title: Parameters associated with design effect of child anthropometry indicators in small-scale field surveys.
abstract: BACKGROUND
  Cluster surveys provide rapid but representative estimates of key nutrition indicators in humanitarian crises. For these surveys, an accurate estimate of the design effect is critical to calculate a sample size that achieves adequate precision with the minimum number of sampling units. This paper describes the variability in design effect for three key nutrition indicators measured in small-scale surveys and models the association of design effect with parameters hypothesized to explain this variability.
  
  
  METHODS
  380 small-scale surveys from 28 countries conducted between 2006 and 2013 were analyzed. We calculated prevalence and design effect of wasting, underweight, and stunting for each survey as well as standard deviations of the underlying continuous Z-score distribution. Mean cluster size, survey location and year were recorded. To describe design effects, median and interquartile ranges were examined. Generalized linear regression models were run to identify potential predictors of design effect.
  
  
  RESULTS
  Median design effect was under 2.00 for all three indicators; for wasting, the median was 1.35, the lowest among the indicators. Multivariable linear regression models suggest significant, positive associations of design effect and mean cluster size for all three indicators, and with prevalence of wasting and underweight, but not stunting. Standard deviation was positively associated with design effect for wasting but negatively associated for stunting. Survey region was significant in all three models.
  
  
  CONCLUSIONS
  This study supports the current field survey guidance recommending the use of 1.5 as a benchmark for design effect of wasting, but suggests this value may not be large enough for surveys with a primary objective of measuring stunting or underweight. The strong relationship between design effect and region in the models underscores the continued need to consider country- and locality-specific estimates when designing surveys. These models also provide empirical evidence of a positive relationship between design effect and both mean cluster size and prevalence, and introduces standard deviation of the underlying continuous variable (Z-scores) as a previously unexplored factor significantly associated with design effect. The magnitude and directionality of this association differed by indicator, underscoring the need for further investigation into the relationship between standard deviation and design effect.
authors.affiliation: Emergency Response and Recovery Branch, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA.
authors.forename: Erin N
authors.initials: EN
authors.lastname: Hulland
authors.affiliation: Emergency Response and Recovery Branch, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA.
authors.forename: Curtis J
authors.initials: CJ
authors.lastname: Blanton
authors.affiliation: Emergency Response and Recovery Branch, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA.
authors.forename: Eva Z
authors.initials: EZ
authors.lastname: Leidman
authors.affiliation: Emergency Response and Recovery Branch, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA.
authors.forename: Oleg O
authors.initials: OO
authors.lastname: Bilukha
keywords: Anthropometry; Cluster surveys; Design effect; Stunting; Survey methodology; Underweight; Wasting