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BIOMARKER MANUAL:
Training Program for Measuring
and Testing for Biomarkers
[DOCUMENT SUBTITLE |
The DHS Program is a five-year project to assist institutions in collecting and analyzing
necessary data to plan, monitor, and evaluate population, health, and nutrition programs.
The DHS Program is funded by the U.S. Agency for International Development (USAID).
The project is implemented by ICF in Rockville, Maryland USA, in partnership with the
Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs,
PATH (formerly, the Program for Appropriate Technology in Health), Avenir Health,
Vysnova Partners, Blue Raster, and EnCompass.
The main objectives of The DHS Program are to: 1) provide improved information through
appropriate data collection, analysis, and evaluation; 2) improve coordination and
partnerships in data collection at the international and country levels; 3) increase host-
country institutionalization of data collection capacity; 4) improve data collection and
analysis tools and methodologies; and 5) improve the dissemination and utilization of
data.
Information about The DHS Program may be obtained from ICF, 530 Gaither Road, Suite
500, Rockville, MD 20850, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; E-
mail: [email protected]; Internet: http://www.dhsprogram.com.
Contents
Chapter 1. INTRODUCTION AND OVERVIEW. ........c:cccseeceeeseeeeeeeeeeeeeseeeeeeeeeseeneeneeeeneenes 1
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1.D. Overview of biomarker measurement... 2
1.E. Overview of the biomarkers in the DHS & the biomarker technician’s role...3
LUF: “SOCAN MASCOT ONC Y sc cise sn ot 4
Chapter 2. general procedures for completing the paper BIOMARKER questionnaire
6
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2.B. Identifying respondents eligible for Biomarker Questionnaire....................... 6
2.C. Documenting [fieldworker] visits on the cover page... 9
2.D. Asking Questions and Reading Informed Consent Statements...................… 10
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2.F. Marking Filters and Following Skip Patterns... 13
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Chapter 3) ANENrOPONTIE ETES RMS eines 16
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3.B. Materials and equipment for anthropometry.............................................. 17
3.C. Procedures and precautions before measuring height and weight.............. 18
D: Deétérmining eléibiIne Essen disant 20
2E: Preparing 10: Take WÉIQMEÉ:.:S....:2 rss esnere sn desien nee n sense annees 21
3.F. Weighing Adults and Children Who Can Stand on the Scale by Themselves
23
3.G. Weighing Infants or Children Who Must be Held by an Adult While on the
Scale 25
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3.1. Preparing to measure height/length....................................................... 28
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3.K. Measuring à Child’s length: lenennintennne 34
Sale Méssünna-an aduitS AE Essen dd ie ns 37
3.M. Dismantling the measuring board... 39
3.N. Quality assurance for anthropometry......................................... eaeenees 40
3.0. Standardization of height and length measurements... 43
Chapter 4. CAPILLARY BLOOD COLLECTION............ccccccceccsseceeeeseeeeeeseeeeeeeaeeaeeeeaeeneas 45
AAs INtrOdUCEIDN sas de Te A dads vetoes vate leek eevee beset iat 45
4.B. Materials and supplies for performing finger or heel pricks......................….. 45
As TOW EO: BUT ON -GIOMOES 4c EE one Seconda nn AS Et el tr dus 48
4.D. Steps in obtaining capillary blood from the finger....................................... 48
4.E. Obtaining capillary blood from a child’s heel............................................. 55
4.F. Precautions to observe when collecting blood samples............................….. 57
4.G. Good blood collection practices... 58
Chapter 5. HEMOGLOBIN MEASUREMENT (ANEMIA SCREENING)................ 60
BRS. WVER OCU CEO 52 ste RER ads ets eee ial a eee wa SS yeas rae ak ne a tte 60
5:B. OVERVIEW: OF CIN see es nn aed ae RAR 60
5.C. Materials and supplies for Hb measurement. 61
5.D. Handling and storage of the HemoCue Hb 201+ analyzer.......................…. 62
5.E. Determine eligibility and obtain informed consent for Hb measurement....63
5.F. Steps in performing the Hb measurement... 65
5.G. Precautions to take during Hb measurement... 69
5.H. Cleaning the HemoCue Hb analyzer.................................. ss 70
5.1. HemoCue analyzer error codes... 72
Chapter 6. Biohazardous Waste Disposal.............................................................. 74
GA TMVEROGUCEON pag eoccrraees cs Ce ne Mee ete th sation: 74
6.B. Collecting and storing waste during trainings and fieldwork....................... 74
6.C. Procedures for disposal of biohazardous waste... 76
6.D. Methods of destroying/decontaminating biohazardous waste... 11
Chapter i AP DONO ses scene qe Mer Rare teen Re te MR 78
7A: Informational pamphlet: sn nee ec Westen tees deans ieee 78
7.B. Severe acute malnutrition referral...................................... ss 79
7.C:. Fieldwork: Malntenance 100: multi tenter entente 80
7B: ‘SEAMGSrOIZAtlOM: TORM 2s, AU A QUE ER RS nt Mn nn ia alg ace 81
7.E. Severe anemia referral................................. sisi 82
Chapter 1.INTRODUCTION AND OVERVIEW
1.A. About this manual
This manual is used as part of the Training Program for Measuring and Testing for
Biomarkers, and provides the core content needed to acquire the following skills
during the training:
How to identify eligible respondents in households for biomarker measurement
How to obtain informed consent from adults, minors and parents/responsible adults
for children
How to complete the Biomarker Questionnaire
How to perform capillary blood collection on adults and children
How to select the appropriate equipment; collect samples; conduct tests and
record, report, and document results for the following, as needed:
Hemoglobin testing for anemia
Height and weight measurements for anthropometry
Demonstrate appropriate universal safety precautions
Demonstrate appropriate disposal of biohazardous waste
1.B. About this training program
Biomarker measurements can serve as diagnostic tools to identify diseases or
conditions in their early stages and can be used as surveillance tools to track
changes in disease patterns or to evaluate intervention programs. In population-
based surveys, biomarkers help assess the prevalence or occurrence of diseases or
conditions in a population; they can also be used at a macro level to measure the
long-term effect of policies and programs. In The Demographic and Health Surveys
(DHS) Program, biomarkers are measured to estimate the prevalence of specific
diseases and health conditions at the population level.
This training program is designed to equip biomarker technicians with skills and
techniques to efficiently and effectively measure and test biomarkers in field
conditions, and accurately record and report the results as part of the survey
process. In addition, this training program will equip biomarker technicians to
collect, process, and package biological specimens for transport to a laboratory for
testing.
1.C. Training program structure
In combination with classroom instruction and practical experience, this manual will
be used to teach you how to collect blood samples and conduct basic tests to
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measure biomarkers for the [YEAR] [COUNTRY] Demographic and Health Survey
(DHS). Before each training session, you should study this manual and the
Biomarker Questionnaire carefully. You are encouraged to ask questions during
training and to discuss problems encountered to avoid making mistakes during
fieldwork. Training consists of the following phases:
Phase |. The chapters of this manual are reviewed in a classroom setting where you
learn how to identify eligible respondents; record biomarker measurements
or test results in the Biomarker Questionnaire or on appropriate field forms;
and handle technical procedures involved in blood collection, testing, and
other related instructions. You will observe the trainers demonstrating the
skills. Then, you will have the opportunity to practice the procedures, with
other trainees, which will include finger pricks for blood collection.
Phase II. You will either 1) visit a health facility and practice measuring biomarkers
from respondents after consent was granted or 2) practice the blood
collection procedures on participants (i.e., mother-child pairs) at the training
venue.
Phase Ill. You will be assigned to a survey trainee team in the field where you will
measure biomarkers from eligible respondents exactly as you would during
the survey. Households that are visited will be in clusters that are not part of
the survey sample.
At the end of the training, your overall performance will be assessed, and the top
performers will be selected to work in the survey.
Your training does not end at the start of fieldwork. Rather, it is a continuous
process. Your team supervisor and the [COUNTRY] DHS coordinators will play
important roles in continuing your training and in ensuring the quality of data you
collect throughout the survey. They will:
e Observe your fieldwork activities periodically to ensure that you are
conducting yourself professionally, obtaining informed consent from
respondents, and following the sample collection and biomarker
measurement protocol correctly
Spot check that you visited the correct households and collected blood samples and
measured biomarkers only from eligible respondents; and
Meet with you regularly to discuss your performance and assign future work
assignments
Note: A biomarker technician who is not performing at the level necessary to
produce the high-quality data required for a successful [COUNTRY] DHS may be
released from service.
1.D. Overview of biomarker measurement
A biomarker may be thought of as a characteristic that can be independently
measured and evaluated as an indicator of normal biologic processes, pathogenic
processes, or pharmacologic response to a therapeutic intervention’. Biomarker
measurements can serve as diagnostic tools to identify diseases in their early
stages and can be used as Surveillance tools to track changes in disease patterns or
to evaluate intervention programs. In population-based surveys, biomarkers help
assess the prevalence or occurrence of diseases or conditions and can also be used
at a macro level to measure the long-term effect of policies and programs.
Biomarker measurements can serve to:
m Assess the prevalence of a health condition among adults and children at
the population level
m Develop and evaluate health-intervention programs to prevent or reduce a
health condition/disease (e.g., iron-deficiency anemia) among adults and
children
m Develop diagnostic tools to identify diseases in their early stages
@ Track changes in disease patterns within the population
Purpose of each biomarker measured in the DHS
Biomarker Purpose
Height and weight Monitor growth in women and children; calculate
the body mass index (BMI) of adults and BMI-for-age
of adolescents
Hemoglobin (anemia) Measure iron status (Acts as a crude marker)
The [YEAR] XDHS is the [NUMBER] DHS survey conducted in [COUNTRY] following
[INSERT PREVIOUS DEMOGRAPHIC AND HEALTH SURVEYS AND YEAR]. The [YEAR]
XDHS will include anemia and anthropometry. Results from this survey will produce
country specific nutritional indicators, and population-based estimates of anemia in
women age 15-49, men age 15-[59], and children age 6-59 months.
1.E. Overview of the biomarkers in the DHS & the biomarker
technician’s role
Anthropometry measurements
In XDHS, the biomarker technician will measure the height and weight of eligible
women, men, and children. The biomarker technician will measure women age 15-
1 Biomarker Definitions Working Group, National Institutes of Health, 2001
49 and men age 15-[59]. The biomarker technician will measure children 0 - 59
months. Children younger than 24 months will be measured lying down on the
measuring board, while biomarker technicians will measure standing height for
older children. They will obtain weight measurements using lightweight, digital
scales.
For children, data are used to calculate three indices that reflect nutritional status:
height-for-age, weight-for-height, and weight-for-age. In presenting the
anthropometric results, the height and weight of children in the survey population
are compared with the 2006 WHO Child Growth Standards that are based on an
international sample of ethnically, culturally, and genetically diverse, healthy
children living under optimum conditions conducive to achieving a child’s full
genetic growth potential.
Children who are severely malnourished will be referred to a local health facility for
assessment and treatment. The biomarker technician will provide all households an
informational pamphlet containing the height and weight of all eligible children and
adults.
Hemoglobin (anemia)
In the XDHS, the biomarker technician will measure hemoglobin (anemia screening)
in eligible women (age 15-49 years), [men (age 15-[59] years] and children (age 6-
59 months). Anemia is a reduction in the normal number of red blood cells or a
decrease in the concentration of hemoglobin (Hb) in the blood, which results in a
decrease in oxygen reaching organs and tissues. Symptoms of anemia include
pallor, fatigue and weakness, shortness of breath, and heart problems.
The biomarker technician will use the HemoCue® 201+ photometer to measure the
Hb concentration from a drop of blood obtained from a finger or heel prick. The
measurement is rapid, allowing results to be reported to the respondent
immediately following the testing procedure.
Individuals who have an Hb level below a defined cut-off will be classified as anemic
and, in cases of severe anemia, referred to a local health facility for assessment and
treatment. The biomarker technician will provide all households an informational
pamphlet containing the Hb measurements of all eligible children and adults.
1.F. Social media policy
The use of social media and other digital media is now common and continues to
grow in popularity. Platforms and applications including blogs, social networking
sites (such as Twitter or Facebook), video streaming sites (such as YouTube), and
digital messaging applications (WhatsApp), have made it easy for anyone to reach a
wide audience very quickly. Public and private companies and their staff also use
these platforms and sites to share work experiences, images, or videos taken in the
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workplace, or to seek professional advice from colleagues or friends. However, in
the XDHS, the use of social media may break the promise we make to our
respondents to maintain their privacy and keep all information confidential. The
XDHS has also made a promise to the ICF Institutional Review Board and the
[COUNTRY] Institutional Review Board to maintain anonymity of all survey
respondents.
To fulfil our promise to all survey respondents to maintain strict confidentiality, all
fieldworkers are obligated to follow these rules:
| Social media rules for maintaining confidentiality of survey respondents |
1. | Survey staff have an ethical obligation to always maintain respondent privacy
and confidentiality.
2. Limiting access to social media postings by using privacy settings is not
enough to ensure privacy or maintain the confidentiality of respondents.
3. Do not transmit any respondent-related image or video that includes the
respondent, respondent household members, or their homes, through any
social media platform.
4. Do not identify respondents, enumeration areas, or clusters by name through
any social media platform. Do not post any information that may lead to the
identification of a respondent or an enumeration area.
5. Do not take any photos or videos of respondents or their homes - not even if
the respondent gives permission - on personal mobile devices - including
mobile phones, tablets, and cameras.
6. Turn off or disable geolocation or geotagging permissions in social media
applications on personal mobile devices while conducting fieldwork.
7. Consult with a supervisor before making any work-related postings.
8. Promptly report any violations of privacy or confidentiality.
What is geolocation and geotagging?
Geolocation or geotagging refers to identifying an object (for example a photo) by
its location. Many social media platforms, including Twitter and Facebook, now
include geolocation or geotagging, so users can add location information to their
messages. The location information can be a broad location such as a city or village,
or a precise location with the exact latitude and longitude of the location from which
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a message was sent. A fieldworker who posts a geolocated or geotagged social
media message from the field violates confidentiality by disclosing the location of
the cluster.
Geolocation or geotagging in social media applications may also have security
implications. In security-risk countries, where fieldwork must undergo stringent
protocols to protect field teams, it is imperative that survey-related staff disable
geolocation from their personal devices to not give away secure locations.
Common Misunderstandings of Social Media
Misuse of social media is often unintentional and the result of misunderstandings of
how social media platforms function. Many factors may contribute to survey-related
staff inadvertently violating survey respondent privacy and confidentiality while
using social media.
Test your knowledge:
TRUE or FALSE?
Q 1. A communication or post is private and can only be seen by the intended
recipient. True or False?
FALSE. Why? Once you send or post something, it can be sent by someone else to
others, without you knowing.
Q 2. You can always delete posted content and make it “go away”. True or False?
FALSE. Why? What happens on the Internet, stays on the Internet.
Chapter 2.GENERAL PROCEDURES FOR COMPLETING THE
PAPER BIOMARKER QUESTIONNAIRE
Learning objective
e Confirm the eligibility of respondents for biomarker collection
e Understand the elements of informed consent
e Know the structure and content of the Biomarker Questionnaire
e This part of the training manual is designed to familiarize you with the
[COUNTRY] DHS paper questionnaire that you will use for field data collection
2.A. Introduction
This chapter describes the [subsample of households selected for biomarker
collection,] requirements for eligibility and informed consent. To collect the
information needed by the [COUNTRY] DHS, you must understand how to ask each
question, what information the question is attempting to collect, and how to handle
problems that might arise during the interview. You must also know how to
correctly record the answers the respondent gives and how to follow special
instructions in the questionnaire.
2.B. Identifying respondents eligible for Biomarker Questionnaire
Eligible respondents
[Not all households are eligible for biomarker measurement and testing.] There are
[NUMBER] households per cluster, [half of which were selected for biomarker
collection.] This means you as a biomarker technician will visit [NUMBER]
households per cluster for biomarker collection. ]
The hierarchy below summarizes which households are eligible for biomarker
collection.
All Households (HHs)
n = [number] HHs
sx ÿ 50% Q
HHs Selected for Male Interview HHs Not Selected for Male Interview
n = [number] HHs n = [number] HHs
Anthropometry: Women 15-49 yrs
Anthropometry: Children 0-4 yrs
Malaria: Children 6-59 months
Anemia: Children 6-59 months
HIV RDT: Women 15-49 & Men 15-54 yrs
HIV DBS: Women 15-49 & Men 15-54 yrs
Adjust the image and all related content to reflect the survey. Once
completed, copy and past into the Introduction and Overview Chapter.
Not everyone in a household is eligible for biomarker measurement. Within
selected households, those eligible for biomarker measurement and testing are:
women age 15-49 years, men age 15-[59] years and children 0 - 59 months who
are usual household residents or visitors who have stayed in the house the night
before the household interview took place.
ble for biomarker Hb measurement (anemia
measuremerWeight Height/ length testing)
children age 0-5 months X X
children age 6-59 months
15-49 years
en age 15-[59] years
X X
X X
X X
Obtaining Eligibility from Computer Assisted Personal Interviewing (CAPI)
The Household Questionnaire, Woman’s Questionnaire, and Man’s Questionnaire
use computer assisted personal interviewing (CAPI) for face-to-face interviews.
However, the Biomarker Questionnaire is still completed on paper. This means that
the interviewer will need to transfer the list of eligible children and adults from the
report generated by the CAPI system using information collected in the Household
Questionnaire to the Biomarker Questionnaire. Only then will the biomarker
technician be able to start the process of identifying eligible respondents, obtaining
informed consent, collecting a blood sample and testing for biomarkers.
On the cover page of the Biomarker Questionnaire, the interviewer will record all
the information required to identify the household. When you receive a Biomarker
Questionnaire, the interviewer should have already recorded the following into the
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identification box:
e Place Name
e Name of Household Head
e Cluster Number
e Household Number
e [COUNTRY-SPECIFIC QUESTION ON BIOMARKER SUBSAMPLING]
You will notice that for both the Cluster Number and Household Number four boxes
are provided. When a number has fewer digits than the number of boxes provided,
the leading zeros should be filled in. For example, if the cluster number is 1 and
household number 3, this information should be recorded on the cover page (by the
interviewer) as cluster number 0001 and household number 0003. The interviewer
will indicate if the household is selected for [country-specific questions on
biomarker subsampling] by writing ‘1’ in the box provided.
IDENTIFICATION (1)
PLACE NAME Terrytown
NAME OF HOUSEHOLD HEAD Patrick Henry
CLUSTER NUMBER
HOUSEHOLD NUMBER
[COUNTRY-SPECIFIC QUESTION ON BIOMARKER SUBSAMPLING]
Using the CAPI function to list those eligible for individual interviews and
biomarkers, the interviewer will record the number of respondents in the household
potentially eligible for biomarker collection. An example of a list is shown below:
CLUSTER: 0001 HOUSEHOLD: 00063
Name of household head: GENEVIEVE DUPUIS
Women Eligible for Individual Interview
Line Sex Age Name
01 2 31 GENEVIEVE DUPUIS
@3 2 28 SHONDA GAYLORD
Children Eligible for Biomarker Collection
Line Sex Age Name
@2 2 02 JULIA FLEURET
@4 1 O04 = MATT TURBYFILL
Check the cover page of the Biomarker Questionnaire to identify the number of
women, men and children who are potentially eligible for biomarker collection. This
information can be found under “Fieldworkers Visit.”
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FIELDWORKER VISITS
FINAL VISIT
DATE
FIELDWORKER'S
NAI
NEXT VISIT: DATE TOTAL NUMBER
OF VISITS
TIME
TOTAL ELIGIBLE
Where to find
the number of
eligible
respondents
TOTAL ELIGIBLE
MEN
TOTAL ELIGIBLE
Lo
Lo
2.C. Documenting [fieldworker] visits on the cover page
As described above, the interviewer will provide the information on the cover page
to identify the household and the total number of eligible children and adults. It is
the responsibility of the biomarker technician to document when he/she visited the
household to collect biomarkers under the section labeled, [FIELDWORKER] VISIT.
You have at least three opportunities to visit the household to complete the
biomarker collection. On your first visit to the household, you will record the date
and write your name. If you do not complete biomarker collection for all the eligible
respondents in your first visit, it will be necessary to make a second visit. You must
arrange this second visit with the respondents or parent/responsible adult and ask
when is the best day and time for you to return. You must record this date and time
on the cover page of the biomarker questionnaire at NEXT VISIT. When you return a
second time, you must document again the date of your second visit and write your
name. When you have finished a household, on your last visit, you must enter the
date under FINAL VISIT as DAY-MONTH-YEAR and record your TOTAL NUMBER OF
VISITS. It is also acceptable for the first and second visit to occur on the same day if
the respondent or the parent/responsible adult requests it. However, if you return
to that household on the same day and the child still is not present, you are
required to make two additional visits to that household.
Example: In a household there is 1 woman, 1 man and 3 eligible children. You
arrive to the house for your first visit on 16 July 2020 and complete biomarker
testing for the woman and all 3 children. You are told by the woman to return on 17
July at 8:00 AM to speak with the male respondent. You make a second visit to the
household on 17 July at 8:00 AM and complete the biomarker testing for the male
respondent. You finished testing the man on 17 July and made 2 visits to the
household. It is important to complete the FIELDWORKER VISITS section daily. Do
not wait until you finish a household to complete this section. You will enter your
final visit only once you have completed the household. You or the interviewer can
record notes in the NOTES section that pertain to the household or respondents.
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FIELDWORKER VISITS
_ 16 July 2020 |17 July 2020 a ELA
7
FIELOWORKER'S MONTH
NAME
ver [2/0 [270]
nexr visir: pate | 17 July 2020 ere
TIME 08:00 AM OF VISITS
NOTES
TOTAL ELIGIBLE 1
WOMEN
TOTAL ELIGIBLE
MEN
TOTAL ELIGIBLE
CHILDREN
SE
The language of the questionnaire is prepopulated. You are responsible for
recording the language of the interview and native language of the respondent
using the LANGUAGE CODES on the cover page. You also must indicate if ‘YES’ a
translator was used by entering 1, or ‘NO’ a translator was not used by entering ‘2’
in the space provided.
LANGUAGE OF LANGUAGE OF 1 NATIVE LANGUAGE TRANSLATOR
QUESTIONNAIRE** INTERVIEW** OF RESPONDENT (YES = 1, NO = 2)
LANGUAGE OF **LANGUAGE CODES
QUESTIONNAIRE*™* ENG LISH 01 ENGLISH 03 LANGUAGE 3 05 LANGUAGE 5
02 LANGUAGE 2 04 LANGUAGE 4 06 LANGUAGE 6
2.D. Asking Questions and Reading Informed Consent Statements
It is very important that you ask each question and read consent statement exactly
as it is written in the questionnaire. Always speak slowly and clearly so that the
respondent will have no difficulty hearing or understanding the question or consent
statement. At times you may need to repeat the question or consent statement to
be sure the respondent understands it. In those cases, do not change the wording,
but repeat it exactly as it is written.
If, after you have repeated a question or consent statement, the respondent still
does not understand it, you may have to restate it. Be very careful when you
change the wording, however, that you do not alter the meaning of the original
question or consent statement.
Prior to biomarker measurement, one of the primary tasks is to explain the purpose
of the measurement or test to eligible respondents or, in the case of children, to the
parent or responsible adult, and to obtain their consent before collecting blood
samples or conducting biomarker measurements. In the absence of a parent, the
consent of a responsible adult who is at least 18 years of age is required. If the
parent or responsible adult does not consent to the test, the test must not be
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performed.
Process of obtaining informed consent for children:
Children (age 6- | Obtain the consent of one of the child’s parents, or, in the
59 months) absence of a parent, the consent of a responsible adult who is
at least 18 years of age. If the parent or responsible adult
does not consent to the test, do not perform the test.
To ensure that these individuals can make an “informed” decision about whether to
have their children tested, the Biomarker Questionnaire includes a consent
statement which you must read to the parent/responsible adult. These consent
statements include the following basic elements:
e A description of the objectives of the test
e Basic information on how the test will be conducted
e Assurances about the confidentiality of the results
e A specific request for permission to collect the sample and do the testing
If you have to reword the consent statement so that the respondent may
understands it, you must still include these four elements of informed consent listed
above.
You will notice that some questions contain one or more words in parentheses. As
shown below, the presence of parentheses indicates that a sentence needs to be
adapted to fit the respondent’s specific situation.
Parentheses that indicate a substitution must be made:
Example:
ASK CONSENT FOR ANEMIA TEST FROM PARENT/RESPONSIBLE ADULT:
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually
results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and
treat anemia. We ask that all children under age 5 take part in anemia testing. The anemia test requires a few drops of blood from a
finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown
away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential
and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
Notice that the word in parentheses is in all capital letters. Words in all caps are
instructions to biomarker technicians that are not meant to be read out
loud. Instead, in this example, you should substitute in the name of child for which
12
you are seeking informed consent for testing. For instance, if you are seeking
informed consent for anemia testing from a woman who has a son named Barack,
ask “Will you allow Barack to participate in the anemia test?”
2.E. Recording Responses
All biomarker technicians should use pens with blue ink to complete all paper
questionnaires. Never use a pencil to complete the survey questionnaire.
There are generally three types of questions in the [COUNTRY] DHS biomarker
questionnaire: 1) questions that have precoded responses; 2) questions that do not
have precoded responses, i.e., those that are “open-ended;” and 3) filters.
Questions with precoded responses
For some questions, we can predict the types of answers a respondent will give or
you know how the procedure in question was performed. The responses to these
questions are listed in the questionnaire. To record a respondent’s answer, you
merely circle the number (code) that corresponds to the reply. Make sure that each
circle surrounds only a single number.
Example:
WAS THE CHILD MEASURED LYING DOWN OR STANDING UP? LYING DOWN
STANDING UP
In some cases, precoded responses will include ‘OTHER.’ The OTHER code should be
selected only when the respondent’s answer is different from any of the precoded
responses listed for the question or when you have encountered an issue in the field
that does not permit you to proceed with the biomarker collection. Before using the
OTHER code, you should make sure the answer does not fit in any of the specified
categories.
Example:
WEIGHT IN KILOGRAMS.
In this case, an acceptable use of ‘OTHER’ would be receiving permission from the
parent/responsible adult to take the weight of the child, but you faced a
mechanical issue with the scale that would not allow you to take the weight,
i.e., no batteries or dead batteries.
Recording responses that are not precoded
13
The answers to some questions are not precoded but require that you write the
appropriate response in the space provided or the respondent’s results.
Example
IF CHILD IS AGE 0-1 YEARS: WHY WAS (NAME) MEASURED STANDING UP?
IF CHILD IS AGE 2-4 YEARS: WHY WAS (NAME) MEASURED LYING DOWN?
The child, age 3, has a disability that makes it impossible for him to stand on his own.
Recording numbers or dates in boxes
In some questions, you will record a number (i.e., result) or date in the boxes
provided. In such cases, you must enter information in all the boxes.
Example: For a child with an anemia result of 6.7 g/dL.
NOT PRESENT 994
REFUSED “sie 995
OTHER 996
RECORD HEMOGLOBIN LEVEL HERE AND IN THE [ANTHROPOMETRY AND ANEMIA
PAMPHLET]
125
When a response has fewer digits than the number of boxes provided, you should
fill in leading zeroes as shown above. An anemia result of 6.7 g/dL needs to be
recorded as 06.7g/dL.
Example: For a child with an anemia result of 10.4 g/dL.
RECORD HEMOGLOBIN LEVEL HERE AND IN THE [ANTHROPOMETRY AND ANEMIA
PAMPHLET}
NOT PRESENT
REFUSED ees 995
OTHER 996
994
Always record the result exactly as given.
2.F. Marking Filters and Following Skip Patterns
Marking Filters
Filters require you to look back to the answer to a previous question and then mark
an ‘X’ in the appropriate box.
Example:
CHECK 103: IS THE CHILD AGE 0-5 MONTHS OR OLDER AGE 0-5 =
IS THE CHILD OLDER? MONTHS 125
To ensure the proper flow of a paper questionnaire, you will sometimes be directed
to check a respondent’s answer to an earlier question, indicate what the response
14
was by marking a box with an ‘X’, and then follow the relevant skip instruction.
Questions of this type are called “filters”; they are used to prevent a respondent
from being asked the same question multiple times. Use caution when answering
filters. Filters involve skip patterns so ensure you are following them correctly.
Following Skip Patters
It is very important not to ask a respondent any questions that are not relevant to
his or her situation. For example, you should not read an anemia consent statement
to a parent/responsible adult of a child age 0-5 months. In cases where a particular
response makes subsequent questions irrelevant, an instruction is written in the
questionnaire directing you to skip to the next appropriate question.
Example:
CHECK 103: IS THE CHILD AGE 0-5 MONTHS OR OLDER AGE 0-5 SZ
IS THE CHILD OLDER? MONTHS © 125
Always follow the skip patterns!
Unless a skip pattern is present, always move directly to the next question.
2.G. Correcting Mistakes
When working with a paper questionnaire, it is very important that you record all
answers neatly. For precoded responses, be sure that you circle the code for the
correct response carefully. When recording responses that are not precoded, the
reply should be written legibly so that it can be easily read. If you made a mistake
in entering a respondent’s result, the respondent wishes to change his/her reply, or
you have made a mistake, be sure that you cross out the incorrect response and
enter the right answer. Just put two diagonal lines through the incorrect response.
Here is how to correct a mistake:
Example:
RECORD HEMOGLOBIN LEVEL HERE AND IN THE [ANTHROPOMETRY AND ANEMIA
PAMPHLET].
CHECK 122: HEMOGLOBIN RESULT BELOW [8.0 G/DL],
SEVERE ANEMIA
[8.0 G/DL] OR ABOVE 125
Remember that if you are not careful to cross out mistakes neatly, it may not be
15
possible to determine the correct answer when the data are entered later into the
computer.
2.H.
Key points to remember
The following steps are important to remember when completing the Biomarker
Questionnaire:
Children should be measured after the mother is interviewed. If the
mother is not present in the household, children should be measured after
the responsible adult has given consent for biomarker collection.
Measure and/or test for biomarkers one respondent at a time. All the
biomarker measurements for the [COUNTRY] DHS should be performed on
one respondent before moving on to the next eligible respondent. Complete
the measurement of all biomarkers from one respondent before proceeding
to the next. Failure to do so may lead to the results of one respondent being
recorded for another respondent.
Never alter any responses or information transferred by the
interviewer from the CAPI list of individuals eligible for the
Biomarker Questionnaire without consulting the interviewer who
completed the Household Questionnaire. Even in cases where there are
concerns about a respondent’s eligibility for testing, proceed with the
biomarker collection. Record in the notes section of the Biomarker
Questionnaire a description of the problem. Provide as many details as
possible. The field organization/central office will decide later what will be
done about the test results for the respondent in question.
Read the applicable consent statements to each adult, minor and
parent/responsible adult exactly as they appear in the Biomarker
Questionnaire. When you arrive at the household and begin talking about
the blood tests with the respondent, you may informally discuss items
included in the informed consent statement. However, before beginning the
testing procedures, you must still read the informed consent statements
exactly as they appear in the Biomarker Questionnaire. If the respondent
finds the statements repetitive, tell him or her that you are required to read
the statements to ensure that they are given all the appropriate information.
Read the informed consent statements clearly. Practice reading the
consent statements out loud so that you become comfortable delivering them
in a clear, natural voice and manner. Avoid speaking rapidly or in a
monotone.
Never attempt to force or coerce consent. Some respondents may be
suspicious or fearful of having their blood collected for biomarker testing.
Others may have questions or want to discuss the procedures before giving
consent. Take time to patiently respond to all questions.
Some parents/responsible adults may be reluctant to allow testing of a child
16
without consulting someone not present at the time of your visit (for
example, a woman may want to consult her husband before giving
permission). In such cases, make an appointment to return to the
household later at an agreed upon time. If you believe it will help, ask
the team supervisor to visit a household where eligible respondents express
fear or reluctance to be tested.
17
Chapter 3. ANTHROPOMETRY
Learning objective
m Define anthropometry
m List materials and equipment for anthropometry
m Assembly and disassembly of measuring board
fa
Complete the appropriate section of the Biomarker Questionnaire related
to anthropometry
Demonstrate measuring weight of adults and children who can stand
Demonstrate measuring weight of infants
Demonstrate measuring height of adults and children who can stand
Demonstrate measuring length of infants
3.A. Introduction
nthropometry refers to the measurement of humans. In the [COUNTRY] DHS, anthropometry
refers solely to the measurement of a person’s height (length) and weight. This
information can be used to assess the nutritional status of a population. For
children, standard indices of physical growth related to nutritional status are height-
for-age, weight-for-height, and weight-for-age. A child who is below minus two
standard deviations (-2 SD) from the median of a reference population in terms of
height-for-age is considered short for his/her age or stunted. A child who is below
minus three standard deviations (-3 SD) from the median of a reference population
in terms of height-for-age is considered severely stunted. Stunting is a measure of
growth faltering and may result from poor diet and recurrent infections or chronic
diseases. A child who is below minus two standard deviations (-2 SD) from the
median of a reference population in terms of weight-for-height is considered too
thin for his/her height or wasted. A child who is below minus three standard
deviations (-3 SD) from the median of a reference population in terms of weight-for-
height is considered severely wasted. Severe wasting is used to identify children
with severe acute malnutrition. Wasting is a measure of acute weight loss and may
result from inadequate food intake, repeated illness or infection. A child who is
above two standard deviations (+2 SD) from the median of a reference population
in terms of weight-for-height is considered heavy for his/her height, or
overweight/obese. Overweight/obesity is a measure of excess weight and results
from an imbalance between energy consumed (too much) and energy expended
(too little). Weight-for-age or underweight is a composite index of stunting and
wasting that reflects children who are stunted, wasted, or both.
mong adults, height and weight measurement are used to calculate a person’s body mass index
18
(BMI) and to assess a woman’s risk of having difficulty during childbirth due to her
short stature (height <145 cm). BMI is calculated by dividing the weight in
kilograms by the height in meters squared (kg/m’). BMI values are used to
determine the percentage of the adult population that is normal, underweight,
overweight and obese.
mong adolescents (age 15-19), sex specific BMi-for-age and low height-for-age in girls are
calculated. Low height-for-age is used to identify stunted adolescents. These
different measurements are used for adolescents because they are still growing,
and the timing of peak growth velocity differs in boys and girls. BMl-for-age is a
ratio of weight relative to height for different age groups and is used to determine
the percentage of the adolescent population that is normal, underweight,
overweight and obese.
3.B. Materials and equipment for anthropometry
In addition to the Biomarker Questionnaire, the following supplies are needed:
SECA 878 U digital scale?: For
weighing children and adults. The
scale has a 200-kg capacity and
weighs in 0.1 kg increments. The
scale is powered by six AA batteries
and has an “ON-OFF” switch located
at the side of the scale.
? The Seca 878 digital floor scale is manufactured by Seca Corporation, Munich, Germany.
These instructions were adapted from instructions that accompany the Uniscale and
revised by Irwin J. Shorr, MPH, MPS.
19
Measuring board: For measuring
the height (length) of children and
adults.
Standard weight: A standard
weight of at least 5 kg is used to
check the accuracy of the scales.
Standard length rod: A rod of a
standard height is used to check the
accuracy of the measuring board.
Two paper handouts are available to parents/responsible adults:
1. Informational pamphlet: a document designed to inform the
parent/responsible adult about anemia, nutrition (and other conditions
measured in the survey), including definitions, symptoms, causes, and
methods of prevention. In addition, the child’s Hb, height, and weight (and
other biomarkers measured in the survey) results are recorded and classified
within this document. See Appendix A for an example of an informational
20
3.C
pamphlet.
Referral for severe acute malnutrition: Severe acute malnutrition is a
life-threatening condition requiring treatment. Children must be referred to a
local clinic or health center for further assessment and appropriate care. See
Appendix B for an example of a referral for severe acute malnutrition.
Procedures and precautions before measuring height and
weight
Layout of the Procedures: Each step of the measurement procedure is
directed at specific participants, who are named in bold letters at the
beginning of each step: "Measurer" and "Assistant".
Two Trained People Required: Two trained people are required to
measure a child's height or length. The Measurer holds the child and takes
the measurements. The assistant helps hold the child and records the
measurements in the Biomarker Questionnaire.
Measuring board and Scale Placement: Be selective about where you
place the measuring board and scale. It is best to measure outdoors during
daylight hours. If it is cold, raining or if too many people congregate and
interfere with the measurements, it may be more comfortable to weigh and
measure indoors. Make sure there is adequate light, but not in direct
sunlight.
The scale should be set up away from electrical appliances including mobile
phones.
The scale and measuring board should always be placed on an even and flat
surface.
The measuring board should always be supported, look for a wall, table or
tree that the measuring board can safely lean against. If there is no support
identified, have someone stand behind the measuring board to hold it.
. Age Assessment: Before you measure, confirm the child's age based on Qs.
103 and 104 in the biomarker questionnaire. If the child is less than age 2
years, measure length (the child lying down). If the child is age 2 years or
older, measure height (the child is standing). If accurate age is not possible
to obtain, measure length if the child is less than 87 cm. Measure height if
the child is equal to or greater than 87 cm.
Weigh and Measure One Child at a Time: If there is more than one
eligible child in a household, complete the weighing and measuring of one
child at a time. Then proceed with the next eligible child. DO NOT weigh and
measure all the children together. Instead complete all of the biomarker
collection for each eligible child before moving to the next child.
21
9. If there is more than one eligible woman in a household, collect all the
biomarker measurements for which she is eligible. Perform the biomarker
collection for all her eligible children before proceeding with the next woman.
Collecting biomarkers from the woman (or mother) first, may make the
process of collection biomarkers from children easier, especially for
anthropometry. Return weighing and measuring equipment to the storage
bags after you complete the measurements for each household.
10.Control the Child: When you weigh and measure, you must control the
child. The strength and mobility of even very young children should not be
underestimated. Be firm yet gentle with children. Your own sense of calm and
self-confidence will be felt by the parent and the child.
Note: When a child has contact with a measuring board, you must hold and control
the child so the child will not trip or fall. Never leave a child alone with a piece of
equipment.
11.Coping with stress: Since weighing and measuring requires touching and
handling children, normal stress levels for this type of survey work are higher
than for surveys where only verbal information is collected.
Explain the weighing and measuring procedures to the mother, father, or other responsible
adult and to a limited extent, the child, to help minimize possible resistance,
fears or discomfort they may feel. You must determine if the child or the
parent is under so much stress that the weighing and measuring must stop.
Remember, young children are often uncooperative; they tend to cry,
scream, kick and sometimes bite. If a child is under severe stress and is
crying excessively, try to calm the child or return the child to the parent
before proceeding with the measuring.
Do not weigh or measure a child if:
e The parent/responsible adult refuses.
e The child is too sick.
e If the child is distressed, wait and attempt to measure the child once
the child calms down.
For children and adults with physical disabilities:
e Measure children and adults with physical disabilities and note the
disability on the questionnaire. Some individuals’ disabilities may make
it difficult to stand, straighten their arms, legs, or back, or hold
themselves steady. In such cases, adapting the measurement
protocols may be required and noted in the questionnaire.
22
12.Recording Measurements and Being Careful: Keep objects out of your
hands and pens out of your mouth, hair or breast pocket when you weigh and
measure so that neither the child nor you will get hurt due to carelessness.
When you are not using a pen, place it in your equipment pack or on the
questionnaire. Make sure you do not have long fingernails. Remove
interfering rings and watches before you weigh and measure.
13.Strive for Improvement: You can be an expert measurer if you strive for
improvement and follow every step of every procedure the same way every
time. The quality and speed of your measurements will improve with
practice. You will be required to measure women, men, and children.
o not take these procedures for granted even though they may seem simple and repetitious. It
is easy to make errors when you are not careful. Do not omit any steps.
Concentrate on what you are doing.
3.D.
Determining eligibility
All eligible, consenting respondents age 0-4 years and 15-[49] years can
be measured.
Verbal permission for anthropometry must be obtained. For children age 0-4 years,
L
verbal permission must be obtained from the parent or responsible adult age
18 years or older.
The interviewer will identify all children who are potentially eligible for
anthropometry based on information collected in the Household
Questionnaire and will enter their names and line numbers in Q. 102. They
will then enter each child’s date of birth and age in Q. 103 and Q. 104,
respectively. For children whose mothers were interviewed, this information
will come from the tablet report. For children whose mothers weren’t
interviewed, Q. 103 and Q. 104 will be completed based on information
provided by a responsible adult. The interviewer will then complete Q. 105.
Using information collected in the Household Questionnaire and presented on
the table report, the interviewer will complete Q. 202-204 for women age 15-
49 and Q. 302-304 for men age 15-[49].
At this point, the interviewer will hand the Biomarker Questionnaire to the
biomarker technician who is responsible for completing the remainder of the
questionnaire.
Note that for children only, it is possible children will be entered into the
Biomarker Questionnaire who are not eligible for measurement. Before
completing Q. 106, check Q105, and confirm the child is age 0-4 years. If the
child is older than age 0-4 years, there will be an X in the box next to NO,
which indicates the child should not be measured. Instead, skip to Q. 125 and
go on to the next eligible child.
23
3.E. Preparing to Take Weight
Before taking any measurements with the scale, cover the second window
display facing the respondent. Dark tape can be used. Covering the second display
window will reduce errors when recording the weight. For example, a weight of 9.60
kg could be erroneously recoded as 6.90 kg if read upside down in the respondent
display window.
Show the scale (Seca 878 digital scale) to the adult and explain that you will weigh
her/him and their children on the scale. Tell her/him that infants and any other
children who will not stand on the scale alone can be held by the adult to obtain the
child’s weight. Ask the adult to wear light clothing while being weighed and to
remove shoes/sandals, any heavy clothing, heavy ornaments, items in pockets, etc.
To obtain an accurate weight, it is important to remove as much clothing as
possible from the child being weighed. Therefore, before beginning, request the
caregiver to remove the child’s clothing until he/she is wearing only undergarments.
Due to cultural preferences or climate, some parents/caregivers may not allow the
child to be measured without clothing. To accommodate this preference and
maintain accuracy, children may be wrapped in a blanket. The blanket must be
weighed prior to weighing the child so wrapping a child in a blanket is only possible
if the child is being held.
Preparing the Scale
1. Placement: Take the scale out of the storage bag and place the scale on a
hard, level surface. Uneven surfaces or vibration may cause the scale to
malfunction.
Seca 878 scale
2. Power supply: The scale is powered by six AA 1.5 V batteries. To install the
batteries, carefully turn over the scale so that the base is accessible. Open
the battery compartment and insert the batteries, checking that the polarity
of each is correct.
24
3. Setting up and aligning the scale: If the surface is not level, align the
scale by turning the foot screws. The air bubble in the spirit level must be in
the center of the circle. Ensure that only the feet of the scale are in contact
with the floor. The scale itself may not be in contact with the hard surface at
any point. The alignment of the base of the scale must be checked and
corrected as necessary every time the location of the scale is changed.
spirit level
4. Power the scale using the ON-OFF switch located at the side of the display
window.
Controls and displays
hold/2 in 1 key start key ON-OFF switch
ON-OFF switch
Scale functions: The “Start” key will start the scale when charged batteries are
in place and the ON-OFF switch in ON. There are two displays on the scale. As
mentioned above, the display facing the respondent should be covered with tape so
that ONLY the display facing the Measurer is visible. The “HOLD” function will
lock the weight in the display so that the Measurer can read the weight. The “2
in 1” function allows a child who needs to be held by an adult to be weighed.
25
The scale will not function correctly if it is bumped, knocked or moved during the
weighing. It is best to use the scale in the shade or indoors with adequate light if
the weather is inhospitable. Handle the scale carefully:
3.F.
e Start the scale for weighing by pressing the “START” key. Press the start
key inward, not down. If the scale has no power, push the ON-OFF switch
to ON.
Do not drop or bump the scale.
Do not weigh a total load of more than 200 kg.
Do not store the scale in direct sunlight or other hot places.
Protect the scale against excess humidity or moisture.
To clean the scale, wipe surfaces with a damp cloth and dry immediately
Never put the scale in water.
After using the scale, power the scale OFF using the ON-OFF switch.
The scale switches off on its own after a certain time:
o After 3 minutes in Normal mode
o After 2 minutes in the “2 in 1” mode
Weighing Adults and Children Who Can Stand on the Scale by
Themselves
o not set up next to electrical appliances, for instance by a television.
i
If the power supply is not activated, push the power switch to position “ON”.
The scale now has power. The display should show “SECA, 8.8.8.8.8 and
“0.00.” The scale automatically sets to zero and is now ready for use. Wait
for the scale to display the numbers “0.00” before asking the adult or child to
step on the scale.
. Before stepping onto the scale, ask the respondent to remove all keys,
mobile phones, etc. from their pockets.
Ask the respondent to step onto the center of the scale and stand still. Ask
him/her to stand straight without leaning and looking straight ahead. Wait
until the numbers are stable on the display window.
26
Feet should be
centered on scale.
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
4. After a quick (Short) press on the “HOLD/2 in 1” key, the “HOLD” anda A
appear in the display window; the weight remains frozen until the next
weighing operation. Record all digits displayed for the weight.
e For children, record the child’s weight measurement in Q. 106. If the
child’s weight was not measured, record the appropriate code in Q.
106 then skip to Q. 108- as shown below.
106 | WEIGHT IN KILOGRAMS.
(4) MR is 5
NOFPRESENT. :::cc.cs 9994
REFUSED: scscuscacecnys 9995 108
HER: “-soseossusmasse 9996
e Record if the child is minimally dressed in Q. 107. The term “minimally
dressed” refers to the child without shoes, heavy ornaments, and
undressed down to the underwear or other light weight undergarment.
If the child is minimally dressed circle ‘1’ for ‘YES.’ Circle ‘2’ for ‘NO’
only if the child is not minimally dressed.
e For adults, record an adult’s weight measurements in Q. 205/305. If
the adult’s weight was not measured, record the appropriate code in Q.
205/305, then skip to Q. 207.
WEIGHT IN KILOGRAMS
NOT PRESENT ....
REFUSED on oj. 2 207
e Record if the adult was wearing only lightweight clothing in Q.
206/Q306. The term “lightweight clothing” refers to the adult without
27
3.G.
shoes, heavy ornaments, and heavy articles of clothing such as thick
jerseys and shawls, jackets, and heavy pants or skirts. If the adult is
wearing lightweight clothing circle ‘1’ for ‘YES.’ Circle ‘2’ for ‘NO’ only if
the adult is not wearing lightweight clothing.
The “HOLD” function can be switched off by a quick (Short) press again on
the “HOLD/2 in 1” key and the “HOLD” display vanishes.
Weighing Infants or Children Who Must be Held by an Adult
While on the Scale
If Child does NOT NEED to be Covered with a Blanket or Cloth:
ote: The adult should be measured separately from the child, recording an adult’s weight while
measuring a child should not be done to avoid incorrect recording in the Biomarker
Questionnaire.
1. Ask the adult to step onto the center of the scale and stand still. Wait until
the numbers are stable on the display window.
While the adult is still on the scale, press (Long) the “HOLD/2 in 1” button.
The scale returns to “0.00” and the “NET” appears in the window display.
Standing directly in front of the scale, give the child to the adult. The scale
will determine the weight of the child even though the adult is on the scale.
Once the value for the child’s weight is stable for about 3 seconds, the value
is retained and “HOLD”, A and “NET” appear in the display window.
G Second, adult
‘ holds child
securely.
First, center adult
on scale.
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
It is very important to understand the use and difference of a Long versus Short
28
press on the “HOLD/2 in 1” button. In the above statement, a Long press on the
“HOLD/2 in 1” button is required to activate the “2 in 1” function needed to
weigh children who need to be held. A Short press on the “HOLD/2 in 1” button
will activate the “HOLD” function to freeze and hold the weight measurement on
the display of an adult respondent or a child who can stand alone until you are
ready to record the result in the Biomarker Questionnaire.
4. Record the weight of the child as displayed on the scale (the scale measures
with 100 g resolution) in the Biomarker Questionnaire. The second digit after the
decimal will ONLY read “0”. Thus, a weight of 6.52 kg isn’t possible, but a
weight of 6.50 kg is possible on the scale.
Note: After recording the weight, press the “Start” button to reset the scale.
there are other children to be weighed who must be held by the adult, finish all measurements
for the first child before moving onto the next.
If Child NEEDS to be Covered with a Blanket or Cloth:
If it is cold and/or the adult wants the child to be covered during the weighing,
follow the instructions below carefully:
1. Wait for the scale to display “0.00”.
2. Give the adult a blanket or cloth and ask him or her to step on the scale.
3. When the numbers in the display window stabilize, press (Long) the
“HOLD/2 in 1” button. The scale returns to “0.00” and the “NET” appears in
the window display.
4. Give the child to the adult and ask him or her to cover the child with the
blanket or cloth.
5. The scale will determine the weight of the child even though the adult is on
the scale. Once the value for the child’s weight is stable for about 3 seconds,
the value is retained and “HOLD”, À and “NET” appear in the display
window.
6. Record the weight of the child as shown on the scale (the scale measures
with a 100 g resolution) in the Biomarker Questionnaire. The second digit
after the decimal will ONLY read “O0”. Thus, a weight of 6.52 kg isn’t possible,
but a weight of 6.50 kg is possible.
For weight measurements, the most frequent causes of errors are:
e Placing the scale on an uneven surface
29
e Placing the scale near an electronic source, including a mobile device or
tablet
+ Forgetting to ask the respondent to remove clothing, shoes, and heavy
ornaments
e Adjusting the position of the respondent while on the scale
e Incorrectly reading the scale, from a slanted angle or not facing the scale
e Incorrectly recording the weight in the Biomarker Questionnaire
Additional Notes on the SECA scale:
e The SECA scale switches off automatically 3 minutes after the last weighing
in the “Normal Mode” or two minutes, if the “2 in 1” function is activated.
+ Do not weigh loads with a total weight of more than 200 kg.
3.H. Troubleshooting
Possible reasons for the scale not taring (returning to “0.00”) after pressing (Long
press) the “2 in 1” key when the adult stands on the scale):
o There was no weight on the scale to tare (i.e., the adult was not on the
scale).
o The “2 in 1” function was not activated.
o The load weighs more than 200 kg; “STOP” appears in the display. If
the load is over 200 kg when an adult is holding a child, use an
individual of less weight to hold the child.
What to do if the Scale Display Shows the Following Errors:
No weight is displayed when there is a load on the scale?
e Ask the adult to step off the scale, and check to see if the ON-OFF
switch at the side of the scale is in the “ON” position.
e Press the “START” key to prepare the scale for weighing if the ON-
OFF switch is set to ON.
e Check the batteries
The scale keeps switching on while being transported? The “START” key has been
activated. Turn the power OFF using the ON-OFF switch.
The scale displays a weight after being transported or after new batteries have
been put in? Press the “START” key; the scale will work normally again.
“0.00" does not appear before weighing? Start the scale again by pressing the
“START” key. There should not be any load on the scale.
“.---" appears instead of “0.00” before weighing? Start the scale again after it
switches off automatically; there should not be any load on the scale.
One segment of the display is illuminated constantly or not at all? There is a
30
problem with that segment of the scale. Inform your supervisor and use a
replacement.
The display shows a battery with split shading? The battery voltage is running low.
The batteries should be changed in a few days.
“batt” appears in the display? The batteries are empty. Replace the batteries.
“STOP” appears in the display? The maximum load capacity of the scale has been
exceeded.
The display flashes? Take the load off the scale and start again. Wait until 0.00
appears and weight again._
Er and a number appear in the display window? Start the scale again after it
switches off automatically. The scale should work normally again. If not, turn the
ON-OFF switch to OFF and then back to ON. If the scale still does not work properly,
inform your supervisor and use a replacement.
3.1. Preparing to measure height/length
Show the measuring board to the adult and explain that you will use it to measure
her/him and the children in the household who are age 0-4 years. Tell her/him that a
child less than age 2 years will be measured lying down on his/her back and a child
2- 4 years will be measured standing. Inform her/him even if a child less than age 2
years can stand on his/her own, he/she will still be measured lying down (length).
Inform the adult that his/her help will be needed to calm and focus the child.
Preparing the measuring board
1. The measuring board requires assembly. It consists of three separate pieces
(“A,” “B,” and “C”) that, for ease of transport, are held together by bolts and
a moveable head/footpiece. In transport mode, the measuring board is stored
in a case.
2. Remove the measuring board
: Height M ing B
prepared for transport from its Se arene ee
case and stand it upright on its | | ne | ere
base. | | |
| 4 | | J TA | :
3. As you face the board, release | | A Ys | :
the front bolt by turning it | À re | à
counter-clockwise. This will | : | Ë
liberate board “C.” Set board | | | f
“pr 7 El JACK OARD
C” aside. | _ |
SHOULDER [een
| Ei STRAP——__
CARRYING || Ë
HANDLE Sn :
IT |
I U
N
PEG
5 il \
t \ Ë | BASE OF BOARD
4. The second bolt attaching board “B” to base “A” is on the back of «gp
base “A.” Turn the second bolt counter-clockwise to liberate board
“B.” You now have three separate pieces: A, B, and C.
5. To assemble, slide board “B” into base “A” and fasten the clasps at |
the back of the board. Next, slide board “C” into board “B” and A
fasten the second set of clasps. Thus, as shown, base “A” is linked
to board “B” and board “B” is linked to board “C”.
6. If it is not possible to clasp the boards together, the pieces have been
assembled improperly - recheck the instructions and try again.
7. The sliding auto-lock head/footpiece is stored at the base of the measuring
board; it can be moved up or down the length of the measuring board and
will stay in place wherever it is positioned. Hold the sliding head/footpiece by
the center triangle and slide it the length of the assembled board to make
Sure it is functioning properly.
8. Make sure that the measuring tape is intact, and the numbers are clearly
visible.
Note: If taller respondents are not being measured, board “C” should be set aside
until needed and the Measurer and Assistant should use base “A” and board “B”
to measure.
3.J. Measuring a child’s height
There are two positions that must be exact when measuring a child’s height.
A line of sight is required for measuring both length and height. For height,
imagine there is a line parallel to the ground from the base of the board to the ear
through the lower eye socket.
An imaginary line, running from the shoulder to the heel, is required for
measuring height. The imaginary line is required to determine if the feet should be
against or away from the back of the board so that the line is perpendicular to the
base of the board.
Both the Measurer and Assistant have 2 responsibilities (the rule of 2).
Measurer Rule of 2: Position child correctly (Line of Sight and Imaginary Line)
and Measurement (note hand placement around chin).
32
_ Measurer
Hand Placement
Assistant will 1) hold the legs (knee and shin) and 2) record the measurement.
Assistant Rule of 2: Hold the Legs and Record the measurement (note the
placement of questionnaire)
+ Tu. à w.
blication/unint/dp_un_int_81_041_6E.pdf
https://unstats.un.org/unsd/pu
1. Measurer or Assistant: Place the measuring board on a hard, flat surface
against a wall, table, tree or staircase. Make sure the measuring board is
stable. Many walls and floors are not at perfect right angles.
2. Measurer or Assistant: Ask the parent to take off the child’s shoes and to
unbraid hair, remove any hair ornaments, or push aside any hair that would
interfere with the height measurement. Ask the parent to bring the child to
the measuring board and to kneel in front of the child so that the child will
look forward at the parent.
33
3. Assistant: Place the questionnaire and pen on the ground (Arrow 1) and
kneel on the right side of the child (Arrow 2).
Measurer: Kneel on the left of the child (Arrow 3). The measurer should
ALWAYS be on the side of the measuring board with the measuring tape.
5. Assistant: Place the child’s knees and feet in the correct position, with knees
and feet either together or apart. There are three possible positions for the
knees and feet:
NU Ji
“Kneegand Knees together, Feet together,
feet thgetter—teerapar—y—krees par
whichever touches first!
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
6. Measurer: Determine if the child’s feet should be against or away from the
back of the height board by observing the imaginary line drawn from the tip
of the shoulder to the heel (Arrow 4). This line should be perpendicular (90°
angle) to the base of the height board where the child is standing (the
Assistant may have to move the child’s feet away from the back of the height
board to put them in the proper position).
Note: with most preschool-age children who are not overweight or obese, the heels
will probably touch the back of the height board._
34
. Questionnaire and pencil on ground
. Assistant kneeling
. Measurer kneeling and at eye level with child
. Hand against shins
. Hand against knees
. Child looking straight ahead
. Hand on chin
. Shoulders level
11. Arms at sides
16. Headpiece firmly on head
4. Body in straight line, check feet against back of
board (most cases)
8. Confirm line of sight
12.Back of head
13. Back of shoulders
14. Buttocks
15. Calves
7. Assistant: With your thumbs against the index finger of each hand, place
your right hand on the child’s shins (Arrow 5) and your left hand on the
child’s knees (Arrow 6). Do not wrap your hands around the knees or feet
(ankles) or squeeze them together. Make sure the child’s legs are straight.
Note: Be sure to avoid gripping the knees which may lead to “wrapping” the knees
together rather than pressing them down gently.
8. Measurer: Ask the child to look straight ahead at the parent if she is
kneeling in front of the child (Arrow 7). Make sure the child’s line of sight is
35
parallel to the ground (Arrow 8). Place the thumb and index finger of your left
hand on each side of the child’s chin, and gradually close your hand (Arrow
9).
Note: with most preschool-age children who are not overweight or obese, the back
of the head will touch the back of the height board (Arrow 12); however, if the child
is overweight or obese, there will be a space between the back of the child’s head
and the back of the measuring board. Make sure the child’s shoulders are level
(Arrow 10), the hands are at the child’s side (Arrow 11), and at least the child’s
buttocks touch the back of the measuring board. Most preschool-age children who
are not overweight or obese, the back of the head, the shoulder blades, the
buttocks, the calves and heels will touch the back of the measuring board (Arrows
12, 13, 14, 15 & 4).
9. Measurer and Assistant: Check the position of the child (Arrows 1-15).
Repeat any steps as necessary.
10.Measurer, then Assistant: When the child’s position is correct, lower the
headpiece on top of the child’s head (Arrow 16) making sure to push through
the child’s hair. Read and call out the measurement to the nearest 0.1 cm.
The Measurer should read the measuring tape at eye level. The Assistant
will repeat aloud the measurement back to the Measurer and the
Measurer will confirm. The Measurer will remove the headpiece from the
child’s head, his or her left hand from the child’s chin, and will allow the child
to return to the parent.
11.Assistant: Record the height measurement in Q. 108. If the child’s height
was not measured, record the appropriate code in Q. 108 and skip to Q. 113.
Record that the child was measured standing up in Q. 109. Show it to the
Measurer for confirmation.
HEIGHT IN CENTIMETERS.
IF CHILD IS AGE 0-1 YEARS, MEASURE LYING DOWN.
IF CHILD IS AGE 2, 3, OR 4 YEARS, MEASURE STANDING UP.
109 | WAS THE CHILD MEASURED LYING DOWN OR STANDING UP? LYING DOWN
STANDING UP
e Record in Q.110 whether the correct measurement procedure was followed
based on the child’s age Q.104 and how the child was measured Q.109. If the
child was measured standing up and they are 2 years or older record ‘YES’
and skip to Q.112. Record ‘NO’ if the child was measured standing up but
they were less than two years old
Note: It is important to record how the child was actually measured in Q. 109
36
whether or not they were supposed to be measured lying down or standing up. This
question is not a reflection of whether you as a measurer performed the correct
procedure. When a child is measured lying down the child will on average be
Slightly taller than if he/ she was measured standing up. Thus, information on the
child’s position during measurement is important later when calculating nutritional
status.
e If the child was not measured following correct procedures, the reason for
this should be recorded in Q. 111. While you should do your best to follow the
correct measurement procedures, there are times that this may be
impossible. For example, the child has a disability or refuses to stand.
Whatever the reason, it should be recorded in Q. 111.
e Record in Q. 112 whether braided or ornamented hair interfered with the
measurement. Record ‘YES’ if the hairstyle or ornamented hair could not be
pushed apart or manipulated to allow the headpiece to rest on the top of the
head. Record ‘NO’ only if braided or ornamented hair did not interfere with
the measurement.
CHECK 104 AND 109: BASED ON CHILD'S AGE, WAS CORRECT MEASUREMENT Pcupwusceh beeen ss 112
PROCEDURE FOLLOWED?
IF CHILD IS AGE 0-1 YEARS: WHY WAS (NAME) MEASURED STANDING UP?
IF CHILD IS AGE 2-4 YEARS: WHY WAS (NAME) MEASURED LYING DOWN?
WAS THE RECORDED MEASUREMENT INTERFERED WITH BY BRAIDED OR
ORNAMENTED HAIR?
12.Measurer: Check the recorded measurement on the questionnaire for
accuracy and legibility. Instruct the Assistant to correct any errors. Mark your
fieldworker number in Q. 113.
13.Assistant: Mark your fieldworker number in Q. 114 and enter the date the
measurement was taken in Q. 115.
3.K. Measuring a child’s length
For children less than age 2 years, both the Measurer and Assistant have 2
responsibilities (the rule of 2). The Measurer will 1) press the child’s knees/shins
down and 2) take the measurement. The Assistant will 1) position the child
correctly for the proper line of sight with the head against the board and 2) record
the measurement. Do not switch roles.
Measurer Rule of 2:
37
e Presses Knees/Shins
e Measurement
https://unstats.un.org/unsd/publication/unint/dp_un_int 81 041 6E.pdf
Assistant Rule of 2:
Line of Sight, head against back of board, note the placement of the
hands
e Record the measurement (note the placement of questionnaire)
38
https://unstats.un.org/unsd/publication/unint/dp_un_int 81 041 6E.pdf
. Questionnaire and pencil on ground
. Assistant kneeling
Measurer kneeling
. Assistant’s hands cupped over ears
. Child facing straight up
Head against base of board
. Child flat against board
. Hand on knees/shins, legs straight
. Feet flat against footpiece
OMNDUNPWNPE
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
1. Measurer or Assistant: Place the measuring board on a hard, flat surface,
such as the ground or floor. Make sure the measuring board is stable.
2. Assistant: Place the questionnaire on the ground, floor or table (Arrow 1)
and kneel behind the base of the measuring board if it is on the ground or
floor (Arrow 2).
3. Measurer: Kneel on the side of the measuring board with the measuring
tape (at the child’s feet) so that you can move the foot piece with your right
hand (Arrow 3). The measurer should ALWAYS be one the side of the
measuring board with the measuring tape.
4. Measurer and Assistant: With the help of the parent, gently lower the child
onto the measuring board, making sure the measurer supports the child at
the trunk of the body while the assistant supports the child’s head.
5. Assistant: Cup your hands over the child’s ears (Arrow 4). With your arms
straight place the child’s head against the base of the board. The child should
be looking straight up (Arrow 5) so that the line of sight is perpendicular to
the board. Your head should be directly over the child’s head. Watch the
child’s head to make sure it is in the correct position against the base of the
board (Arrow 6). Confirm the line of sight by looking at the profile of the child
lying down. Again, an imaginary line should be drawn from the ear to the
lower eye socket.
6. Measurer: Make sure the child is lying flat in the center of the board (Arrow
7).
Place the child’s knees and feet in the correct position, with knees and feet either together
39
or apart. There are three possible positions for the knees and feet:
“Kneesand Knees together, Feet together,
feet together feet apart knees apart
whichever touches first!
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
With your thumb against your index finger, place your left hand on the child’s knees (Arrow
8) and press them gently, but firmly against the board. Do not wrap your
hand around the knees or squeeze them together. Make sure the child’s legs
are straight.
Note: It is not possible to straighten the knees of a newborn to the same degree as
older children. If the child is agitated and both legs cannot be held in position,
measure with one leg in position.
7. Measurer: Check the position of the child (Arrows 1-8). Repeat any steps as
necessary.
8. Measurer, then Assistant: When the child’s position is correct, move the
foot piece with your right hand until it is firmly against the child’s heels
(Arrow 9). Read the measurement to the nearest 0.1 cm and call out the
measurement to the Assistant. The Assistant will repeat the
measurement and the Measurer will confirm.
9. Assistant: Record the height measurement in Q. 108. If the child’s height
was not measured, record the appropriate code in Q108 and skip to Q. 113.
Record that that the child was measured lying down in Q. 109. Show it to the
Measurer for confirmation.
e Record in Q. 110 whether the correct measurement procedure was
followed based on the child’s age Q. 104 and how the child was
measured Q. 109. If the child was measured following correct
procedures record ‘YES’ and skip to Q. 112. Record ‘NO’ only if the
child was not measured following correct procedures.
e If the child was not measured following correct procedures, the
reason for this should be recorded in Q. 111. For example, a child
age 0-1 may have refused to lie down and so was measured
standing up.
40
e Record in Q. 112 whether braided or ornamented hair interfered
with the measurement. Record ‘YES’ if the hairstyle or ornamented
hair could not be pushed apart or manipulated to allow the
headpiece to rest on the top of the head. Record ‘NO’ only if
braided or ornamented hair did not interfere with the
measurement.
10.Measurer: Check the recorded measurement on the questionnaire for
accuracy and legibility. Instruct the Assistant to correct any errors. Mark
your fieldworker number in Q. 113.
11.Assistant: Mark your fieldworker number in Q. 114 and enter the date in Q.
LES:
3.L. Measuring an adult’s height
The height of adults can be taken by one person alone, the Measurer. However, an
Assistant can be used to record the measurement.
Measurer: Place the measuring board on a hard, flat surface against a wall, table,
tree or staircase. Make sure the measuring board is stable. Many walls and floors
are not at perfect right angles.
1. Measurer: Ask the person to take off his/her shoes and ask him/her to
unbraid or push aside any hair that would interfere with the height
measurement. Ask the person to stand on the base of the height measuring
board and to face forward.
2. Measurer: Place the questionnaire and pen on the ground and stand on the
left-hand side of the person (the same side as the measuring tape).
3. Measurer: Determine if the person’s feet should be against or away from the
back of the height board by observing the imaginary line drawn from the tip
of the shoulder to the heel (Arrow 1). This line should be perpendicular (90°
angle) to the base of the height board where the person is standing. Note
that with almost all adults, the measurer will have to move the person's feet
away from the back of the board to put them in the proper position; (Arrow
2).
4. Measurer: Place the knees and feet in the correct position, with knees and
feet either together or apart. There are three possible positions for the knees
and feet:
e Knees together and feet toge
er
e Knees together and feet apar whichever touches first!
+ Knees apart and feet togethe
41
5. Measurer: Ask the person to look straight ahead. Cup the respondent’s chin
between the thumb and index finger of your left hand and gradually close
your hand. Position the person’s head so that the line of sight is parallel to
the ground (Arrow 3).
With most adults, the back of the head will not touch the back of the Measuring
board —there will be a space between the back of the person’s head and the
back of the measuring board (Arrow 4). After you have placed the person’s head
in the proper position, release your hand from the person’s chin and ask him/her
to hold his/her head in the position you have just placed it in.
Make sure the person’s shoulders are level, the hands are at the person’s side
(Arrow 7), and at least the buttocks touch the back of the measuring board.
Note that with most adults, only the buttocks and perhaps the shoulder blades,
will touch the back of the measuring board (Arrows 5 & 6).
. Body ina straight line
. Feet away from back of board (most
cases)
. Confirm line of sight
. Back of head may not touch board
(most cases)
. Back of shoulders
. Buttocks
. Hands on side
https://www.fantaproject.org/sites/default/files/resources/FANTA-Anthropometry-Guide-May2018.pdf
6. Measurer: Check the position of the person. Repeat any steps as necessary.
7. Measurer: When the person’s position is correct, lower the headpiece on top
of the head making sure to push through the person’s hair. Read and call out
the measurement to the nearest 0.1 cm. Remove the headpiece from the
person’s head and escort the person off the height board.
Note: The tape should be read at eye level. If a respondent is taller than the
Measurer, the Measurer will need to stand on a chair to read the tape at eye
level; alternatively, they may need to bend down or kneel if the respondent is
shorter than the Measurer.
42
Measurer:
Immediately record the measurement on the questionnaire. Record an adult’s
height measurements in Q. 207/307. If the adult’s height was not measured,
record the appropriate code in Q. 207/307 and skip to Q. 209/309.
Measurer: Record in Q. 208/308 whether braided or ornamented hair interfered with the
measurement. Record ‘YES’ if the hairstyle or ornamented hair could not be
pushed apart or manipulated to allow the headpiece to rest on the top of the
head. Record ‘NO’ only if braided or ornamented hair did not interfere with
the measurement.
Measurer: Check the recorded measurement on the questionnaire for
accuracy and legibility. Correct any errors. Enter your fieldworker number in
Q. 209/309. If there is an Assistant, enter their fieldworker number in Q.
210/310 or mark 9999 if there is no Assistant. Enter the date of measurement
in Q. 211/311.
For length/height measurements, the most frequent causes of errors are:
Incorrectly positioning the body on the measuring board leading to an invalid
imaginary line (shoulder to heel)
Invalid line of sight (ear to lower eye socket)
Incorrect positioning of the head/footpiece
Incorrectly reading the measurement and not having ones’ eye perpendicular
to the measuring tape
Incorrect recording of length/height on the Biomarker Questionnaire
The Measurer and Assistant not following the rule of 2
. Dismantling the measuring board
. Stand the measuring board upright and step on the base with one foot to
stabilize it.
Slide the head/foot piece into the base, “A.”
Release the clasp on the back of both boards, “B” and “C.” Put the clasp flat
against both the boards.
. Stand the base, “A,” and place the back of board “B” against base “A.” This
should result in the measuring tape on board “B” facing you.
Make sure all sides, corners and extension pieces are straight and in line with
each other. Once this is done, push the bolt behind base “A” into board “B”
and screw it clockwise to secure.
Take board “C” and place it against board “B” so that the measuring tape on
board “C” is facing inward to board “B.”
43
7. Make sure all sides, corners and extension pieces are straight and in line with
each other. Once this is done, push the bolt on board “C” into board “B” and
screw it clockwise to secure.
8. In this arrangement, board “B” should be in between base “A” and board “C.”
Board “C” should be facing you without the measuring tape showing.
3.N. Quality assurance for anthropometry
Errors in the precision and accuracy of height/length and weight measurements
affect the validity of the indices derived from these measurements. Two types of
errors can occur: random and systematic measurement errors. These errors
commonly arise from inadequate training, instrument error, and improper recording
of measurements. These errors can be minimized by training personnel to use
standardized, validated measurement techniques and instruments that are precise,
accurate, and correctly maintained.
In the [YEAR] [COUNTRY] DHS, accuracy and precision of height and weight
measurements will be ensured by regular checking of the accuracy of measuring
equipment and standardization of biomarker technicians. This process of
standardization must be completed during training? and prior to main field work.
Inventory of equipment
Inventory of equipment is conducted during training and during fieldwork.
During training, it is important to:
1. Ensure that all measuring boards are functioning well and are not broken.
a. All the measuring boards are given a unique identification number.
b. Check measuring boards for loose screws, loose clamps, cracks, and
damaged head pieces.
c. Measure a rod of standard height on each of the boards. For each
board, record the measurement in a table comparable to the one
shown below.
Date: MM/DD/YYYY
Inventory of NEW Measuring Boards |
BoardID |Measurement incm [Condition
2. Ensure that all weighing scales are functioning well and are not broken.
3 The standardization process should take place during the pretest/training of trainers and
the main training of the field staff.
44
All scales are given a unique identification number.
Weigh an object of standard weight on the weighing scales. For each
scale, record weight measurements in the table comparable to the one
shown below:
oo
Date: MM/DD/YYYY
Inventory of NEW weighing scales
Measurement in kg Condition
|| the weighing scales that indicate correct weight are given a unique identification number.
nly measuring boards and scales that correctly measure the rods and scales will be used during
fieldwork.
uring fieldwork, daily checks are required to ensure the accuracy of the measuring boards and
scales during field work. The check should be done using a rod of known length and
an object with a constant weight every morning before fieldwork begins. Teams
should complete the fieldwork equipment maintenance log for the measuring boards
and scales as shown below. See Appendix C for the complete fieldwork equipment
maintenance logs for measuring boards and scales.
JELDWORK DAILY MAINTENANCE LOG - MEASURING BOARD
Equipment Date Cluster Measurement in Condition/Remarks Not in [Fieldworker]
ID (DD/MM/YYYY) Number cm
001 04082020 [1 | 110.1
001 05082020 | 1 ___—| ast0.4
oo: 06108200 [1 | 1100
FIELDWORK DAILY MAINTENANCE LOG - WEIGHING SCALE
45
Equipment Date Cluster | Measurement in Condition/Remarks Not in [Fieldworker]
ID (DD/MM/YYYY) Number number
04/08/2020 [1 | 480 [rime |
kg
1
05/08/2020 | 1 4.80
soso |i [aco rine =
It is ok for there to be some minor fluctuations in the daily measurements. For the
rods and scales acceptable fluctuations are +/- 0.5 cm and +/- 0.50 kg,
respectively.
If equipment is malfunctioning, all height/length and weight measurements should
stop until the implementing agency provides new equipment. The team supervisor
should contact the field coordinator immediately and request a replacement.
Remeasurement of children
Obtaining accurate height and weight measurements especially for young children
is difficult. Even small measurement errors can result in invalid data. Special
procedures that require biomarker technicians to conduct remeasurements of
specific children before the teams leave the cluster have been put in place to
improve the data quality.
Completed Biomarker Questionnaires will be entered into the CAPI system. The
team supervisor will run a program to identify children who are eligible for
remeasurement. Children are eligible for remeasurement for two reasons:
1. Their first height and weight measurements are so extreme that the
measurements are almost certainly invalid.
2. They are randomly selected. About 1 in 10 households will have a child
randomly selected for remeasurement regardless of whether their first
anthropometry measurement was acceptable.
The biomarker team will receive a Remeasurement Questionnaire from the team
supervisor with the name, line number, and date of birth of the child filled in. The
biomarker team will also receive an informational pamphlet to record the
remeasurements. The biomarker team must return to the household(s) to
remeasure eligible child(ren). Only children eligible for remeasurement should have
their height and weight remeasured, the other children in the household do not
need to be remeasured.
The biomarker teams should return the completed Remeasurement Questionnaires
to the team supervisor for data entry.
Wasting Referral
46
During data collection, children’s’ weight-for-height Z-scores are calculated in CAPI.
This information is only available in CAPI surveys. The CAPI program will provide
information on the children who have severe acute malnutrition (a Z-score of less
than -3 for weight-for-height). The information can be accessed by the survey team
only after the completion of the children’s height and weight measurements and
remeasurements. The biomarker technician or the team supervisor should provide
a severe acute malnutrition referral form to the parent/responsible adult of a child
identified with severe acute malnutrition. A completed form will contain the name,
height (cm), weight (kg), and weight-for-height (Z-score) result of the severely
acute malnourished child (defined as a Z-score of less than -3 for weight-for-height).
See Appendix B for an example of a severe acute malnutrition referral form.
The parent/responsible adult should be informed about the effects of severe acute
malnutrition and instructed to take the child to a local clinic or health center to
ensure the child receives proper assessment and treatment for severe acute
malnutrition. The parent/responsible adult should be instructed to take the referral
form with them when they go to the clinic or health center.
3.0. Standardization of height and length measurements
Once all biomarker technicians have adequately practiced the measurement and
recording techniques, and feel comfortable with their performance,
standardization exercises must be carried out on children 0-59 months to
assess the biomarker technicians’ accuracy and precision (Figure 1).
Accuracy means how close a measured value is to the actual (true) value. In the
standardization exercise, the true value is the average of two measurements made
by the trainer (gold standard). The measurer will make two measurements on the
same children as the trainer and his or her average measurement will be compared
against the true value to assess accuracy.
Precision means how close the measured values are to each other. In the
standardization exercise, the measurer’s two measurements from the same child
will be compared to each other assess precision.
The technical error of measurement (TEM) is used to assess the measurers’
precision and accuracy across the 10 children. Each measurer must pass the
standardization exercise on both precision and accuracy. The criteria for passing
has been established by WHO/UNICEF
(https://www.who.int/nutrition/publications/anthropometry-data-quality-report/en/).
Height or length measurement acceptable TEM is <0.6 cm for precision and <0.8
cm for accuracy. The TEM is generated based on the sum of the average
differences between measurements over total number of children measured. The
more outliers (in either direction), the greater will be the TEM.
47
Fig. 1 Illustration on accuracy and precision
Low accuracy High accuracy High accuracy
High precision Low precision High precision
Procedures for the standardization exercise are provided in Appendix D.
48
Chapter 4. CAPILLARY BLOOD COLLECTION
Learning objectives
m List supplies for blood collection
m Determine the site of blood collection for the appropriate age group
@ List steps involved in obtaining a capillary blood sample from the finger
m Perform steps involved in obtaining a capillary blood sample from the
finger
@ List steps involved in obtaining a capillary blood sample from the heel
m Apply steps involved in obtaining a capillary blood sample from the heel
m List best practices and precautions to observe when collecting blood
4.A. Introduction
This chapter describes the materials needed for and, the steps involved in, capillary
blood collection.
Capillary blood will be collected as part of the survey to test for anemia. Capillary
blood can be obtained from the palm side of the tip of a finger or from a heel. For
adults and children age 12 months and older, a finger should be used. For children
less than age 12 months, the heel should be used. For children who are
undernourished or skinny a heel puncture is also recommended because the finger
tissue can be thin, and the lancet may pierce the bone.
4.B. Materials and supplies for performing finger or heel pricks
The capillary blood drops collected for biomarker testing will be drawn from a finger
or heel. The following supplies and materials will be used in performing the finger or
heel prick.
Disposable latex gloves: Used to reduce
the risk of bloodborne diseases. Gloves a
must be worn by the biomarker technician IS
and by anyone else who may assist with # a
the blood collection. ’ ML di
Jd
49
Absorbent paper sheets: The surface
area where your supplies will be placed
while you collect the blood. Place the
plastic/shiny side of the absorbent sheet
face down (the absorbent side without
plastic on it should be facing up).
Alcohol preps: Used for cleaning the skin
prior to pricking the finger or heel.
Safety lancets: The lancet is a single-use,
disposable device used to prick the
fingertip or heel. The needle is retractable;
when the trigger is pressed, a surgical
blade quickly protrudes from the device,
punctures the skin, and then automatically
retracts.
à A
XN
N
A
NN
à
K NO
N
N
50
Sterile gauze pads: Used to wipe away
the first drop(s) of blood to stimulate
capillary blood flow.
Adhesive bandages: Applied to the
puncture site to minimize the risk of
infection.
Biohazardous waste bags: Plastic bags
that are provided to hold all the
biohazardous waste generated during the
day except sharps. All waste bags are
labeled with “biohazard” logo.
Sharps containers: All biohazardous
sharps that have pointed tips such as
lancets and microcuvettes, [as well as
capillary blood collection devices. ]
51
4.C.
How to put on gloves
Donning (putting on gloves)
L:
Measure your hand using the glove-sizing chart before choosing a glove to
reduce the potential for tearing.
If possible, thoroughly wash hands before donning gloves and after each
glove change.
Open glove at the cuff and extend opposite hand until thumb crotch is to the
cuff of the glove.
. Once the hand is properly aligned in the glove, move your fingers down into
the glove's fingers.
. Roll the cuff of the glove down the wrist until the glove is secure.
. Replace gloves frequently, including whenever changing tasks.
Doffing (taking off gloves)
1,
4.
4.D.
Pull the glove from above the cuff up on the hand inside out to trap potential
contaminants inside the used glove.
Place the used glove into the palm of the opposite hand (which remains
gloved).
Repeat step 1 on the opposite hand, trapping the first glove inside the
second.
Discard gloves and wash hands.
Steps in obtaining capillary blood from the finger
The following steps describe how to obtain a capillary blood drop sample from the
finger. They apply to the collection of samples from adults and children age 12
months and older. Remember, the informed consent statement must be read, and
consent must be granted, for each eligible adult respondent or parent/guardian of
each eligible child before blood collection.
Preparing the session
L:
If possible, find an indoor site to encourage privacy. The site should have a
table or other furniture with a flat surface where you can lay out the supplies.
A couch, bed, or mat should be readily available if the respondent feels faint
and needs to lie down. If you must do the testing outdoors, find a site in the
full shade and away from rain, dust, and other environmental elements that
might affect the sample.
Describe to the respondent exactly what will be done during blood
collection. For children, describe to the parent or responsible adult
exactly what will be done during the collection of the blood sample and
how they can assist by holding the child on their lap and holding the child’s
hand during the collection of the sample.
52
3. When collecting blood from a child, note that the child may be fearful or
anxious about what is going to happen. Therefore, using a calm and
reassuring manner is important as you begin to collect the blood sample.
Remember that nonverbal communication is important, so maintain eye
contact with the child as you prepare to take the sample. Encourage the
parent/responsible adult to hold the child on his or her lap and place the
child’s legs in between his or hers so that the child does not kick the table
and place his or her arms around the child.
Figure 3-1. How a parent should hold a child for a finger prick.
1. Put on gloves before beginning the
collection of the blood sample from the first
respondent.
2. Kneel on the side of the respondent
opposite to the hand/heel from which
you will collect blood. For example, if
you want to collect the sample from the left
hand, place yourself to the right side of the
respondent. Do not sit on a chair.
53
3. Use the third or fourth finger for
collecting blood. Do not use a finger with
a scar, a wound or cut, swelling, a
deformity, a rash, or an infection. Also do
not use a finger on which the respondent is
wearing a ring, because the ring may
disrupt the free flow of blood to the tip of
the finger. You can ask the respondent to
remove the ring.
Puncture sites
4. Ask the adult respondent to briskly
rub his/her hands together to warm
the fingers.
For children, ask the parent/responsible adult to
warm the child’s hand by briskly rubbing
the child’s fingers in between their palms.
5. Set up your station:
Take out a clean absorbent paper sheet
and spread the shiny side down over a
flat surface where you will lay out your
supplies.
Open the sterile gauze package.
Separate the two pieces of gauze and
lay them down on the package so they
do not touch the absorbent pad.
Open the outer package of the adhesive
bandage. Place the bandage on the
packaging.
package.
Remove the blade slot cover of the
lancet. Prepare the lancet for use.
Simply twist the blade slot cover 360°
until the cover comes out. Do not
remove the blade slot cover from the
lancet other than as instructed here, as
this may damage the lancet and cause it
to malfunction.
Open the alcohol prep
54
6. With an alcohol prep pad, clean the
skin of the finger or heel thoroughly. If
the skin is dirty, use a second pad. Clean
the finger before pricking.
7. Allow the finger or heel to air dry
completely. Do not blow on the area to
dry the alcohol. Blowing may allow
bacteria to contaminate the site. Allow the
alcohol to air dry. If the finger is not
properly dry, you run the risk of mixing
alcohol with the blood. It takes 15-20
seconds for the alcohol to dry. If the alcohol
used to clean the puncture site mixes with
the blood, it can cause hemolysis of the
sample leading to errors in the test results.
8. Position the hand palm side facing up.
Form a pad with your index and middle
finger behind the base of the respondent’s
middle finger and your thumb in front of the
respondent’s finger.
55
9. Using a rolling movement of your
thumb, push blood from the base of
the finger to the tip. This action will
stimulate a flow of blood to the fingertip.
For children, it may be helpful if the parent or
responsible adult assists you by holding the
child’s hand.
Note: Never “milk” the finger. Milking is excessive massaging or squeezing
of the finger, which will cause tissue juice to mix with and dilute the blood.
This will result in erroneous test results, specifically, a lower Hb
concentration. Instead, the biomarker technician should employ only mild
pressure by using the thumb and the index and middle fingers to support the
base of the finger.
Figure 3-2. How to hold the finger for a finger prick.
Biomarker
Tech’s Thumb
Biomarker
Tech’s Index
and Middle
Finger
This position will make the connective tissue underlying the skin more porous
and allow the capillary blood to flow easily after the incision.
56
10.Place the lancet firmly against the skin
with the trigger facing up, so that the
arrow on the lancet is visible and pointing
towards the prick site. Use the lancet to
prick the skin by placing the blade-slot
surface against the area and pressing the
trigger. (The tip of the blade ejects through
the blade slot, producing a micro-incision in
the skin, and immediately retracts into the
device.) After pricking the skin, drop the
used lancet into the Sharps container.
Note: Avoid placing the lancet on the very tip of the finger or the sides beyond the
palmar area or you will risk piercing the underlying bone. You can first place and
press the lancet into the finger without pushing the trigger. The lancet is equipped
with “teeth” that will indent the skin to demonstrate where the puncture will occur.
Re-adjust the placement of the lancet if needed. Using the arrow on the lancet, be
sure to pierce the skin perpendicular and not parallel to the fingerprint pattern.
Pricking the finger perpendicular to the fingerprint pattern will allow the blood drop
to form on the surface of the finger and not drip down the side.
Figure 3-3. How a position the lancet to prick the finger.
Orientation Arrow
57
11.When your thumb reaches the fingertip,
maintain a gentle pressure to trap the
blood in the fingertip.
12.When the blood appears, use a sterile
gauze pad to wipe away the first and
second blood drops. Collect the third
blood drop for anemia testing.
13.When blood collection is completed,
apply a piece of sterile gauze at the
prick site to stop the blood flow.
58
14.Apply an adhesive bandage to the
prick site.
15.Discard all materials used in the blood
collection procedure in a labeled
biohazardous waste bag.
4.E. Obtaining capillary blood from a child’s heel
The heel is the puncture site for children age 6 - 11 months, or malnourished
(skinny) children whose fingers are very thin. A lancet that punctures to a depth of
1.8 - 2.0 mm will be used to puncture the heel. The following describes the steps
that are involved in obtaining a capillary blood drop from the heel.
59
1. Prepare to prick outside an imaginary line
drawn from the middle of the big toe to the
heel or outside an imaginary line drawn
from the area between the fourth and fifth
toes to the heel. Take care to avoid the
central area of the foot (to avoid injury to
the nerves and tendons) or the center of
the heel (to avoid piercing the heel bone).
Ÿ Do not
\prick here
\
2. Hold the heel firmly. Apply moderate
pressure near the puncture site by
wrapping the heel using your thumb and
second finger.
3. Clean the site with an alcohol prep.
Make sure the site is dry before puncturing
the skin with the lancet. In selecting a
puncture site, avoid any areas of the skin
that are broken or infected.
4. Place the blade-slot surface against
the skin and press the trigger. Ensure
the free flow of blood.
5. When the blood appears, use a sterile
gauze pad to wipe away the first two
drops of blood, use the third drop for
anemia testing.
60
6. Apply an adhesive bandage to the
prick site.
7. Discard all materials used in the blood
collection procedure in a labeled
biohazardous waste bag.
4.F. Precautions to observe when collecting blood samples“
This section describes the universal (general) precautions to be followed during
blood collection.” You should take precautions when collecting blood to prevent
exposure to blood borne infections such as hepatitis B or HIV. Follow the steps
below to ensure protection against blood borne infections.
m@ If you must prick a second time, do not prick the same finger or heel.
m@ Do not use the same pair of gloves for more than one respondent.
If you have worked with one respondent and your gloves do not appear
soiled, you must still discard them and put on a fresh pair of gloves when
working with a different respondent. It is also possible that you use more
than one pair of gloves when working with just one respondent if the
gloves become heavily soiled.
m Keep intermittent pressure on the finger or heel during the blood
collection process.
m Do not milk the finger: milking the finger may cause the interstitial fluid
to mix with blood and dilute the blood sample giving false results. Also, if
a large volume of tissue fluid mixes with the blood, the sample will be like
a plasma sample instead of a whole blood sample.
4 Adapted from National Committee for Clinical Laboratory Standards (NCCLS) 1997
> For the universal precautions regarding bloodborne pathogens, see the U.S. Centers for
Disease Control and Prevention guidelines and the U.S. Occupational Safety and Health
Administration (OSHA) standards for protection from exposure to bloodborne pathogen.
61
If your gloves are soiled with blood, complete the blood collection
process and change them immediately once you have finished with that
respondent.
Wear latex gloves. Gloves help to prevent skin and mucous-membrane
exposure to blood. Gloves should be worn during blood collection, until the
specimen(s) from a respondent is collected and all waste materials
produced during the collection are disposed. At that point, the used gloves
should be treated as biohazardous waste. A new pair of latex gloves should
be used with each respondent. Gloves must never be re-used!
Avoid penetrating injuries. Although gloves can prevent blood
contamination of intact and non-intact skin surfaces, they cannot prevent
penetrating injuries caused by the instruments used for finger or heel
pricks. Safety lancet devices reduce the risk of penetrating injuries.
Do not use lancets for purposes other than a single finger or heel
prick to collect blood for the biomarker testing. The lancets should not be
broken or destroyed for curiosity or other purposes. After the device is
used, it should be placed in a puncture-resistant sharps container.
Wash contaminated areas. If an accident occurs, any skin surfaces or
mucous membranes that become contaminated with blood, should be
immediately and thoroughly washed with running water or a large quantify
of water from a bucket or basin.
Never eat or drink during the testing. Eating or drinking while
collecting blood samples may result in contaminating yourself and is
prohibited during the blood collection and testing procedures.
Properly dispose of all biohazardous materials. All materials coming
in contact with blood must be placed in a biohazardous waste container
after use and disposed of according to the survey’s policy on infectious
waste disposal. Take precautions when storing and transporting the waste
during the fieldwork.
Good blood collection practices
Good position in relation to the respondent. Position yourself well
before you make a puncture on the respondent’s finger or a child’s heel, such
as kneeling below the respondent’s heart level.
Do not prick the finger or heel if it is cold! Warm the hands by asking
the adult to rub his/her hands together. For children, ask the
parent/responsible adult to rub the child’s hand or heel vigorously to warm
the prick site.
Never “milk” the finger. Excessive massaging or squeezing of the finger or
foot will cause tissue juice to mix with and dilute the blood.
62
Never mix alcohol with the blood. If the alcohol used to clean the
puncture site mixes with the blood, it can cause hemolysis of the sample
leading to errors in the testing results. To avoid this problem, the finger or
heel must be air dried completely before being punctured.
Avoid obstructing blood flow. It is important to hold the finger properly to
allow the accumulation of blood at the puncture site. Holding the finger too
tightly can obstruct blood flow to the finger.
Push lancet in firmly to avoid shallow punctures. A deep puncture
should be made for better blood flow and to have a representative
concentration of red blood cells.
Dispose of biohazard materials as they are used. Keep the biohazard
bag and sharps container open during blood collection and drop each
disposable item in the appropriate container as you finish using it.
If blood flow stops before all biomarkers are collected/tested, lay out all new
supplies to make a second prick.
NEVER leave behind or give biohazardous waste to respondents or
parents/responsible adults, even if they request it.
63
Chapter 5. HEMOGLOBIN MEASUREMENT (ANEMIA
SCREENING)
Learning objectives
e Define anemia and its causes
e List supplies for measuring hemoglobin (Hb)
e List steps for anemia testing among children
e Demonstrate proper use and care of the HemoCue Hb analyzer
e List precautions in measuring Hb
e List steps in providing test results and anemia information for adults
and children
5.A. Introduction
Red blood cells contain hemoglobin (Hb), an iron-rich protein that binds oxygen in
the lungs and carries it to tissues and organs throughout the body. Anemia is
defined as a reduction in the normal number of red blood cells or a decrease in the
concentration of Hb in the blood. During the [COUNTRY] DHS, we will measure the
amount of Hb in a respondent’s blood. Respondents who have an Hb level below a
defined cut-off will be classified as anemic.
Symptoms of anemia range include fatigue and weakness, shortness of breath and
heart problems. During the [COUNTRY] DHS, we will measure the
amount of Hb in the blood of men, women and children. Any
respondent with an Hb level below 8.0 g/dL will be classified as
severely anemic. Hemoglobin testing in the [COUNTRY] DHS will be
performed using a HemoCue analyzer (Hb 201+). This widely used
system measures Hb concentration from a drop of capillary blood
obtained from a finger or heel prick. The test is rapid, allowing results
to be reported to the adult respondent or parent/responsible adult of
children and adolescents immediately following the testing procedure.
Respondents found to have severe anemia will be referred to a health
facility for treatment.
This chapter discusses the materials needed and the procedure for hemoglobin
testing. In addition, guidelines regarding precautions to take during
collection and testing, recording results in the Biomarker
Questionnaire, and providing test results and anemia information to
households are outlined.
5.B. Overview of anemia
Common causes of anemia include:
64
e Iron deficiency from inadequate intake of foods containing iron, such as
red meat.
e Intake of foods that contain non-bioavailable iron such as iron
compounds that have been used for fortification of food.
e Malaria and other parasitic infections (for example, schistosomiasis;
hookworm).
e Blood disorders (for example, sickle cell anemia; thalassemia).
Anemia is a common and significant global health problem. Consequences of
anemia include an increased risk of maternal and child mortality, impaired cognitive
development in children, and increased numbers of pre-term and low birth weight
babies.
The measurement of Hb is the primary method of screening for anemia. Hb
measurement in the DHS provides an opportunity to:
e Estimate the prevalence of anemia in a nationally representative
sample.
e Link the levels of anemia with demographic data so as to examine the
socioeconomic, residential, and demographic differences in the
prevalence of anemia among populations.
e Design programs to prevent iron-deficiency anemia among the
populations most in need of intervention (for example, iron
supplementation programs for young children living in rural districts).
5.C. Materials and supplies for Hb measurement
In addition to the Biomarker Questionnaire and supplies listed in Chapter 3, the
following equipment and supplies are required for hemoglobin measurement:
Microcuvette:
a plastic disposable unit that
serves as both a reagent vessel @
and a measuring device. The tip
of the microcuvette contains a
dry, yellow reagent (sodium
azide). The microcuvette is
designed to draw up the exact
amount of blood needed for the
test.
65
HemoCue Hb 201 + analyzer:
a device that uses the absorption
of light to measure the
hemoglobin concentration of a
single drop of blood collected in a
microcuvette. Test results are
presented on the analyzer’s
display.
HemoCue Optronic Cleaning
Swab:
a cleaning swab used 1-2 times a
week to clean the optronic unit in
the HemoCue analyzer. Swabs ee]
are designed to absorb blood
without smearing it.
Two paper handouts are available to parents/responsible adults:
1. Informational pamphlet: a one-page document listing the causes of
anemia, ways to prevent anemia and a record of household results for
anemia and anthropometry measurements. See Appendix A for an example
of an informational pamphlet.
2. Anemia referral form for severely anemic respondents: A completed
form will contain the name and Hb result of the severely anemic respondent
(defined as an Hb level below 8.0 g/dL) and should be given to the adult
respondent or a child/adolescent’s parent/responsible adult. The respondent
should take the referral to a local clinic or health center to ensure he/she
receives proper treatment for severe anemia. See Appendix E for an
example of a severe anemia referral form.
5.D. Handling and storage of the HemoCue Hb 201+ analyzer
licrocuvettes:
though the HemoCue analyzer has proven to be durable and reliable under field conditions,
there are some technical limitations related to the fact that microcuvettes are
sensitive to humidity. Follow these instructions for the proper handling and storage
of microcuvettes.
1. Always check the printed expiration date on the side of the container of
microcuvettes before using or opening a new container. If the container is
66
expired, throw the microcuvettes away in the Sharps bin and open a new
container.
2. Keep the microcuvette container at room temperature and avoid exposing
the container to heat or strong sunlight.
3. Record on the microcuvette container the date it was first opened.
4. Remove only one microcuvette at a time from the container; use it
immediately.
5. Remove the microcuvette by holding the side opposite the tip.
6. After taking a microcuvette out of the container, immediately snap the
container lid back on tightly.
nder these conditions, the microcuvettes can be stored for up to 3 months (90 days) after
opening. HOWEVER, under field conditions, it is advisable to store the
microcuvettes in the opened container for no more than one month (30 days).
Microcuvettes from unopened containers can be used up to the expiration date on
the container.
he HemoCue Analyzer:
> ensure the HemoCue Hb 201+ system operates properly, allow the analyzer to come to the
ambient temperature and protect it from direct sunlight. The device operates
optimally between 18 and 30° C. The photometer has an internal electronic
“SELFTEST”; every time the analyzer is turned on, it automatically verifies the
performance of its optronic unit.
1e analyzer’s black microcuvette holder has three operating positions: 1) pushed in, for
measuring; 2) pulled out until “clicked,” for placing the microcuvette; 3) completely
withdrawn for cleaning.
5.E. Determine eligibility and obtain informed consent for Hb
measurement
Children: Follow the steps below for anemia testing of eligible children 6-59
months.
You must first verify the eligibility of the child for anemia testing. To do so, follow
the steps in the questionnaire starting at Q. 117.
Q. 117: CHECK 103: IS THE CHILD AGE 0-5 MONTHS OR IS THE CHILD OLDER?
Children age 0-5 months (i.e., <6 months), are not eligible for blood collection and
67
are therefore not eligible for either anemia testing.
Q. 118: RECORD NAME OF PARENT/RESPONSIBLE ADULT FOR THE CHILD.
This person will be asked for their informed consent to anemia testing for that child.
Do not enter any information into the boxes labeled LINE NUMBER.
Q. 119: ASK CONSENT FOR ANEMIA TESTS FROM PARENT/RESPONSIBLE ADULT.
Process of obtaining informed consent for children:
Process
Obtain the consent of one of the child’s parents, or, in the
absence of a parent, the consent of a responsible adult who is at
least 18 years of age. If the parent or responsible adult does not
consent to the test, do not perform the test.
Q. 120: CIRCLE THE CODE.
After reading the consent statement, record the parent/responsible adult’s response
to the request to allow the child to participate in the testing. If the
parent/responsible adult agrees, circle ‘1’ (GRANTED). If the parent/responsible
adult refuses to allow the child to participate in the testing, circle ‘2,’
(REFUSED) and skip to Q. 122.
. 121: SIGN NAME AND ENTER [FIELDWORKER] NUMBER OF HEMOGLOBIN
MEASURER.
At this point, set up your station and proceed with the anemia testing.
Adolescents: Follow the steps below for anemia testing of an eligible adolescent
age 15-17 years.
Example taken from the women’s section of the Biomarker Questionnaire; the
procedures are the same for adolescent males.
Q. 212: CHECK 203:
Since the respondent is age 15-17, put an X in the box ‘AGE 15-17 YEARS.’
Q. 213: CHECK 204:
Since the respondent has never been in a union, put an X in the box ‘CODE 4
(NEVER IN UNION)’ and skip to Q. 217.
_217: RECORD LINE NUMBER AND NAME OF THE PARENT/OTHER ADULT
RESPONSIBLE FOR ADOLESCENT.
This person will be asked for their informed consent to anemia testing for
that adolescent.
Q. 218: ASK CONSENT FOR ANEMIA TEST FROM PARENT/RESPONSIBLE ADULT:
Read the informed consent statement to the parent/responsible adult.
Q. 219: CIRCLE THE CODE.
If the parent/other adult responsible agrees, circle ‘1’ (GRANTED). If he/she refuses
to allow adolescent to participate in the testing, circle ‘2,’ (REFUSED). If the
68
parent/other adult responsible for the adolescent is not present/other, circle ‘3’ and
skip to Q. 225.
Q. 220: SIGN NAME AND ENTER [FIELDWORKER] NUMBER OF HEMOGLOBIN
MEASURER.
Sign your name and entering your fieldworker number in the space provided.
Q. 221: CHECK 219:
Check Q. 219, if consent was granted to have the adolescent tested, put an X in box
‘CONSENT GRANTED.’ If consent was not granted, put an X in box ‘CONSENT
REFUSED’ and skip to Q. 225.
Q. 222: ASK ASSENT FOR ANEMIA TEST FROM ADOLESCENT RESPONDENT.
Read the informed consent statement to adolescent respondent.
Q. 223: CIRCLE THE CODE.
If the adolescent agrees, circle ‘1’ (GRANTED). If she refuses to participate in the
testing, circle ‘2,’ (REFUSED). If the adolescent refuses anemia testing, the test
cannot be performed. If the adolescent is not present/other, circle ‘3’ and skip to Q.
225;
Q. 224: SIGN NAME AND ENTER [FIELDWORKER] NUMBER OF HEMOGLOBIN
MEASURER.
Sign your name and entering your fieldworker number.
Adults: Follow the steps below for anemia testing of an eligible adult age 18-[49]
years.
Example taken from women section of the Biomarker Questionnaire; the procedures
are the same for men.
Q. 212: CHECK 203:
Since the respondent is age 18-49, put an X in the box ‘AGE 18-49 YEARS.’
Q. 214: ASK CONSENT FOR ANEMIA TEST.
Read the following informed consent statement to the adult woman and allow for
questions.
Q. 215: CIRCLE THE CODE.
If the adult respondent agrees, circle ‘1’ (GRANTED). If she refuses to participate in
the testing, circle ‘2,’ (REFUSED). If the woman is not present/other, circle ‘3’ and
skip to Q. 225.
Q. 216: SIGN NAME AND ENTER [FIELDWORKER] NUMBER OF HEMOGLOBIN
MEASURER.
Sign your name and entering your fieldworker number in the space provided. Skip
to Q. 225.
69
5.F. Steps in performing the Hb measurement
Prepare the supplies following
instructions in Chapter 3, prepare
blood collection supplies. Take
one microcuvette from the
container and close the container
tightly. Place the microcuvette on
top of the analyzer.
Pull out the microcuvette holder
to the “load” position
Press and hold the blue on/off
button until the display is
activated. After 10 seconds, the
display will show “READY” and - -
-. This indicates the analyzer is
ready for use.
If consent was granted, collect a
blood sample from the
respondent’s finger or heel (for
children 6-11 months) following
the procedure described in
Chapter 3. Use a sterile gauze
pad to wipe away the FIRST
large blood drop from the
finger or the heel. Use the
SECOND large blood drop for
[additional biomarkers].
Continue to apply light
pressure to the finger until
the THIRD drop of blood
appears. When the blood drop is
large enough, fill the microcuvette
in one continuous process. Check
to make sure that the yellow area
of the microcuvette is completely
70
filled. DO NOT “top-off” or refill
the microcuvette. DO NOT let
the microcuvette touch the skin.
Wipe any surplus blood off
both sides of the microcuvette
“like butter from a knife,” using
the clean end of a sterile gauze
pad. Ensure that no blood is
sucked out of the microcuvette
when wiping it. Do not let the tip
of the filled microcuvette touch
the gauze.
Visually inspect the
microcuvette for air bubbles
or improper filling. Since air
bubbles may influence the
hemoglobin measurement, any
microcuvette containing air
bubbles must be discarded. In
such cases, obtain permission
from the adult or adolescent
respondent or the
parent/responsible adult of a child
to repeat the test using a different
finger or heel if the blood has
clotted. You must use new
disposable supplies and follow all
the steps described previously in
obtaining the new sample.
Always use a new finger or
different heel if repeating the test!
8. Place the microcuvette in its
holder and gently close the
holder.
Note: If the three dashed lines - - -
disappear, simply press the on/off
button and they will reappear. The
analyzer is then ready to perform the
Hb measurement.
9. After the blood drop collection,
wipe any remaining blood
from the prick site with a
sterile gauze pad. Press the
gauze pad against the prick site
until the blood flow has stopped
completely.
10. Apply an adhesive bandage to
the prick site. For children,
advise the parent or responsible
adult, especially when the child is
a toddler, to carefully watch that
the child does not take off the
bandage and put it in his/her
mouth as the child may choke on
it.
11. Read the Hb result. The
microcuvette should be analyzed
immediately, and no later than
ten minutes after being filled. The
blood hemoglobin level in grams
per deciliter (g/dl) is displayed 15
to 45 seconds after the drawer is
closed.
72
Note: HemoCue values rarely fall below
4 g/dL and cannot exceed 25.6 g/dL.
12. Remove one glove to record the hemoglobin level as shown on the
HemoCue analyzer in the appropriate box in the Biomarker
Questionnaire and on the anthropometry and anemia pamphlet. If
there is no value to record because the respondent was not present, the
parent/responsible adult refused to consent to the test, or there was some
other problem, record the appropriate code.
13. Using your gloved hand, take
out the microcuvette and put
it in the Sharps container.
Gather up all the other used
testing materials and your gloves
and put them in a labeled
biohazardous waste bag.
Note: Throughout the entire collection
process, biohazardous waste should
have been disposed of immediately into
either a biohazardous waste bag or
Sharps container. Never leave
biohazardous waste on the absorbent
pad to dispose of after the blood
collection and hemoglobin reading are
recorded!
14. Give the informational
pamphlet to the adult or
parent/responsible adult.
Inform him/her of the result and
provide him/her with the
informational pamphlet. When
reporting the result, briefly
explain what the Hb reading
means, using the informational
pamphlet as a guide.
73
15. Provide a written referral to any respondent with severe anemia,
defined as an Hb level below 8 g/dL. Inform the adult or the
parent/responsible adult of children and adolescents about the effects of
severe anemia. Record the Hb measurement on a Severe Anemia Referral
form and encourage the respondent to seek follow-up medical attention.
5.G. Precautions to take during Hb measurement
Please take the following precautions while doing hemoglobin measurement:
If you must prick a respondent a second time, do not prick the same finger or heel.
Keep intermittent pressure on the finger or heel during the blood collection process.
Do not milk the finger: milking the finger may cause the interstitial fluid to mix with
blood and dilute the blood sample giving false results. Also, if a large volume
of tissue fluid mixes with the blood, the sample will be like a plasma sample
instead of a whole blood sample.
If your gloves are soiled with blood, complete the blood collection process and
change them immediately once you have finished with that respondent.
Never remove a microcuvette from the container with fingers wet with
alcohol. This can result in alcohol coming into contact with the reagents
inside the microcuvette and destroying them. Using fingers wet with alcohol
to handle other microcuvettes in the container can also affect them.
Never use the first two drops of blood for hemoglobin testing. [Wipe away
the first blood drop, use the second for [biomarker]]. Always use the third
blood drop for anemia testing. This ensures the free flow of blood and allows
for the collection of blood with a representative concentration of red blood
cells.
Avoid inadequate filling or re-filling of the microcuvette. The chamber of the
microcuvette that contains dry reagents (yellow portion) has to be completely
filled. The microcuvette should be filled with a drop of blood in one
continuous motion. A microcuvette that contains air bubbles should be
discarded.
Avoid getting blood on the outside of the microcuvette. Blood on the exterior
of the microcuvette should be removed; failure to clean the exterior of the
microcuvette can lead to an erroneously high hemoglobin reading.
Avoid keeping the microcuvette out for too long. Keeping the microcuvette
out of the container for too long before using it can lead to errors. Remove
the microcuvettes from its container immediately before starting the testing
procedure.
Avoid misalignment of the microcuvette in the HemoCue analyzer. The
microcuvette only fits into the photometer’s microcuvette holder in one
position. Therefore, place it carefully in the holder and slowly push the holder
inside the photometer to obtain a reading. Slamming the microcuvette holder
74
can cause blood to spray onto the optronic system, an action that can
damage the photometer.
Do not use any microcuvette from a container that has been opened for
more than 30 days or improperly stored microcuvettes for testing.
While in the field, microcuvettes should not be used if more than 1 month has
elapsed since the seal on the container was broken. The containers must be
kept closed when not in use to avoid exposure to moisture, which can destroy
5.H. Cleaning the HemoCue Hb analyzer
After each day of field work, clean the microcuvette holder.
the reagents.
An alcohol swab or
cotton wool/cotton tipped swab moistened with 70% ethanol or isopropanol can be
used to clean the microcuvette holder.
microcuvette holder:
Follow these procedures to clean the
1.
Check that the analyzer is turned off
and the display window is blank.
. Pull the microcuvette holder out of
its loading position. Carefully press
the small catch positioned in the
upper right corner of the
microcuvette holder.
While pressing the catch, carefully
rotate the microcuvette holder
towards the left as far as possible.
Carefully pull the microcuvette
holder away from the analyzer.
Clean the microcuvette holder with
an alcohol swab or cotton wool
moistened with 70% alcohol
(ethanol or isopropyl alcohol). It is
important that the microcuvette
holder is completely dry prior to
reinserting it in the photometer.
75
5. Once or twice per week, clean the
optronic unit with the HemoCue
cleaning swab provided by pushing
the swab into the opening of the
microcuvette holder. The
microcuvette holder should still be
removed. Move the cleaner from
side to side 5-10 times. If the swab
is stained (blood or dirt), repeat the
cleaning procedure with a new
swab. Do not clean the optronic unit
with 70% alcohol. It is important
that the microcuvette holder is
completely dry prior to reinserting it
in the analyzer.
6. Wait 15 minutes before reassembling the draw to the HemoCue analyzer.
Note: The optronic unit of the HemoCue analyzer should be cleaned 1-2 times a
week with a HemoCue cleaning swab. Blood may get on the optronic system if
you do not wipe the outside of the microcuvette before placing the microcuvette
in the holder. If this happens, you will get an error message (E01-E05; E09-E30).
Clean the HemoCue analyzer as described above when you get one of these error
messages. A complete list of error codes is provided at the end of this chapter.
76
5.1.
HemoCue analyzer error codes
Symptom Explanation Action
The analyzer shows an error code. | May be a temporary fault Turn off the analyzer and turn it on again after 30 seconds.
Take a new microcuvette and repeat the measurement.
If the problem continues, see specific error code below.
E00 No stable endpoint is found within the time range. 1a. Check the expiration date for the microcuvettes.
1. The cuvette is faulty. 1b. Take a new microcuvette and repeat the measurement.
2. The circuit board is out of order. 2. The analyzer needs service. Contact HemoCue, Inc.
E01-E05 1. Dirty optronic unit or faulty electronic or optronic 1a. Turn off the analyzer and clean the optronic unit
unit as descriped in the maintance section.
1b. The analyzer needs service. Contact HemoCue, Inc.
E06 1. Unstable blank value The analyzer might be cold. 1. Turn off the analyzer and allow it to reach room
temperature. If the problem continues, the analyzer
needs service. Contact HemoCue, Inc.
E07 1. The battery power is too low. 1a. The batteries need to be replaced. Turn off the analyzer
and replace the batteries, 4 type AA.
1b. Use the power adapter.
E08 The absorbance is too high. 1a. Check that the analyzer and microcuvettes are being
1. An item is blocking the light in the cuvette holder. used according to the HemoCue Hb 201+ operating
manual and instructions for use.
1b. The analyzer needs service. Contact HemoCue, Inc.
E09-E30 1. Dirty optronic unit or faulty electronic or optronic 1a. Turn off the analyzer and clean the optronic unit
unit as described in the maintance section.
1b. The analyzer needs service. Contact HemoCue, Inc.
Symptom Explanation Action
HHH 1. Measured value exceeds 25.6 g/dL (256 g/L, 15.9 mmol/L)
No characters on the display 1. The analyzer is not receiving power. 1a. Check that the power adapter is connected to the
N
. If on battery power, the batteries need to be replaced.
3. The display is out of order.
AC power supply.
1b. Check that the power adapter is securely connected
to the analyzer.
1c. Check that the cable is not damaged.
2. Turn off the analyzer and replace the batteries,
4 type AA.
3. The analyzer needs service. Contact HemoCue, Inc.
The display gives erroneous
characters.
1. The display is out of order.
2. The microprocessor is out of order.
1. The analyzer needs service. Contact HemoCue, Inc.
2. The analyzer needs service. Contact HemoCue, Inc.
The display shows “<—=". 1. The batteries need to be replaced. 1. Turn off the analyzer and replace the batteries,
2. If on AC power, the power adapter or the circuit 4 type AA.
board is out of order. 2a. Check that the power adapter is properly connected
and working.
2b. The analyzer needs service. Contact HemoCue, Inc.
The display does not switch from | 1. The magnet in the cuvette holder may be missing. 1. The analyzer needs service. Contact HemoCue, Inc.
“g"and “Hb” to three flashing 2. The magnetic sensor is out of order. 2. The analyzer needs service. Contact HemoCue, Inc.
dashes and “ ® “(ready for
measuring).
77
Symptom
Explanation
Action
Measurements on control
materials are out of range -
either too HIGH or too LOW.
É
on
The microcuvettes are beyond their expiration date,
damaged or have been improperly stored.
. The optical eye of the microcuvette is contaminated.
. The control has not been mixed properly and/or is not
at room temperature.
. Air bubbles in the microcuvette
The optronic unit is dirty.
. The control is not suitable for use with the HemoCue
Hb 201+ system.
. The calibration of the analyzer has been changed.
. The controls are beyond their expiration dates or have
been improperly stored.
CA
2.
3. Make sure that the control is mixed properly and at
Check the expiration date and the storage conditions
of the microcuvettes.
Remeasure the sample with a new microcuvette.
room temperature.
. Check the microcuvette for air bubbles. Remeasure the
sample with a new microcuvette.
. Clean the optronic unit as described in the maintance
section.
. Only use controls intended for the HemoCue Hb 201+
system. Contact HemoCue, Inc. for control information.
. The analyzer needs service. Contact HemoCue, Inc.
. Check the expiration date and the storage conditions
of the control. Take a new microcuvette and repeat
the measurement from a new vial/bottle of control.
Measurements on patient
samples are higher or lower
than anticipated.
. Improper sampling technique
2. The microcuvettes are beyond their expiration date,
nus w
damaged or have been improperly stored.
The optical eye of the microcuvette is contaminated.
. Air bubbles in the microcuvette
The optronic unit is dirty.
. The calibration of the analyzer has changed.
. See pages 8-17 in this manual.
. Check the expiration date and the storage conditions
of the microcuvettes. Check the entire system with a
commercial control.
. Remeasure the sample with a new microcuvette.
. Check the microcuvette for air bubbles. Remeasure the
sample with a new microcuvette.
. Clean the optronic unit as described in the maintance
section.
. The analyzer needs service. Contact HemoCue, Inc.
78
Chapter 6. BIOHAZARDOUS WASTE DISPOSAL
Learning objectives
m Define biohazardous waste
Define biohazardous waste disposal
How to collect and store biohazardous waste during training and fieldwork
Procedures for field disposal of biohazardous waste
Methods of destroying biohazardous waste
6.A. Introduction
Any material that has come in contact with blood or other bodily fluids such as
lancets, microcuvettes, alcohol swabs, gauze, and gloves are considered to be
biohazardous waste (hazardous to other humans). Safe disposal of such material
(biohazardous waste disposal) is crucial to prevent the transmission and spread of
various bloodborne diseases, such as hepatitis B and HIV, among survey personnel
and survey respondents. Biohazardous waste must be collected in biohazardous
waste bags or sharps containers immediately following blood collection and testing,
securely stored and transported, and safely disposed of prior to leaving a cluster.
Both biohazardous waste bags and sharps containers have a special logo warning
about biohazardous content. Sharps containers should be securely closed for safe
storage and transportation of used sharp materials.
6.B. Collecting and storing waste during trainings and fieldwork
During training and while in the field/during data collection, all soiled (containing
blood) biomarker supplies (for example: absorbent sheets, gloves, gauze, etc.), and
their packaging will be placed in a biohazardous waste bag. Items identified as
sharps, posing a personal health risk to biomarker technicians, respondents and
anyone disposing of waste (for example: microcuvettes, safety-engineered lancets,
etc.) will be collected in a sharps container.
Biohazardous Waste Bags
For the [YEAR] [COUNTRY] [SURVEY], three sizes of biohazardous waste bags are
provided: small 2-3 gallon (7.5-11.3 liters), medium 7-10 gallon (26.5-37.8 liters)
and large 12-14 gallon (45.4-52.9 liters). The small “household” waste bag will be
used to collect all the non-sharps biohazardous waste from one household. Once
the biomarker technician has completed processing all eligible respondents within a
single household, the small biohazardous waste bag should be tied in a knot making
sure to remove any excess air. When traveling from one household to another, all
individually knotted small biohazardous waste bags should be stored in a medium
79
“field” waste bag for easier transport. Thus, the biomarker technician can carry
around one medium biohazardous waste bag instead of five or so small waste bags.
At the team space or vehicle (wherever the biohazardous waste is being stored), all
used medium biohazardous waste bags should have the excess air removed from
them and be transferred for storage into a large “cluster” waste bag. The large
biohazardous bag should hold all the waste collected within a cluster. If not, a
second cluster bag may be used. See the table below for each biohazardous waste
bag and their appropriate use.
Biohazardous Appropriate Use Storage When Filled
Waste Bag
2 to 3-gallon Small household biohazardous Store inside of medium
waste bag biohazardous bag
7 to 10-gallon Stores the small biohazardous Store inside of large
waste bags used in households for biohazardous bags
easier transport though the field
12 to 14-gallon Stores the medium biohazardous | Store at the team space until
waste bags per cluster disposal at a local health
facility
If all the waste from one household will not fit into one 2-3 gallon small
biohazardous waste bag, please use another small bag to collect the remaining
household waste. Generally, 1-2 large cluster bags are enough to hold all the waste
from one cluster.
Sharps Containers
For the [YEAR] [COUNTRY] [SURVEY], [SIZE] sharps containers are provided. Sharps
are any items used to measure biomarkers (and as a result are contaminated with
biohazardous bodily fluids or blood) that can puncture through the thin plastic
biohazardous waste bags. Examples include lancets, microcuvettes, rapid
diagnostic test cartridges, capillary tubes, and glass slides. All sharps containers
used in the XDHS are made of puncture-proof plastic so any item placed inside of
them will not puncture through the material. This is not the case for the plastic
biohazardous waste bags. Sharp items include, but are not limited to, safety-
engineered lancets, lancet covers and microcuvettes. To protect both the biomarker
technicians and the respondents, safety-engineered lancets are used to reduce
exposure to blood and injuries. These lancets are one-time use and thus, the blade
permanently retracts into the casing after being triggered. However, if these
lancets are tampered with after use (i.e., taken apart), it is possible to recover the
blade inside the casing, so we place lancets inside the sharps container. Unlike the
biohazardous waste bag, items cannot be recovered from the sharps container once
80
they are sealed.
Note: you should NEVER attempt to remove any biohazardous waste
material once it is discarded in the biohazardous waste bag or sharps
container!
See the table below for sharps containers and their appropriate use.
Sharps Containers Appropriate Use Storage When Filled
5 quarts Sharp biohazardous waste froma | Store at the team space until
(4.7 liters) cluster disposal at a local health
facility
All sharps containers recommended by The DHS Program have a fill line printed on
the outside. Do not fill the sharps containers with material past this line. Sharps
containers once sealed cannot be reused. So once a sharps container is filled, close
the lid and dispose of at a health facility. Start each cluster with a new sharps
container even if the last sharps container from the previous cluster has yet to
reach the fill line.
Sharps container labels
6.C. Procedures for disposal of biohazardous waste
Biohazardous waste is generated at three stages during the YEAR] [COUNTRY] DHS:
during the training, during field practice, and during fieldwork. Prior to generating
any biohazardous waste, [Implementing Agency] in partnership with the [Ministry of
Health, NACP or other country specific agencies] must identify health facilities that
will dispose of the biohazardous waste collected according to [COUNTRY] national
standards. A list of these health facilities and their contact information should be
provided to the team supervisors by the [implementing agency] along with a letter
from the MOH detailing the mission of the survey, introducing the team, and
outlining the services needed from that facility.
81
At the end of training and after each blood collection within the household, all non-
sharps materials used during the testing (i.e., gloves, alcohol swabs, and gauze
pads) are to be placed in a 2-3 gallon household biohazardous waste bag. All sharp
materials (i.e., lancets and microcuvettes) are to be placed in the sharps container.
All biohazardous materials should be immediately placed in the appropriate waste
bag or container after use. For instance, once you have pricked the finger or heel
with the lancet, you should place the lancet directly into the sharps container, do
not place the lancet back on the absorbent sheet.
Before proceeding to new cluster, team supervisors should identify (from the list of
facilities provided by [IMPLEMENTING AGENCY], the local health facility where the
waste can be safely destroyed. Team supervisors should contact the health facility
prior to or soon after entering the cluster to introduce themselves and inform the
local health facility that the team intends to dispose of the biohazardous waste from
the cluster(s) there. One health facility may be used for the disposing of waste from
multiple clusters; hence it is considerate to inform the local health facility ahead of
time.
6.D. Methods of destroying/decontaminating biohazardous waste
It is likely that the local health facilities identified by the government for safe
disposal of biohazardous waste during the [YEAR] [COUNTRY] DHS will use one or a
combination of the following methods to destroy or decontaminate the
biohazardous waste. The two methods listed below are the best management
options for solid infectious waste for small-scale activities.
Incineration
Incineration is the process of burning biohazardous waste and reducing the waste
volume by about 80%. Incineration can take place in a chamber or drum/brick
furnace. Through this method, 99% of microorganisms on biohazardous waste and
contaminated sharps are destroyed. However, the sharps found in ashes can still
pose a physical hazard. Open-air incineration is less effective at disinfecting and
has the potential for incomplete burning (leaving behind infectious material), is
more hazardous to the staff involved and runs a greater risk of unburned supplies
being scavenged by people and animals.
Autoclave
Autoclaving is the process of sterilizing waste with steam treating at high
temperature and pressure. In order to be effective, the steam needs to be able to
penetrate the waste. Autoclaving can also be used to sterilize reusable medical
waste. We do not autoclave and reuse any of the materials used in the [YEAR]
[COUNTRY] DHS.
82
A few points to remember when you are collecting and storing biohazardous waste
in the field:
+ NEVER leave biohazardous waste in households
e Biohazardous waste should NEVER be disposed of in general solid waste
containers or facilities
e Never store anything in the biohazardous waste bags or sharps containers
other than biohazardous waste
+ Once closed, the sharps containers cannot be reopened, so take care when
moving through the field not to close the container prior to reaching the fill
line
83
Chapter 7. APPENDIX
What IS malnutrition?
7.A. Informational pamphlet
Malnutrition is a serious health condition that
refers to undernutrition, micronutrient HEIGHT AND WEIGHT MEASURES
deficiencies, or overweight. Name Name Name Name Name
What CAUSES malnutrition?
9 Not having enough to eat or not eating
frequently enough. WEIGHT,
Not eating enough of the right foods. Kg Ka Kg Kg Kg
Poor health care and feeding practices. HEIGHT
Frequent infections or disease.
- ESA cm cm cm cm cm
Why is malnutrition DANGEROUS?
à It increases risk of death, infections, and
chronic disease. HAEMOGLOBIN
à Causes cognitive impairment leading to
poor education performance. gl g/dl gl gl g/dl
What do the Height and Weight Haemoglobin level diagnosis (circle one)
results MEAN? Normal | Normal | Normal Normal | Normal
9 Height and weight on their own do not 5 5 : 5
provide enough information on Mu Mild Mild Mild Mu
malnutrition status. Seek advice from a Moderate | Moderate | Moderate | Moderate | Moderate
healthcare provider for more information.
Severe |Severe |Severe |Severe | Severe
How can malnutrition be PREVENTED?
9 Exclusively breastfeed your child for the
first 6 months of life and continue to
breastfeed up to 2 years or beyond.
Hemoglobin values (Hb g/dl) in populations living at sea level:
9 Eat a variety of food, including fruits or
vegetables for those 6 months or older.
9 Avoid beverages or foods with lots of
Men
213.0
110-129
Moderate Anemia | 7099 [7099 | 109-80 | 109-80
SeveeAnemia [<70 [<70 | <80 <30
sugar or salt.
9 Practice good hygiene and proper food
handling.
® Prevent and treat infections and chronic
diseases.
How can Anaemia be PREVENTED?
© Pregnant mothers and children should
take iron tablets or syrup.
à Eat a diet adequate in iron-rich foods such
as dark green vegetables, liver, meat or
fish, and fruits rich in vitamin C.
9 Avoid giving tea to infants and young
children.
Avoid taking coffee or tea with meals.
Prevent and treat worms.
Prevent malaria by using mosquito nets.
Limit the number of births through child
spacing and delaying first pregnancies.
sf
To increase the body's use of iron, eat more
fruits and vegetables rich in vitamin C:
eee
Iron Rich Foods:
dark green vegetables
meat, liver or fish
oranges
lemons
Mangoes
red bell peppers
Add MOH ADD IA
LOGO LOGO
HERE HERE
What IS Anaemia?
Anaemia is a serious health condition in
which there are not enough red blood cells
or haemoglobin in the blood.
Haemoglobin is a substance in the blood
that carries oxygen to the body. Iron is
important for making haemoglobin.
Why is Anaemia DANGEROUS?
9 It reduces one’s resistance to infections.
9 Severe anaemia can lead to heart failure
during childbirth, anaemic women are
more likely to die from excessive
bleeding.
© Anaemic children have low birth weight,
poor learning capacity, and less
resistance to infections than other
children.
What do the Anaemia Test results MEAN?
Severe Anaemia: You have a seriously
low level of haemoglobin in your blood. You
need to see your doctor or health centre
immediately for treatment. Eat more foods
rich in iron and treat malaria and worms.
Moderate and Mild Anaemia: You
should visit your doctor or health centre
when possible to learn the cause of your
anaemia. Eat more foods rich in iron and
treat malaria and worms.
What CAUSES Anaemia?
9 Loss of blood due to
+ parasites, especially hookworms;
+ excessive menstrual losses;
* chronic diseases.
© Lack of iron in the diet or inability of the
body to absorb iron from food.
COUNTRY Ministry of
Health
COUNTRY IMPLEMENTING
AGENCY
Contact Information: [ADDRESS]
[LAST NAME AND FIRST NAME]
Ph: (+XXX) XXX XXX
Name Date
MOH and [IA] are conducting the YEAR
COUNTRY Demographic and Health
Survey in which testing for anaemia is
included. The study will help us identify
whether there are problems with anaemia
and other illnesses among women, and
young children in COUNTRY.
We appreciate that you allowed us to
interview you, test for anaemia, and
measurement your height and weight.
Thank you for your cooperation.
Please look inside
for the results of your
household's
height and weight and for
your anaemia testing.
84
7.B. Severe acute malnutrition referral
1.A. [YEAR COUNTRY] DEMOGRAPHIC AND HEALTH
SURVEY:
1.B. Severe Acute Malnutrition Referral Form
During the [YEAR COUNTRY] DHS
(Name), age____ months / years, was assessed for acute
malnutrition.
His/her weight was _____. kg and his/her height was |
cm
His/her weight-for-height was - __. _ Z-scores, which indicates
he/she has severe acute malnutrition.
THIS PERSON NEEDS MEDICAL ATTENTION FOR ACUTE
MALNUTRITION IN A HEALTH FACILITY RIGHT AWAY.
Acute Malnutrition Referral Form is given when chi/d’s weight-
85
7.C. Fieldwork maintenance log
FIELDWORK DAILY MAINTENANCE LOG - MEASURING BOARD
Measurement in
Number
Condition/Remarks Not in [Fieldworker]
cm use number
en ic ou RS ee") ee
001
001
FIELDWORK DAILY MAINTENANCE LOG - WEIGHING SCALE
Equipment
1D
Date
(ODIMMIYYYY)
Cluster
Number
Condition/Remarks
[Fieldworker]
number
86
7.D. Standardization form
[COUNTRY] DEMOGRAPHIC AND HEALTH SURVEY
Standardization of Measurers
First reading |
second reading |}
Name of Measurer: of Measurer: Date:
ee of the child
Name of Child nm
Lying down.
Standing up...
i an
Lying down. 1 aan 5
Standing up..........2
2
wingdown..t | LTT JC)
Standing up..........2
Lying down.
Standing up
Lying down.
Standing up
hild 10 Lying down
| | = | Standing up..........2 2 | |
87
7.E. Severe anemia referral
1.N. [YEAR COUNTRY] DEMOGRAPHIC AND HEALTH
SURVEY: Anemia Referral Form
During the [YEAR COUNTRY] DHS (Name), age __
months / years, was tested for anemia on . His/her
level of hemoglobin was_____. __ g/dl, which indicates he/she has
severe anemia. THIS PERSON NEEDS MEDICAL ATTENTION FOR
THE ANEMIA IN A HEALTH FACILITY RIGHT AWAY.
Anemia Referral Form to be given when a respondent’s
hemoglobin level is below 8.0 g/dL.
88