemia
Iron def
NonVit A def
pregnant
BMI <17
women
BMI >25
15-49
Iodine def
years
Folate def
Other
Other
50%
70%
50%
50%
Men
Anemia
18+ years
Other
Other
target Other
group Other
[Enter 1 if no stratification]
50%
50%
Complete column J OR columns L and M for children:
1,399
1,399
10%
1,554
1,264
1,264
10%
1,404
1,082
1,082
10%
1,202
1,148
1,148
10%
1,275
1,354
1,354
10%
1,504
1,535
1,535
10%
1,705
1,454
1,454
10%
1,615
or
Complete column J OR columns L and M for non-pregnant women:
1,194
1,194
7.0%
1.5
10%
1,327
1,069
1,069
7.0%
1.5
10%
1,188
or
43%
63%
40%
40%
10.0%
10.0%
42%
42%
1.5
1.5
581
581
581
581
10%
10%
6.5
or
Complete column J OR columns L and M for this target group:
2.3
25%
1.5
25%
or
6.5
1,162
10%
10%
10%
10%
10%
10%
10%
2,160
1,951
1,670
1,773
2,090
2,370
2,245
10%
10%
1,844
1,651
10%
10%
897
897
12.3%
20.0%
646
646
Complete column J OR columns L and M for men:
8.0%
8.0%
6.5
10%
23.3%
10%
10%
28
IRAQ National Micronutrient Survey 2007
Annex 3: Example of a cluster control form
CLUSTER CONTROL FORM
REGION: _______________________
Governorate:
__________________
Cluster number: ______________________
Children
6-59
months
HH
No:
Name of Head of HH
1
Children 6-59 months only
√
2
Children 6-59 months only
√
3
All
√
4
Children 6-59 months only
√
5
Children 6-59 months only
√
6
All
√
7
Children 6-59 months only
√
8
Children 6-59 months only
√
9
All
√
10
Children 6-59 months only
√
Nonpregnan
t women
15-49
years
Men 1850 years
√
√
√
√
√
√
√
√
√
Children
6-14
years
Date and
time of
visit 1
Date
and
time of
visit 2
Date
and
time of
visit 3
Complete
TEAM NUMBER:
29
IRAQ National Micronutrient Survey 2007
Annex 4: Supplemental information for protection of human research participants
Description of risks (physical, social, psychological) to the individual
The only physical risk of participation in nutrition assessment surveys includes only those of finger stick
and phlebotomy. Both procedures involve some discomfort but there are only very rarely any adverse
risks associated. Only qualified survey team members are allowed to perform these procedures, and
these personnel monitor survey participants for some minutes after the procedure to ensure that there is
no bleeding, serious bruising, or vasovagal syncope.
Social and psychological risks are minimal. No sensitive questions will be asked during interviews.
Although in many communities, privacy is difficult to achieve during data collection, all possible efforts will
be made to keep participants responses and findings as private as possible. No survey data will ever be
connected to identifying information in a report, manuscript, or verbal debriefing.
Anticipated benefits of participating in the survey
As mentioned above, participants will learn the results of the hemoglobin and may benefit from referral.
In addition, indirect benefits to survey participants include the benefits accrued to the entire population as
a result of the interventions based on the survey findings.
Description of the potential risks to anticipated benefit ratio
The risk of participation includes only the minimal risk of finger stick and phlebotomy for a sub sample of
the survey participants. The benefit includes the implementation of critical food and nutrition programs in
population with potentially serious nutritional deficiencies.
Justification for involving vulnerable participant populations
Protein-energy malnutrition and most micronutrient deficiencies occur in vulnerable populations, such as
young children and women of child-bearing age. As a result, assessment of these problems must be
directed to these vulnerable populations to achieve the maximum likelihood of detecting these conditions
if they are present in the population.
Procedures for implementing and documenting informed consent
Prior to enrollment, verbal consent will be obtained from all adults and from parents or caretakers of
children selected for participation in the survey. The explanation of the survey will include the purpose of
the survey, the types of questions which will be asked, the procedure for weighing and measuring
children 6-59 months of age and women of child-bearing age and a description of the type and quantity of
biologic specimens to be obtained as well as the procedures necessary for specimen collection. The
granting of verbal consent will be indicated on the data collection form. Written consent is not practical in
most circumstances due to high rates of illiteracy, the risks to survey participants are very small, and the
time necessary for extensive explanation of all facets of the survey is not available.
Survey team members will advise survey coordinators regarding the culturally most appropriate way to
explain the survey and obtain verbal consent.
30
IRAQ National Micronutrient Survey 2007
Procedures for implementing and documenting the assent process of children
Because the children included in most nutrition assessment surveys are less than 5 years of age, assent
is not required. Consent will be obtained from the mothers or guardians of all children in the survey.
Provisions for protecting privacy/confidentiality
The paper data collection forms completed in the field will not contain identifying information. As a result,
the computer dataset resulting from data entry of these forms will also not contain any identifying
information. Data collection forms and laboratory specimens are matched by recording on both forms
and specimens a numeric code number which is specific for each household and individual participant.
In this survey a sample list, which lists all the households or individuals selected for that cluster (cluster
control form) will be created when the final selection of households or individuals is made during the
sampling process. These cluster control forms will contain both identifying information and the numeric
code described above, and thus can serve as a key to match the code numbers to specific individual
participants. At the end of the survey, these sample lists will be destroyed or permanently stored
separately from the paper data collection forms. Only authorized survey coordinators will have access to
the sample lists and data collection forms.
31
IRAQ National Micronutrient Survey 2007
Annex 5: Iraq survey timeline
Task
Jul
06
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
07
Aug Sep Oct Nov Dec
Calculate final sample size (2000)
(CDC, COSIT, MoH/NRI)
Create list of equipment and supplies
(CDC)
Select clusters (COSIT & CDC)
Write draft protocol (CDC & MoH/NRI)
Send to NRI and COSIT CDC survey
materials (CDC)
Write list of roles and responsibilities for
partners (NRI/MoH, CDC)
Advocacy presentation to sector working
group to solicit resources for survey
(NRI/MoH)
Identify and engage survey manager
(NRI/MoH)
Create steering committee (MoH)
Steering committee monthly meetings,
minutes to be shared with all
stakeholders
Identify potential laboratories for testing
specimens (CDC & NRI/MoH)
Data collection form development
Prepare final budget and submit to
donors (NRI/MoH)
Identify regional coordinators and
governorate focal points
Identify CDC & Iraqi lab persons to
travel to laboratory(ies) (CDC,
NRI/MoH)
Finalize protocol (CDC, NRI/MoH)
32
IRAQ National Micronutrient Survey 2007
Task
Jul
06
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
07
Aug Sep Oct Nov Dec
Submit protocol to IMR for ethical
clearance (CDC, NRI/MoH)
Order supplies and equipment (UNICEF
or NRI)
Assess laboratory capacity in Iraq
(NRI/MoH, CDC)
Establish quality assurance for Iraq
laboratory (CDC, NRI/MoH)
Funds to be assured (UNICEF, WHO,
WFP, NRI/MoH)
Identify trainer of trainers
Identify potential field workers and
schedule them for the training
Finalize data collection instrument
Translate and back translate data
collection forms
Plan training curriculum
Create survey manual and training
materials
Prepare data entry computer program
Train data entry personnel
Ensure arrival of correct type and
quantity of supplies and equipment
Training - Training of trainers (in
Amman)
Training of field staff (in Iraq)
Conduct field work
33
IRAQ National Micronutrient Survey 2007
Task list
Jan Feb Mar Apr May Jun Jul
200
8
Aug
Enter data into computer
Clean data
Analyze laboratory specimens
Analyze data
Write draft report
Dissemination of results
34
IRAQ National Micronutrient Survey 2007
Annex 6: Cost of laboratory analysis of specimens, based on using Dr Khatib’s
laboratory
Hemoglobin
Ferritin
CRP
Retinol
Vitamin D
Number of tests
3693
1850
1850
1569
1011
Cost/test (US$)
1.00
4.50
5.00
10.00
6.00
Serum folate
839
5.00
Total cost of
lab testing
3,693.00
8,325.85
9,250.95
15,689.70
6,065.28
4,196.55
$
47,221
35