|Nutrition Guidelines (MSF, 1995, 191 p.)|
|Part I: Nutrition Strategies in Emergency Situations|
|1. Food crises|
|2. Assessment of the nutritional situation|
|3. Interventions: ensuring adequate general food availability and accessibility|
|4. Interventions: selective feeding programmes|
|Part II: Rapid Nutrition Surveys|
|1. Introduction to anthropometric surveys|
|2. Anthropometric measurements and indices|
|3. Sampling methods|
|4. Analysis, interpretation and recommendations|
|Part III Selective feeding programmes|
|1. Justification for selective programmes|
|2. Criteria for admission and discharge to selective feeding programmes|
|3. Screening and selection|
|4.Treatment in a therapeutic feeding centre|
|5. Treatment in supplementary feeding programmes|
|6. Implementation and management of a feeding centre|
|7. Registration and monitoring|
|8. Evaluation of feeding programmes|
|9. Food management|
|Annex 1: Rapid assessment of the state of health of displaced populations or refugees (A.Moren - Medical News, No. 1)|
|Annex 2: Mid - Upper Arm Circumference (MUAC)|
|Annex 3: Nutritional status assessment in adults and adolescents|
|Annex 4: Agencies involved in food relief|
|Annex 5: Food composition table|
|Annex 6: GENERAL RATION: How to calculate the energetic value|
|Annex 7: Micronutrient deficiencies|
|Annex 8: Food basket monitoring methodology|
|Annex 9: Analyzing nutritional survey data|
|Annex 10: Drawing of a random number|
|Annex 11: Standardization of anthropometric measuring techniques|
|Annex 12: Data collection forms|
|Annex 13: W/H Reference tables|
|Annex 14: Selection of food items for selective feeding programmes|
|Annex 15: Oral rehydration for severely malnourished children|
|Annex 16a: Preparation of High Energy Milk|
|Annex 16b: Recipes for porridge for use in therapeutic and wet supplementary feeding programmes|
|Annex 16c: Recipes for premix for dry ration supplementary feeding programmes|
|Annex 17a:Example of a Therapeutic feeding centre|
|Annex 17b: example of layouth of a <<wet>> supplementary feeding centre|
|Annex 17c: Example of a DRY SFP|
|Annex 18a: Example of an Attendance register (tfp or SFP)|
|Annex 18b: Example of a Nutritional Status Monitoring (SFP)|
|Annex 19a: TFP individual monitoring card|
|Annex 19b: SFP individual monitoring card|
|Annex 19c: Individual card for Supplementary feeding centre|
|Annex 19d: Example of an individual card for dry blanket SFC|
|Annex 20: Feeding programme indicator graphs|
|Annex 22: MSF nutrition kits|
When dealing with populations in emergency situations (refugees or displaced people), planners, health officers and officers in charge need to evaluate the nutrition situation quickly and precisely. This evaluation is based on surveillance data, demographic indicators, direct observation, advice from experts and in some cases rapid anthropometric surveys. The quick anthropometric assessment survey (measuring the prevalence of malnutrition) is one of the many tools for evaluation of the nutrition situation, allowing the quantification of malnutrition in the population.
ANTHROPOMETRIC SURVEYS: WHY AND WHEN?
· In the initial phase of an emergency, to assess the situation and take short term relief action.
· In the course of a programme, to assess the evolution of nutritional status, to redirect nutritional programmes and to assess their coverage and impact. The survey may also help in assessing the impact of the programme: was the prevalence of malnutrition reduced? Was the target population covered?
· In the course of a programme, when deterioration or amelioration of nutritional status is suggested by various sources of information: clinics, food availability.
However, an anthropometric survey is not always a priority in emergency situations. A rapid screening of children presenting a high risk of mortality may be needed urgently in order to take immediate life saving action. An anthropometric survey only becomes a priority when there is an urgent need for intervention in order to take decisions to implement actions.
OBJECTIVES FOR SURVEYS
The objectives should include notions of time, place and persons.
The objectives of anthropometric surveys may be:
- to quantify malnutrition in a specified population, at a given time, using indicators of malnutrition;
- to identify higher risk groups. These may be a certain age group, newly arrived refugees, nomads as compared to sedentary people, etc...;
- to estimate the number of children who may benefit from a nutrition programme, e.g. how many children should be expected to need treatment in an intensive feeding care unit with an entry criteria based on a given nutrition index value? How many children could be eligible for supplementary rations?
- to assess trends in nutrition status based on repeated surveys;
- to evaluate a programme in comparison with a target objective;
- to compare the nutrition status of refugees and the local population.
Preparing to do a survey
MEET THE PEOPLE IN CHARGE
Most of the time a survey is carried out in response to the needs for information expressed by the people in charge. The objectives have to be precisely specified with them at this point. They need to understand the methodology used, its constraints, the means required and the limitations of the expected results. People in charge may provide a map of the camp or of the region, and a list or a register of the refugees if available.
GATHER AVAILABLE INFORMATION
Before starting the anthropometric survey, all locally available information should be gathered. Have there been any previous surveys? What were the findings and recommendations? Is there a reliable mortality surveillance system? What information related to food resources is available?...
Collecting demographic information prior to the survey is essential when this information is not readily available or reliable.
DEFINE DATA TO BE COLLECTED, THE PLAN OF ANALYSIS AND THE QUESTIONNAIRE
Data to be collected
During an anthropometric survey, the following basic data needs to be collected:
and possibly, according to the specific objectives of the survey:
- measles immunization status
- date of arrival in the camp
- availability of cooking equipment/fuel at the household level.
- availability of food
The additional questions that could be included should be limited in number. Data collectors and families should not be overwhelmed by the number of questions asked. Only variables with direct relation to nutritional status should be considered. A variable must be easy to measure, and its value should be precisely coded: has this child been correctly immunized against measles (Yes or No)? What is the month of arrival of this child in the camp? Only factors for which action can be taken should be included, such as the number of cooking pots per household.
Variables which are not precisely definable or easy to measure should not be included. For example, the presence of anaemia, because clinical assessment is not reliable and will vary from one data collector to another. Vitamin A or C deficiency assessment can only be included if all data collectors have been well trained in detection
Plan of analysis
Once the objectives have been clearly defined, a plan of analysis should be drawn up. The method of expression should be pre-determined for each indicator. The format for presentation of results can be pre-defined, and tables of results should be constructed without filling in the values. Doing this guarantees that appropriate measurements will be taken, appropriate questions asked and hence, that the objectives of the survey will be met.
The plan of analysis is composed of two parts:
· Descriptive analysis
In this first part, distributions according to the different variable data are constructed: how many boys and girls are there in the sample? Are all age groups represented? What is the proportion of oedema in the sample? This allows verification of sample representativeness and orientation of the analysis (see Annex 9).
· Interpretive analysis
Selected variable data is cross tabulated, in order to compare different groups of the sample according to certain characteristics: are younger children more malnourished than older children? Are the newly arrived refugees more malnourished than those currently in the camp?...
The number of cross tabulations should be kept to a minimum, concentrating on relevant information in order to take action for particular sub-groups of the population. (For an example of a plan of analysis, see Annex 9.)
Questionnaire and information collecting form:
The plan of analysis helps to realize what information must be collected. The questionnaire must be designed to clearly collect all the necessary information (see Annex 12). The questionnaire is used in conjunction with a "surveyor manual" which summarizes the questions as they should be asked and answers most of the questions that a data collector will come across during the course of the survey. Age criteria (6 - 59 month), as well as definitions used in coding the variable data should be included in the surveyor manual (e.g. a correct vaccination against measles is a vaccination reported by card and administered after 9 month of age).
The date of the survey will be chosen with the help of community leaders and administrators. Special dates, such as a local celebration or a food distribution day, should be avoided because most of the people will not be found at home on such a day. The schedule of the survey should allow time for preparation, training, community mobilization, collection of data, analysis and writing of the report.
MEET THE COMMUNITY LEADERS
The community should fully understand the objectives of the survey and be included in the planning of the survey - community members should also be encouraged to participate during data collection. Important points, such as why children should be visited in their households and not in the clinics or feeding centres, should be stressed.
A list of the required equipment should be drawn up, including transport, fuel, measuring equipment, paper and pens, per diem, etc... (Annex 22).
SELECTION AND TRAINING OF THE DATA COLLECTORS. PRE-SURVEY
Data collectors currently involved in delivering health services to the population can be selected if their participation in the survey does not disturb health care delivery to the population. Data collectors do not need to be health professionals, anyone from the community can be selected and trained as long as they are able to read and write. In some cultures, women might be needed in order to deal with young children.
A survey team is composed of 3 people: 2 measurers and a supervisor. Two to four teams may be needed according to the size of the area to be covered.
The training of the data collectors is the corner stone in the course of an anthropometric survey. Each and every data collector should undergo the same training whatever his former experience.
The training takes 2 to 3 days, according to the number of people to be trained and the availability of trainers.
- The objectives of the surveys are explained.
- The sampling method and its rationale are detailed, stressing the importance of a representative sample.
- Height and weight measures are demonstrated. At least 20 height and weight measures should be performed by each enumerator. A test of standardization of anthropometric measurement is used in order to assess the performance of each data collector (the procedure for the test can be found in Annex 11). This test evaluates the precision and exactitude of the data collectors and allows misunderstanding of measurement techniques to be detected prior to the survey.
An on-site visit should be a part of the training, to see that all team members understand the sampling procedure, select the right children and correctly measure and question the respondents. The questionnaire should also be assessed for ease of use and suitability. This may mean having to do additional training or alter the questionnaire after the trial. Data collected during this pre-survey should not be included in the actual survey results.
· Define the survey objectives.
· Collect available information.
· Meet the people in charge.
· Define a plan of analysis.
· Draw up the questionnaire.
· Inform the community.
· Draw up a schedule.
· Gather the necessary equipment.
· Select and train the data collectors.