i

April 2005

NUTRITIONA Guide to Data Collection, Analysis, Interpretation and Use

Food Security Analysis Unit

for SomaliaFSAU is managed by FAO

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First published 2003Second edition 2005Food Security Analysis Unit for Somalia (FSAU)

The contents of this manual may be copied, reproduced or stored without permission, with FSAU acknowledged asthe source.

This guide is published by theFood Security Analysis Unit for Somalia (FSAU)P.O. Box 1230, Village Market, NairobiTel: +254 (020) 374–1299Fax: +254 (020) 374–0598Email: fsauinfo@fsau.or.keWebsite: www.fsausomalia.org

Design and layout by Jacaranda Designs Ltd.

Printed in Nairobi, Kenya

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Acknowledgements

The original version of this manual was developed in November 2003 by the Nutrition ProjectTeam within the Food Security Analysis Unit (FSAU). Valuable contributions have been madeby Bernard Owadi, Nurah Gureh, Sicily Matu Nyamai, Mohamoud Hersi, James King’ori,Mohammed Moalim, Susan Kilobia, Osman Warsame, Ahono Busili, Khalif Nuur and the entirefood security analysis unit. The development of the manual was supported by Margaret Wagahand the initiative supervised by Noreen Prendiville.

The current revision has been undertaken following the use of the manual during numeroustraining workshops throughout Somalia. Valuable comments have been made by Nurah Gureh,Sicily Matu Nyamai, Mohamoud Hersi, James King’ori, Mohammed Moalim, Osman Warsame,Ahono Busili, Khalif Nouh, Abukar Nur, Mohammed Haji, Mohammed Hassan, AbdikarimDualle, Abdikarim Aden, Fuad Hassan Mohammed, Abdirahaman Hersi, Ibrahim Mohamoudand partners involved in the workshops

A revision by FSAU’s team has been found necessary to expound on evolving issues such asdietary assessments, sentinel sites surveillance and micro-nutrient deficiencies.

The team wishes to thank our partners in Somalia and in the Nutrition Working Group for theirvaluable comments on the original version, which have now been incorporated into thisrevision. Their input in the piloting of the manual during three training workshops in Hargeisa,Garowe and Huddur was very valuable.

Finally, the team is grateful for the input of FAO Rome, ESNA and ESNP.

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Foreword

Nutrition is about people and the measurement of the nutritional status of a population is one ofthe most useful indicators of a population’s overall welfare. Nowhere is this more importantthan in countries prone to crises and emergencies like Somalia. In the absence of other basicsources of data in Somalia, the demand for good quality nutrition information has increased.Both governmental and non-governmental bodies collect, understand and use information. Thecontinued high levels of malnutrition among Somali populations (including areas inneighbouring Ethiopia and Kenya) calls for a greater analysis of the causative factors.

As part of its commitment to improve the nutritional status of the Somali people, the UnitedNations Food and Agriculture Organization (FAO) supports the Food Security Analysis Unit(FSAU) in the implementation of food security and nutrition analysis. FSAU works with partnersto strengthen the quality of nutrition-related information in Somalia. These partnerships havestrengthened over the past four years. FSAU now acts as the focal point for the collection,analysis, storage and dissemination of this information. As a result of these partnerships, therehas been strong collaboration across sectors, in particular food security and health.

In response to demands from partners for specific information on nutrition data management, awide range of materials have evolved over the past four years. Methodologies have beenstandardized and guidelines have been developed through a process of consultations and fieldtesting. During the past two years, these materials have been compiled and used during trainingsessions for mid-level management. The training sessions were held in various locationsthroughout Somalia, Somaliland and Puntland, and the materials developed formed the basisfor the production of this manual.

This manual targets mid-level managers in all sectors who would like to better understandnutrition information and its use. In addition, certain sections have been adapted and translatedfor use by survey enumerators, health facility workers and other field workers. Additionalmaterials have also been prepared to support the use of the manual during training.

Noreen PrendivilleProject ManagerFSAU

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Table of Contents

Acknowledgements ........................................................................................................... iii

Foreword ........................................................................................................................... iv

1 Introduction to nutrition information ............................................................................ 11.1 Background ........................................................................................................... 11.2 Use of nutrition-related information ....................................................................... 1

1.2.1 Nutrition information in early warning ........................................................ 21.2.2 Nutrition information in program management ........................................... 2

2 Understanding nutritional vulnerability ........................................................................ 52.1 Overall concepts related to nutrition ..................................................................... 52.2 Nutritional vulnerability ........................................................................................ 52.3 Conceptual framework for understanding possible causes of

poor nutritional status ............................................................................................ 62.3.1 Socio economic and political environment ................................................. 72.3.2 Food security ............................................................................................... 82.3.3 Health, water and sanitation ...................................................................... 102.3.4 Care practices ........................................................................................... 112.3.5 Food consumption .................................................................................... 122.3.6 Food utilization in the body ...................................................................... 122.3.7 Nutritional status ....................................................................................... 12

2.4 Summary of the framework .................................................................................. 12

3 Measuring nutritional status ........................................................................................ 133.1 Anthropometric assessment ................................................................................. 133.2 Biochemical methods .......................................................................................... 143.3 Clinical assessment .............................................................................................. 15

3.3.1 Detection of malnutrition during clinical assessment ................................. 153.4 Dietary methods .................................................................................................. 17

4 Methods of nutritional assessment and analysis .......................................................... 194.1 Current sources of information on nutrition ......................................................... 194.2 Data collection methodologies ............................................................................ 19

4.2.1 Nutrition survey ........................................................................................ 204.2.2 Rapid assessment ...................................................................................... 244.2.3 Health facility data .................................................................................... 254.2.4 Sentinel sites surveillance .......................................................................... 264.2.5 Dietary assessments ................................................................................... 26

4.3 Qualitative data ................................................................................................... 26

5 Analysis and intepretation of the nutrition situation ................................................... 29Steps in data analysis and interpretation ...................................................................... 29Case study ................................................................................................................. 33

Bibliography ................................................................................................................. 35

Appendices ................................................................................................................. 37Appendix 1 ................................................................................................................. 37Appendix 2 ................................................................................................................. 39Appendix 3 ................................................................................................................. 40Appendix 4 ................................................................................................................. 41Appendix 5 ................................................................................................................. 43Appendix 6 ................................................................................................................. 45Appendix 7 ................................................................................................................. 45Appendix 8 ................................................................................................................. 46

FiguresFigure 1 Nutritional status conceptual framework ......................................................... 8Figure 2 Somalia: Current nutrition situation, January 2005 ........................................ 48Figure 3 Somalia: Nutrition surveys (1999 - 2004) ...................................................... 49Figure 4 Somalia: Nutrition surveillance locations (health facilities) ............................ 50Figure 5 Somalia: Nutrition status trends (1999 - January 2005) .................................. 51

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Knowing what people eat is critical for nutritional analysis(photo by FSAU)

1 Introduction to nutrition information

1.1 BackgroundMeasurement of nutritional status is one of thekey indicators for:

• monitoring the overall welfare of apopulation and

• measuring the impact of change in factorsthat affect the welfare of a population.

Negative change in the nutritional status of apopulation indicates a problem. The effects ofincreasing malnutrition are felt in a society bothin the short term and long term. In much of sub-Saharan Africa, measurement (anthropometry) ofchildren under the age of five is the mostcommonly used method for estimating thenutritional status of the population as a whole,although strictly speaking, one cannot imply thatbecause children are malnourished, that thewhole population is malnourished.

The availability of good data provides a strongfoundation for the more important next step -the analysis of the information. Malnutritionrates are meaningless without explanations forthe levels and trends. Frameworks help in theanalysis of information and facilitate a betterunderstanding of the factors that interact toinfluence nutrition at both the individual andpopulation level.

A better understanding of causes of malnutritionprovides a sound basis for the design andimplementation of interventions across thesectors. Understanding the roles of differentactors leads to more effective strategies andefficient use of limited resources.

1.2 Use of nutrition-relatedinformationUsing information on nutrition and otherbackground information supports analysis anddecisions on interventions and programs forboth short and long-term projects. Morespecifically, nutrition information:

• Serves as a vital indicator of the overallhealth and welfare of populationsespecially where regular demographic andhealth surveys are lacking.

• Is critical during crises and emergenciesfor (i) the identification of most vulnerableor affected individuals or groups, (ii) as a

screening tool to identify malnourishedindividuals needing special assistance, (iii)to evaluate the progress of growth amongstthe nutritionally vulnerable groups and (iv)to monitor effects of nutrition interventionsamong vulnerable groups.

• Is invaluable for program management(planning, implementation, monitoringand evaluation) in many sectors includingfood security (agriculture and livestock),health, water and sanitation, educationand environment.

• Nutrition information can contribute todesigning of food, health and otherdevelopment policies.

• Facilitates analysis of socio-economicfactors, demographics, food security andcultural aspects of a population.

• Can be used in crisis mitigation especiallyas an early-warning indicator. This speedsup response to threats like droughts ordisease outbreaks.

The principal users of nutrition information are:• Government authorities and Non

Governmental Organizations (NGOs) thatsupport food security, health and nutrition-related programs

• Donors

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FSAU staff sharing information with health facility staff (photo by FSAU)

• Communities involved in the design,planning and management of nutrition-related programs

• Health workers who produce the data• Food aid agencies like WFP and CARE

1.2.1 Nutrition information in early warning

Populations respond to changes in theirenvironment in many ways and these responsescan ultimately be reflected in changes in foodconsumption and health status. Thesepopulation responses vary from one situationto another with some populations changingtheir nutrition related behaviour, manifesting asincreasing malnutrition quite early in a crisisand before any apparent deterioration in foodsecurity. On the other hand, other populationswill use all means available to avoid anyreduction in the quality or quantity of food,often sacrificing livelihoods in the process.Therefore, a deterioration in nutritional statuscan be an early indicator of impending hardshipif interpreted together with disease and foodsecurity patterns. Continuous analysis of thenutrition situation combined with reliablemeasurement of outcomes can help to identifythe stages of a drought process and the responseof the population to events around them.

Nutrition-related information provides anauthoritative basis for the formulation of anappropriate response. Once data is available,appropriate emergency preparedness andresponse can be undertaken well in advance.However, for nutritional surveillance to beused as an effective tool for early warning, itmust incorporate both quantitative andqualitative aspects of data collection, analysisand interpretation.

1.2.2 Nutrition information in programmanagement

Planning and Implementation

Planning involves assessing, analyzingproblems and opportunities, setting objectivesand designing appropriate interventions thatcan achieve objectives. Nutrition-relatedinformation is used to analyze the situation inrelation to factors across the sectors – inparticular health, food security, care practices,livelihoods and other underlying factors. Thecauses of malnutrition may not be obvious. Itis important to differentiate the immediate life-threatening problems from the underlyingcauses and to develop appropriateinterventions.

In both emergency and development,analysis of nutrition information

helps to identifyindividuals at risk and

where they arelocated. It

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facilitates the design of appropriateinterventions based on the causes and effects.The analysis helps to formulate goals,objectives, strategies and activities that theproject/program intends to address. The severityof malnutrition, its nature and the related healthrisks determine the choice of response from theproblem analysis. Where lives are threatened,quick action is necessary.

Monitoring and evaluation

Nutrition information is useful for monitoringand evaluation in both emergency anddevelopment interventions. Nutrition-relatedinformation is used during projectimplementation for monitoring purposes. It isalso used at the evaluation stage to assess theextent and impact of the project.

Monitoring and evaluation assesses thenutritional performance against set objectives.It ensures that the planned activities are

conducted accordingly. Project monitoring iscontinuous and focuses mainly on short-termactivities and results. Evaluation on the otherhand is periodic and focuses on theachievement of the project objectives and theimpact of the project.

Monitoring can therefore be defined as thecontinuous process of collecting informationand presenting data, through out the projectcycle, in order to assess the impact and lead toimprovements in the effectiveness of theprogram.

Evaluation focuses on:• Relevance• Appropriateness• Effectiveness and efficiency• Timeliness and management of the project• Achievement of the project overall goal• Lessons learned for future planning

Nutrition provides us with both a tool and aforum to monitor and evaluate interventions.

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Mother with two children, close in age (photo by FSAU)

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Children with their mothers awaiting nutrition screening (photo by FSAU)

2.1 Overall concepts relatedto nutritionFood insecurity and therefore nutritionalvulnerability is complex. It is attributed to arange of factors that vary in importance acrossregions, countries, socio-economic groups andtime. These factors can be grouped into fourareas of potential vulnerability:

1. Socio-economic and politicalenvironment

2. Food security3. Care practices4. Health and sanitation

Fragile socio-economic and poli t icalenvironment, food insecurity, unfavourablecare practices and health environment leadto a cycle of malnutrition and furtherinadequate intake of energy and othernutrients. The conceptual framework in thischapter illustrates how key factors interactto influence nutritional status.

2.2 Nutritional vulnerabilityNutritional vulnerability occurs whenconsumption and utilization by the body of food

of adequate quality and quantity is threatened.This can occur during period of food insecurity,high incidences of communicable diseases orwhen care is substandard (as a result ofdestitution, illiteracy, displacement or tradition).

In any population or sub group, somemembers are at higher risk of becomingmalnourished, usually with more seriousconsequences. They include:

• Infants and young children (due to theirproportionately high demand fornutritional requirements). Consumption of

2 Understanding nutritional vulnerability

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Pastoral livelihood (photo by FSAU)

inadequate proteins, calories andmicronutrients retard growth anddevelopment, often irreversibly.

• Pregnant and lactating mothers (nutrientrequirements increasing during pregnancydue to physiological changes associatedwith the growing foetus). Malnutrition hasa direct impact on maternal and infantmortality and morbidity.

• The elderly. (Diminished sense of taste andisolation affect dietary intake) Malnutritioncauses general ill-health and earlydebilitation due to osteoporosis.

• Those with chronic disease.• Socially marginalised groups including

displaced and orphans.

2.3 Conceptual framework forunderstanding possible causes ofpoor nutritional statusFood insecurity, poor conditions of health andsanitation, and inappropriate care and feedingpractices are the major causes of poornutritional status.

A number of frameworks are in use, eachassisting in the development of a betterunderstanding of the possible causes ofmalnutrition. The most popular of these are theFIVIMS Framework shown here and theUNICEF Framework (Refer to appendix 6). Withslight variations in the approach used, bothdemonstrate the need to examine a wide range

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A pastoral household migrating due to stress (photo by FSAU)

of factors during analysis. Both frameworkspoint to the importance of addressing theproblem of malnutrition using broad multi-sectoral approaches. As shown in theframework diagram, the possible causes of lowfood consumption and poor nutritional statusfalls under the following headings:

2.3.1 Socio economic and politicalenvironment

At the national level, socio-economic andpolitical environmental issues include:

• population (movement, characteristics/dynamics),

• education (institutions, policies and levels),• macroeconomic factors (inflation rates,

money supply and employment levels),• natural resource endowment (productive

land, minerals, forests, water bodies like.rivers for irrigation or sea ports),

• market conditions (availability of marketchannels for local produce and operationof such markets) and

• the agricultural sector (livestock conditionand productivity, crude or mechanisedcrop farming).

The political environment determines theappropriateness of all the above factors.

Allocation of resources and investment in theeconomy largely depends not on the politicalwill but also on the political condition.

In Somalia where the political climate has beenfragile, there are high levels of illiteracy. Thereare few institutions and policies in place toaddress agriculture. Few powerful clan leadersand businessmen mainly influence moneysupply and inflation. These factors directly affectthe food security, health services and generaldevelopment of the country.

At sub-national or regional level, cultural attitudestowards what to eat, what to own; the socialinstitutions like clan set-up and relationships,livelihood systems (agro-pastoralists, purepastoralists and pure crop producers) andhousehold characteristics such as proportion ofworking adults affect food security.

In Somalia, the main livelihood systems includepastoralism, riverine, agro-pastoralism andurban. Riverine are normally more permanentand prone to heightened food insecurity andnutritional vulnerability. This results fromlocalized seasonal rainfall and crop productionfailures. Pastoralists who may have the optionof moving to a different locality where waterand pasture are available, are less vulnerableto food insecurity.

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STABILITY OF FOODSUPPLIES AND

ACCESS (variability)

Food productionIncomesMarkets

Social entitlements

SOCIO-ECONOMICAND POLITICALENVIRONMENT

National level

PopulationEducation

MacroeconomyPolicy environment

Natural resourceendowment

Agricultural sectorMarket conditions

Subnational level

Householdcharacteristics

Livelihood systemsSocial institutionsCultural attitudes

FOOD AVAILABILITY(trends and levels)

ProductionImports (net)

Utilization (food,non-food) stocks

ACCESS TO FOOD(trends and levels)

Purchasing powerMarket integrationAccess to markets

HEALTH ANDSANITATION

Health care practicesHygiene

Water qualitySanitation

Food safety andquality

CARE PRACTICES

Child careFeeding practices

Nutrition educationFood preparation

Eating habitsIntrahousehold food

distribution

FOOODCONSUMPTION

Energy intakeNutrient intake

FOODUTILIZATIONBY THE BODY

Health status

NUTRITIONALSTATUS

Figure 1 FIVIMS Nutritional status conceptual framework

2.3.2 Food security

Food security has been defined as a situationthat exists when all people, at all times, havephysical, social and economic access tosufficient, safe and nutritious food that meetstheir dietary needs and preferences for an activeand healthy life. Thus, food insecurity is asituation that exists when people lack secure

access to sufficient amounts of safe andnutritious food for normal growth anddevelopment and an active and healthy life.Food insecurity may be caused by theunavailability of food, insufficient purchasingpower, inappropriate distribution or inadequateuse of food at the household level. It may bechronic, seasonal or transitory.

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Among chronically food insecure people, bothmacro- and micronutrient deficiencies are likelyto be present. Diversification of diets is usuallysufficient to redress these imbalances, but thecost is often too high. People may experiencenutritional imbalances even when obtainingsufficient dietary energy.

Food security has three basic components—food availability, food stability and foodaccess although some frameworks alsoinclude food utilization.

Food availability

Food availability is a factor of productioncapacity, amount of imports and amount thatis normally used at a given period in time andof the availability of storage. Food availabilityis also influenced by the availability of seeds,pest infestation/attack, weather conditions,availability of pasture, land acreage undercultivation, labour availability and insecurityissues. The amount of food used by households,traded or stored, all influence food availabilityat the household level.

In Somalia, there have been varying weatherconditions characterized by frequent localizeddroughts. The droughts have reduced thepeople’s capacity to produce food (crop andlivestock production) in some areas. Infestationof crops by insects and pests like quela quelahas also affected the food production. In the

urban centres of Somalia the presence ofimported food commodities is common.

Food stability

Food stability is influenced by both supply andaccess factors. Seasonal fluctuations inproduction and access are a major feature inSomalia. There are many incidences ofrecurrent localized droughts, unpredictableweather changes and seasonal employmentopportunities. These factors affect incomeopportunities for the Somalia population. As aresult, there are variations in food production,food prices, export prices of food items,movement of food commodities, and changesin production techniques.

During the ‘hunger gap’ period in southernSomalia (between late May and early July), foodintake is low. Malnutrition and food insecurityis normally heightened unless the stored stocksfrom previous harvests were substantial.

Food access

Many factors affect people’s access to food.These include:

• Cultural factors. (when women are not‘allowed’ to eat certain foods)

• Reduced purchasing power (wherehouseholds can’t afford the food inshops/markets)

• Logistical/geographic obstacles to markets(rivers becoming impassable)

Sale of livestock products e.g. milk as one of the income sources (photo by FSAU)

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Water catchment, a common water source in Somalia(photo by FSAU)

• Insecurity (food may be in the market butthe market may be inaccessible becauseof fighting)

In Somalia where a significant proportion of thepopulation is considered poor (especially in urbancentres) accessibility to food is a major problemeven when food is available in the markets. Forinstance, in 2003 there was a significantdeterioration of food security and nutritional statusof the population in Sool plateau of NorthernSomalia. Food items remained largely availablein the market. The prices were relatively low butthe population could not access the food as alltheir income sources had been depleted byrecurrent droughts.

Household food access is also determined byseasonal patterns. For instance, the main foodcrop produced may not be sufficient to meet thehousehold needs at all times. Among pastoralcommunities, milk production varies with rainfalland availability of grazing lands. Furthermore,opportunities for employment, migration and theavailability of fish and wild foods are often highlyseasonal. Household income and expendituremay vary according to season hence affectingfood consumption patterns.

Coping strategies

Coping strategies are means adopted bypopulations to survive a change for the worstin their circumstances. They save thepopulation from deterioration of their wellbeing. In Somalia, this could be in the light ofincome sources, food access, movement fromproblem areas, as well as other resilience inlifestyle. Household members may split, move,change foods consumed or sell their assets.

2.3.3 Health, water and sanitation

Practices that promote and maintain goodhealth in the population are influenced by anumber of factors including knowledge andenvironment. During i l l-health, thesepractices include seeking health servicesfrom qualified personnel; access to healthservices; as well as control and treatment ofcommunicable diseases.

The poor health of individuals is normallyassociated with the inability to engage inmeaningful productive activities, and higherexpenditures on treatment at the expense offood items. Poor health increases vulnerabilityto food insecurity and therefore nutritionalvulnerability. There is also a synergisticinteraction between malnutrition and poorhealth status as one fuels the other.

Sanitation issues like disposal of human waste,disposal of garbage and cleanliness of thehousehold environment affect the health of apopulation. Sanitation is especially important inurban areas where people are relativelycongested. Poor sanitation results in diseaseoutbreaks and also interferes with foodconsumption and utilization.

Water availability is also an important indicatorof food security. Access to sufficient quality andquantity of water is essential to nutritionalsecurity. Households require water for choreslike cooking, cleaning clothes and drinking.This water must be safe for consumption andsufficient in quantity. Distance to water pointsdetermines the amount of time dedicated toother productive activities like childcare.

In Somalia, the main water sources are openwells, berkards, boreholes and rivers. Asignificant proportion of these sources areunprotected and are prone to contamination.Consumption of contaminated waterpredisposes humans to diarrhoea, diseases thatinterfere with food absorption. Furthermore,drinking water sources are commonly sharedwith animals thus increasing the possibility ofcontamination. The problem becomes acuteduring dry seasons. In wet seasons, there is oftenflooding along the riverbanks. The floods notonly destroy crops but are also a breeding placefor mosquitoes.

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A severely malnourished child (photo by FSAU)

2.3.4 Care practices

The environment, tradition and practices withinthe household and the community influencenutritional status. Good care at the householdlevel ensures that the food and healthcareresources provided to individual members resultin optimal survival, growth and development.Care practices vary with age and culture.Beneficial practices need to be supported andharmful practices need to be discouraged. InSomalia, care practices like the provision ofinappropriate liquids to infants immediatelyafter childbirth, delays in starting to breastfeedand discarding of colostrum impact on a child’snutritional status.

Care practices involve:• Psychosocial care: Responsiveness and

attention to the needs of individualhousehold members

• Food preparation (cooking andpresentation methods, hygienic storage).

• Hygienic practices. (bathing, hand-washing, food hygiene, hygiene ofclothing, bedding, contact environment).

• Home health practices. (Promotion ofgood health, home remedies andmanagement of common ailments,recognizing ill-health, deciding to seekassistance

• Specific care during periods ofvulnerability e.g. childhood, pregnancy,illness.

• Intra-household food distribution. Ensuringthat needs of all household members aremet, prioritizing the vulnerable members.

• Eating habits: This dictates the quantity,type of food and frequency of eating. Forinstance, pastoralists normally do not eatvegetables if animal products are available.

Care resources

Caregivers need the following resources toprovide adequate attention and focus on children.

• Human resources: Caregiver’s knowledge,beliefs, education and the ability to putknowledge into practice.

• Economic resources: Finances and timerequired for the provision of adequate care.

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• Organizational resources: Alternativecaregivers and community arrangements tofacilitate care practices.

2.3.5 Food consumption

Food availability, stability, accessibility and carepractices influence the amount (quantity) offood consumed, variety (diversity) of the diets,frequency of consumption, quality of food,proportion of cereals and of other essentialfoods in the diet.

While the intake of energy is important in thediet, other nutrients such as vitamins, proteins,and minerals are also required. Nutritionalwellbeing is determined by the proportions ofessential nutrients in the diet. Micronutrientdeficiencies are common even in areas wheremacronutrient intake is adequate and stable.Hence food diversity in the diet is an importantpointer to nutritional security.

2.3.6 Food utilization in the body

Eating enough food may not necessarily leadto nutritional security. The food eaten must beutilized by the body for nourishment. The healthstatus of an individual influences foodutilization by the body. Illness often leads toincreased dietary requirements for body repairof tissues damaged by the disease and to caterfor increased loss of nutrients caused by thedisease condition, malabsorption of nutrients,altered metabolism and loss of appetite. Poorhealth also leads to poor appetite thus reducingintake. Measles, diarrhoea, HIV/AIDS,tuberculosis (TB), and respiratory infectionshave a major influence on an individual’snutritional status. Undernourished children arealso likely to be ill more often due to theirinability to resist or fight infections.

Variety of food in the diet also influences foodutilization in the body. Due to inter-nutrientinteraction, some foods enhance the absorptionof others for instance fruits, vegetables and oilenhance the absorption of some proteins andcereals. Foods can also interact negatively asin the case of tea inhibiting the absorption ofiron, or sugar upsetting the calcium: phosphorusbalance, leading to increased calciumreabsorption from the bone tissue, and resultingin depleted bone density.

2.3.7 Nutritional status

The complex interaction of different factorswithin the framework is finally reflected inthe welfare or nutritional status of anindividual or the population. Good Nutritionis therefore an outcome of the individual orpopulation receiving and utilizing theappropriate diet. This diet maintains normalfunctions in processes l ike growth,maintenance of tissues, resistance to diseaseand participation in active physical work.

Malnutrition on the other hand, is animbalance or deficiency of nutrients in thebody. It is a condition caused by inadequateintake or inadequate digestion and utilizationof nutrients.

2.4 Summary of the frameworkThe main issues that arise from the frameworkare:

• Poor nutritional status or malnutritionresults from a complex set of elements andnot one simple cause.

• Food, care and health are all necessaryconditions, but not sufficient on their own.They must also be linked to the socio-economic and political environment.

• The different elements that causemalnutrition interact with one another.

• The framework can help to analyze andunderstand the causes of poor nutritionalstatus

• Poor nutritional status or malnutritioncannot be overcome by ‘simply’improving access to an adequate diet.This would only solve one or a part ofthe problem. Diseases and infections,poor maternal health and childcarepractices may be as important a causeof malnutrition as inadequate foodintake. Solutions are not found on onelevel only. Different levels need toimprove at the same moment.

• Understanding the cause of nutritionalvulnerability and malnutrition will enabledecision makers to address both theunderlying and the direct factors thatinfluence nutrition.

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Nutritional assessment is the process ofevaluating the nutritional status of an individual.Four methods are available that can be referredto as the ‘ABCD’ of nutritional assessment.

1. Anthropometric assessment2. Biochemical or laboratory assessment3. Clinical assessment4. Dietary Assessment

3.1 Anthropometric assessmentAnthropometry is the measurement of thebody’s physical dimensions. The physicaldimensions are used to develop anunderstanding on an individual’s nutritionalstatus. The following measurements arecommonly used.

Weight: Changes in weight among youngchildren can be a useful indicator of the

general health andwellbeing ofthe entirepopulation.

Under certain special circumstanceshowever, it may be essential to measureother age groups.

Height/Length: Height or length of childrenchanges over time and is dependent ontheir nutrient intake and utilization.

Mid Upper Arm Circumference (MUAC):These are rapid and effective measures thatpredict risks of death among children aged12 - 59 months. MUAC is a usefulscreening tool for determining children atrisk in emergencies.

Body Mass Index (BMI): Is a useful tool whenmeasuring an adult’s nutritional status.Weight and height measurements aretaken, then used to compute the index.Use of BMI in older people can beunreliable as accuracy in height may beimpeded by age-related factors like spinalcurvature. MUAC is therefore anappropriate measure since is relativelyindependent of aging.

Oedema: Abnormal accumulation of fluidindicating severe malnutrition.

Age as an indicator

Age is used to develop nutritional indicators incombination with certain anthropometricmeasurements like height and weight. Fornutritional assessment in emergencies, childrenless than 5 years are commonly measured sincetheir measurements are more sensitive to factorsthat influence nutritional status such as illnessor food shortages.

Anthropometry related indicators

The body measurements of weight, height andage are converted into nutritional indices. Togenerate the indicators, any of the two variablesmeasured are related. That is, weight, heightand age as follows:

• Weight for height• Weight for age• Height for age

Weight for Height/Length (W/H)- measures ‘wasting’ or ‘acute’ malnutrition

• Expresses the weight of the child in relationto the height.

3 Measuring nutritional status

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• In children under 5 years of age, therelationship of weight to height is almostconstant regardless of their sex or race andfollows a constant evolution as they grow.Internationally accepted reference valuesof weight-for-height for under five-year-oldchildren are available.

• Body weight is sensitive to rapid changesin food supply or disease, while heightchanges very slowly.

• Low weight for height is characterizedby wasting and loss of muscle fat. It isan indicator of thinness and identifiesacute malnutrition.

• This is the most useful index for screeningand targeting vulnerable groups inemergencies. It is a useful indicator foradmissions and discharge in and out offeeding programs.

• Alongside oedema, it is the mostappropriate index used to detect existingmalnutrition or recent onset of malnutritionin the population.

Height for Age (H/A)- measures “stunting” or chronic

malnutrition

• It is a measure of chronic malnutrition.That is, long-term and persistentmalnutrition normally associated withlong-term factors such as poverty andfrequent illness.

• A child’s height is compared to the medianheight (length) of the reference populationof the same age and sex to give H/A index.Children falling below the cut off point of–2 SD from the median of the referencepopulation are classified as too short fortheir age or stunted.

Weight for Age (W/A) - measures underweight

• It conveys the weight of a child in relationto the child’s age.

• WH index is a useful index for monitoringgrowth and development of children.

• When used in growth monitoring athealth facil i t ies, a child’s W/A iscommonly plotted on the Road to Healthgrowth chart. This allows for betterunderstanding of the child’s positive ornegative growth.

• At population level, the measurementindicates the total proportion ofunderweight children.

Oedema

• It is the abnormal accumulation of largeamounts of body fluid in the intercellulartissues.

• It is a key clinical feature of severemalnutrition and is associated with highmortality rates in children.

• Oedema increases the child’s weight. Ittherefore tends to hide the true picture ofthe nutritional status of the child.

• All cases of oedema should be separatedfrom the rest of the respondents duringanalysis and treated as severe acutemalnutrition.

• Oedema should always be used as a majorcriteria for admission into therapeuticfeeding programs.

Mid Upper Arm Circumference (MUAC)

• MUAC measurements are a good predictorof immediate risk of death.

• It is an initial screening tool in feedingprograms as it is simple and fast to use.

• It is useful when access to population isdifficult, resources limited or when WHmeasurement is not possible.

• MUAC results provide indications fornutritional status and are less accurate.

Taking anthropometrical measurements (seeappendix 1)

3.2 Biochemical methodsThis is a measure of nutrients in blood, urineand other biological samples. Compared toother methods, biochemical methods ofnutritional assessment provide the mostobjective and quantitative data on nutritionalstatus. The usefulness of biochemical tests isthat they provide indications of nutrient deficitslong before clinical manifestations and signsappear.

Biochemical tests are also important invalidation of data especially where respondentsare under-reporting or over-reporting what theyeat. These tests are therefore particularly usefulin complementing and validating dietary intakesurveys.

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The major disadvantages of biochemicalmethods is that they are complex, expensiveand require a high level of expertise.

3.3 Clinical assessmentClinical signs in the assessment of nutritionalstatus result from both lack of nutrients and non-nutritional causes. Signs and symptoms shouldbe investigated and combined withanthropometrical, dietary evaluation andbiochemical tests for accurate analysis andinterpretation of data.

Clinical assessment involves:a) medical history,b) dietary history andc) physical examination by a health

professional to identify signs andsymptoms associated with malnutrition.

The medical history of the respondent is thefirst step in clinical analysis. This can beobtained by:

• Finding out the respondent’s past andpresent health status. Many diseases suchas malaria, measles, tuberculosis and HIV/AIDS can affect the nutritional status.

• Identifying conditions such as diarrhoeaand lack of appetite.

• Evaluating a child’s age, or a woman’sobstetric history.

• Analysing socio-economic support andaccess to healthcare.

Dietary history includes determining therespondent’s eating habits. For instance timingand frequency of meals, tastes, allergies, abilityto access food physically and economically,how food is prepared and how food isdistributed at household level.

3.3.1 Detection of malnutrition duringclinical assessment

Acute malnutrition

This is a classical form of malnutrition relatedto low intake of energy-giving foods andproteins in the body. Acute malnutrition is themost common form of malnutrition. The termcovers a range of clinical disorders that occur

as a result of an inadequate intake of energy,protein and other nutrients. The most severeclinical forms of acute malnutrition aremarasmus and kwashiorkor. These conditionsare characterized by growth failure. Acutemalnutrition has a wide range of manifestationsthat range from weight loss (thinness) to stunting(shortness) or a combination of both.

Marasmus: This is a very serious form ofacute malnutrition characterized by severeweight loss or wasting. Marasmus is acondition commonly associated with lowintake of energy-giving foods. It requiresimmediate treatment.

Kwashiorkor: This is a very serious form of acutemalnutrition characterized by oedema, apathyand loss of appetite. It is a condition commonlyassociated with low intake of proteins orinadequate synthesis of proteins in the body.The condition requires immediate attention.

Oedema

This is fluid accumulation in the body as a resultof severe nutritional deficiency. Bilateraloedema is an indicator of acute malnutritionand may be detected by pressing the thumb onthe feet just above the ankle for three seconds.This will leave a dent.

Bilateral oedema is a manifestation of severeacute malnutrition and requires immediatetreatment.

Micronutrient deficiency

This is a deficiency that results from theinadequate intake of nutrients required by thebody in minute quantities for the normalfunction of the body. The main micronutrientdeficiencies of public health concern are IronDeficiency Anaemia (IDA), Vitamin ADeficiency (VAD), Iodine Deficiency Disorder(IDD) and Zinc deficiency. These deficienciesmay cause permanent damage to health andeven death.

Outbreaks of other types of micronutrientdeficiencies occasionally experienced inemergencies include vitamin C (scurvy), niacin(pellagra) and thiamine (beriberi).

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Signs and symptoms of malnutrition

Clinical assessment Possible nutritionaldeficiency

Hair Dull, dry, brittle, wire-like All associated withacute malnutrition

Thin, wider gaps between hairsLightening of normal hair colourCan be pulled out easily

Eyes Bitot spots Vitamin A deficiencyDry greyish yellow or white foamy spots on whites of the eye.

Conjunctival Xerosis. Vitamin A deficiencyInner lids and white of eyes appear dull dry and pigmented.

Corneal Xerosis Vitamin A deficiencyCornea (coloured part of the eye) becomes dull, milky,hazy, opaque.

Teeth Mottled Enamel Excessive fluorineWhite or brownish patches in tooth enamel;pitting of enamel most obvious in front teeth.

Gums Purplish, red, spongy and swollen.Bleed easily with slight pressure

Glands Enlarged Thyroid. Iodine deficiencyMay be visible or felt. More visible with head tipped back

Subcutaneous Oedema Sodium and waterretention

Tissue Bilateral swelling usually of ankles and feet first. associated withacute malnutrition

Bones Knock-knees - Curve inward at knees Past Vitamin D andBowlegs - Legs are bowed outward. Calcium deficiency

Osteomalacia Calcium deficiency

Tender and brittle bones in adults

Joint pain Possible Vitamin Cdeficiency

Muscles Muscle wasting Associated with severeacute malnutrition

Excess folding of skin under buttocks

Skin Dry or Scaly skin; cracking, yellow pigmentation Vitamin A, Zinc, andVitamin C deficiencies.

Pellagrous dermatitis Niacin deficiency

Flaky paint dermatitis acute malnutrition

Other Poor wound healing Associated withZinc deficiency

Weakness and fatigue Iron andVitamin B1 deficiency

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Children of school going age engaged in herding ratherthan attanding school (photo by FSAU)

3.4 Dietary methods

Dietary methods generally involve theassessment of food consumption over a periodof time. In nutrition surveillance, the dietaryassessment involves identifying foodavailability, accessibility, who consumed andat what frequency. Data on foods consumedassist in the identification of nutrient intake.Interpretation of dietary intake involves use offood consumption tables. Nutrient intake indietary methods is used to complementanthropometry, biochemical or clinical data.

Analysis of dietary intake involves:• grouping of foods according to a

predetermined system (e.g. FAO or USDA)to determine diversity

• Determining the frequency ofconsumption of foods in each food group.

• In some circumstances, based on thisbaseline and the level of acute

malnutrition, using regression analysis toproject the level of acute malnutrition inforeseeable circumstances

Food frequency recall

This is an assessment method commonly usedin nutrition assessments or surveys to determinedietary intake. It involves establishing thefrequency of which certain types of foods (thoseof particular interest in the survey) areconsumed over a specified time-frame normallya week or two. It is easier to administer thanthe 24-hour recall method. The frequency ofconsumption could be coded as:

a) ‘Frequently consumed’ - food itemconsumed once a week to many timesa day.

b) ‘Not frequently consumed’ – food itemconsumed no more than twice a month

c) ‘Never Consumed’ – food item notconsumed at all.

The 24-hour dietary recall

In this method, the respondent is asked toremember in detail the type and quantity offoods consumed during the previous 24 hours.Asking respondents about their activities duringthe day can assist in recalling what they ateand provides valuable information in estimatingthe level of activity and energyexpenditure. The values of thesemeasurements are converted intograms or millilitres (drinks andbeverages). The amounts of variousnutrients are then calculated usingthe food composition tables and/or nutrition computer packagesdesigned for this particularnutritional assessment method.

The method is reasonablyquick and inexpensive butrespondents may withholdor alter information aboutwhat they ate due toembarrassment or toinfluence the research. Todevelop an understanding ofseasonality, the assessmentshould be repeated atintervals throughout theyear. (see Appendix 3)

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An enumerator interviewing a mother during a nutrition survey (photo by FSAU)

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4.1 Current sources of informationon nutritionNutrition surveillance undertaken by FSAU andpartners utilizes a diverse range of informationsources on nutrition. These include nutritionsurveys, health facility information, rapidassessments and sentinel site surveillance (beingdeveloped). Information on the wide range offactors affecting nutrition is also collected frompartners in other sectors including, health, foodsecurity, water and security.

1. Nutrition surveys: Use weight for heightindicator and standard surveymethodologies as per nutrition surveyguidelines for Somalia. Thesemethodologies are endorsed by theNutrition Working Group of the SomaliaAid Coordination Body.

2. Health facilities: Currently there arearound two hundred health facilitiesthroughout Somalia. Over one hundredof these health facilities collect nutritiondata on a monthly basis throughanthropometrical measurements ofchildren under the age of five. Nutritiondata collected from these facilities servesas an early-warning indicator in case ofa crisis. The health facility data alsoindicates trends in malnutrition rates overa period of time. Health facility data arenot representative of the entire populationgiven that not all children are brought tothe health centre. Caution shouldtherefore be exercised when interpretingthis data.

Some of the health facilities providetherapeutic and supplementary feedingservices to severely and moderatelymalnourished children, respectively. Thetrend of admissions and re-admissionsmay be a pointer to the incidences ofacute malnutrition in the facility’scatchment area.

3. Rapid assessments: These are mainlycarried out on an ad hoc basis and areuseful when nutrition information isurgently needed or when resources forcarrying out a nutrition survey are limited.A combination of methods is used to

conduct rapid assessments. MUAC is oneof the methods of data collection duringrapid nutrition assessment.

4. Sentinel site surveillance: This involvessurveillance in a limited number of sitesor population for the purpose of detectingtrends in the overall well being of thepopulation. The sites may be specificpopulation groups or villages whichcover populations at risk. FSAU usuallyundertakes this in highly vulnerable areasthat require close monitoring. Trends aremonitored for various indicatorsincluding nutritional status, morbidity,dietary issues, coping strategies and foodsecurity. In Somalia, sentinel sitessurveillance has been undertaken in partsof Sool, Sanaag, Nugal and Bari regions.

5. Dietary assessments: These are part ofnutrition surveys and sentinel sitesurveillance. The general objective is toobtain information on the overalladequacy of the diet consumed byhouseholds.

The 24 hour recall method is used todetermine dietary intake. Depending onthe objective of the dietary assessment,actual estimates of amounts of foodconsumed may be determined throughweighing or volume estimates

4.2 Data collection methodologiesInformation on nutrition can be collected usingeither quantitative or qualitative researchmethodologies. Quantitative approachesprovide actual statistics on nutritional statuswhile qualitative research methodologies offerexplanations into the actual causes ofmalnutrition. The use of both approaches isrequired to develop a useful understanding ofthe nutrition situation in any population.

Qualitative research explores, discovers;asks why, how and under whatcircumstances. It involves respondents asactive participants rather than subjects. Theinvestigator is an instrument of research. Inqualitative research, there is the participantwho contributes the information and theresearcher who guides the research process

4 Methods of nutrition surveillance and analysis

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A survey team member reviewing health facility information (photo by FSAU)

and knowledge generation. These two areessentially partners and the process towardsknowledge generation is based on mutualtrust and understanding of a common goal.

4.2.1 Nutrition survey

Standard survey methodology is used in allsurveys. Guidelines are available from theNutrition Working Group of SACB

During a survey, anthropometric and otherquantitative data are collected on individualchildren. Sampling procedures are used toensure that the children are representativeof the whole population. Qualitative data onnutrition and related factors are collected toenable an interpretation of the quantitativedata collected.

Issues of interest in planning a survey

A nutrition survey is used to determine thenutritional status of a population when:

• No major differences are expectedbetween the various groups in thatpopulation

• Access to all populations in the area ofinterest is possible to ensure that randomsampling is undertaken

Remember:• A nutrition survey will provide one result

that is relevant to the whole area surveyed;it is not possible to break down the resultsby cluster and to draw conclusions for usein targeting

• Nutrition surveys require a seriousinvestment in time - around one monthand in budget.

• The survey should never be attemptedwithout the support of technical expertiseduring planning, implementation andanalysis.

Main functions of a survey

• To establish a baseline• To measure impact of impending or actual

food insecurity on population• To measure progress or impact of nutrition

projects

Steps in conducting a nutrition survey

1. Plan the survey2. Administer the survey

Plan the survey

Successful planning is guided by the followingprinciples:

i. Review existing information related tothe anticipated survey area. In particular,determine the nutritional and healthstatus, socio-economic background,food security, cultural issues, geographiclocation, population and settlementpatterns. Such information is useful inunderstanding the actual nutritionproblem, defining appropriateobjectives, selecting relevant resources,

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A enumerator pre-testing data collection instruments (photo by FSAU)

planning for adequate equipment anddeveloping the survey schedule.

ii. Identify survey goals and objectives. Setobjectives for the survey to ensureeffective outcome of the survey results.All nutrition surveys should be guidedby clearly stated objectives. The surveycoordinator needs to know:

• Why is the nutrition survey beingconducted?

• What types of nutrition informationare needed?

• How will the survey information beused?

iii. Identify survey indicators. I t isimportant to establish a range ofvariables well in advance. The surveyindicators include anthropometricindicators and mortality data with thepossible addition of morbidityprevalence, infant feeding, carepractices and household foodconsumption patterns.

iv. Selecting survey methodology. Isimportant to determine the type of thesurvey design during planning. For

example, is the survey focusing on allhouseholds in the project area ortargeted populations only?

v. Select survey sample. When dealingwith large population groups it is notpossible to survey the entire populationdue to cost and time constraints. Forthis reason, a portion of the populationis selected. This proportion of the wholepopulation is the sample.

Four main sampling methods are used(See appendix for details)1. Two-Stage Cluster sampling2. Random sampling3. Systematic sampling4. Stratified sampling

vi. Identify types of personnel, equipmentand resources needed for conductingthe nutrition survey.

vii. Agree on roles and responsibilities ofpartners. Ensure that partners in allsectors are involved in the survey.

viii. Plan a detailed time and activityschedule to be completed within the settime frame and cost.

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Weight measurment during a nutrition survey (photo by FSAU)

ix. Develop data collection instrumentslike questionnaires, focus groupdiscussion guides, interview schedulesand observation checklists.

x. Pre-test the data collection instruments.

Administer the survey

• The plans are translated into actions andinclude:

• Logistical arrangements• Selecting the survey team• Training research personnel• Supervising the survey process• Data collection activities like

anthropometric measurements

• Selecting appropriate data processingmethods and ensuring quality controlprocedures

• Analyzing data using appropriate statisticaltools

• Interpreting data• Report writing• Discussing findings and recommendations• Sharing the survey findings with partners

On completion of the survey, there is need tofollow up with stakeholders on how to usenutrition data generated from survey;Implement nutrition survey recommendationscontinue monitoring and evaluation of thesituation.

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Interpreting nutrition survey data

Cut off points for indicators of malnutrition

Description of Weight for Height Index Oedema MUACNutritional Status

W/H % of Z Score (SD)the Median

Severe Acute < 70% <-3 Z scores (less than minus 3) Present <11 cmMalnutrition

Moderate Acute ≥ 70% and Less than - 2 Z-scores BUT greater <12.5 cmMalnutrition < 80% than or equal to -3 Z-score ≥ 11 cm

Global / Total < 80% <-2 Z scores Present <12.5 cmAcute malnutrition(moderate plus severe)

Normal ≥ 80% ≥-2 Z-scores (Greater than or ≥ 13.5 cmequal to -2Z-scores)

At risk <13.5 cm≥ 12.5 cm

≤ means less than or equal to; < means less than; ≥ means greater than or equal to

*The presence of oedema always implies severe malnutrition.

Classification of global acute malnutrition using Z- scores

The following classifications for malnutrition have been established by WHO as levels forinterpreting weight for height Z-score in emergencies.

Global Acute Malnutrition W/H Z score Interpretation

< 5% Acceptable level

5 – 9.9% Poor

10 – 14.9% Serious

> 15% Critical

Mortality assessment

In Somalia, mortality data has beenconcurrently collected during standard nutritionsurveys (as described above). Mortality datacollection uses the same methodology exceptthat while the nutrition data requires thirtyunder-five children in each cluster (which mightbe found in twenty households), mortality datacollection will require a minimum of thirtyhouseholds. The mortality questionnaire is

administered to a responsible member of thathousehold and death statistics are collectedretrospectively. The recall period commonly usedis three months. All households encountered inthe sampling process for under-five childrenshould be included until the desired sample sizeis attained regardless of whether a child belowthe age of five is present or not as a householdwith no children could indicate that a child orchildren had died prior to the survey.

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Classification of mortality data

Indicator Definition Interpretation

Crude Mortality Rate (CMR) An estimate of the rate at which members of <1/10,000/day indicates athe population die during a specified period. situation that is acceptableThis is the number of deaths from all causes ≥1 to <2/10,000/dayper 10,000 people per day. indicates a situation of alert

≥2/10,000/day indicates anemergency situation

CMR=Total number of deaths over a specified time period* 10,000Total estimated population (current)* specified time period in days

Under Five Mortality The number of deaths among children <2/10,000/day indicates aRate (U5MR) between birth and their fifth birthday situation that is acceptable

expressed per 10,000 live births. This is the ≥ 2 to 4/10,000/daynumber of deaths from all causes per 10,000 indicates a situation of alertof under five year old children per day. ≥4/10,000/day indicates an

emergency situation

U5MR= Total number of under 5 deaths over a specified time period* 10,000Total estimated under 5 population (mid/current)*specified time period in days

Note:

Anthropometric data alone is not sufficient for analysis and interpretation. Contextual information collected during thesurvey or from other sources is crucial for an in-depth and broad interpretation of the results. Verification of both qualitativeand quantitative data is important.

4.2.2 Rapid assessment

As the name suggests, this is a method used togather nutrition information within the shortesttime possible and is particularly useful insituations where physical access to populationis limited or when the speed of the assessmentis a major consideration. The results of rapidassessment provide a basis for planning duringan emergency. The purpose of rapid assessmentis to determine the severity and extent of thenutrition situation without embarking on a fullscale survey.

In carrying out a rapid nutritional assessment,Mid Upper Arm Circumference (MUAC) is thecommonly used screening tool in measuringmalnutrition levels especially in emergencies.MUAC assessments are further complementedby qualitative methods to generate informationon such issues as food security, health,environment, and care practices.

Rapid assessments need to involve intersectoralteams and a variety of data collection methods

will be required to facilitate triangulation andverification of all information.

Steps in planning Rapid Nutritional Assessment:

• Define objectives of the assessment• Determine target site, area or population• Develop most appropriate methods of data

collection• Identify and train personnel to be involved

in the assessment• Assemble materials and equipment

needed during the assessment• Develop the time plan and activity

schedules

Using MUAC in Rapid Nutritional Assessment

Like data collection during nutrition surveys,selection of survey children should be asrepresentative as possible. Depending on thesize of the population either total populationor a sample may be assessed using MUAC. If asample is to be used, a 30 by 30 clustermethodology will be adopted as used in surveys

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or in other random sampling procedure. Butsince MUAC assessment is rapid, an assessmentof all children in selected clusters/villages iscommonly used. All children aged 12-59months in the selected villages are measured.

Data for assessing the nutritional status usingMUAC is taken for all children ages 12-59months. MUAC should be taken by the mostexperienced member of the team to ensureaccuracy in data collection.

Use of MUAC alone is not a sufficient tool forscreening during rapid nutritional assessment.Qualitative data is used to complement MUACusing semi-structured interviews with keyinformants and various groups in thecommunity. Direct observation, seasonalcalendars, transect walks, review of documentsincluding health facility records are additionalmethods used.*For detailed steps used in Measuring MUAC(See appendix 1)

Using the methodologies described elsewherein this chapter, information should be collectedon the issues influencing nutritional status inall sectors. These will include the following,among other issues:

• Food availability in area under assessment(Is food readily available? What foods areavailable?)

• Water sources (type, number and status)• Common diseases in the area• Accessibility to health services (What is the

distance of the health facility from thevillage?)

• Any livestock movements (If yes, fromwhere to where and what is the reason forthat movement)

• Any population movements (If yes, fromwhere to where and why)

• Weaning foods for children aged 6-59months

• Feeding pattern (usual number of mealsper day, current number of meals; usualand current composition of meals

• Security situation

Other methods of information collection usedin the analysis of the nutrition data

Focus Group Discussions: Group discussionsof 6-12 people that engage in understandingthe qualitative aspects of the nutritional statusof a given population.

Direct Observation: Involves observing visibleindications of malnutrition and related issuesthat could influence nutritional status like poorenvironmental health and sanitation.Key Informant Interviews: Involves interviewingkey persons with specialized information on thesubject under study like nutritionists, healthofficers and agriculturalists.Case study: involves an in-depth and focusedstudy on subjects with similar characteristicslike less than 2-year old children with episodesof diarrhoea.Transect Walks: Observations of all aspects oflife in the area of interest during a walk fromone edge of the area to the other.Mapping: Supports focus of questions,identification of resources and understandingof livelihoods.

4.2.3 Health facility data

Nutrition data is collected at health facilitiesand summarized at the end of each month.FSAU monitors nutrition data from over 100health facilities. Data from health facilities isentered in the Health Information System (HIS)database. This database also containscomponents on diseases (morbidity) andimmunization. Health facility personnel areencouraged to provide explanations for upwardor downward trends in levels of malnutritionamong children attending the health facility.

The major limitation of the health facility datais that not all children are brought to the healthcentre for growth monitoring. The method istherefore not representative of the entirepopulation. Care should be taken wheninterpreting health facility data.

FSAU undertakes on-the-job training andfollow-up support at health facility level thatcovers the following areas:

• Importance of carrying out nutritionsurveillance

• Methods of carrying out nutritionsurveillance

• Anthropometric measurement proceduresin terms of accuracy and possible errors

• Recording and reporting proceduresthrough use of standard registers and (HIS)forms

• Interpretation of nutrition data using Zscores

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A team examining existing documents during a nutrition assessment (photo by FSAU)

• Diagnosis of the causes of malnutritionboth at individual and population level

• Integrity of the equipment• Flow of information• Growth monitoring process• Supplementary (SFP) and Therapeutic

Feeding Programs (TFP). Data is collectedon new and re-admissions, origin and ageof the participants.

4.2.4 Sentinel sites surveillance

The sentinel sites are purposively selected inhighly vulnerable areas following a predefinedcriterion. Selection of households in each siteis then undertaken in a random manner and ahousehold questionnaire administered in eachby FSAU staff in collaboration with key partnersand community assistants on the ground.Qualitative data is collected through focusgroup discussions, key informants andobservations. Data analysis is furtherundertaken using EPIINFO and Microsoft Excel.Trends observed on the key indicators especiallynutritional status indicate the sites forcontinuation in monitoring.

4.2.5 Dietary assessmentsA section of the household survey comprisesof a table on dietary intake data collection. Therespondents are required to recall the foodsconsumed in the previous 24 hour.

Key issues like food frequency, types of foodgroups consumed and the relationshipsbetween malnutrition and dietary diversity areinvestigated. At the analysis stage, diversity ofthe diet is determined by analysing the rangeof food groups consumed during the recallperiod.

4.3 Qualitative data

Qualitative research techniques:A number of qualitative research techniques areused for nutrition studies. They include:

_ Focus group discussions_ In-depth interviews_ Case studies_ Observational studies_ Experience survey

Focus group discussions

In a focus group discussion, the interviewer actsas a moderator/facilitator of the groupdiscussion process, his/her role involvesintroducing the topics, probing questions andeliciting responses from the respondents. Themoderator’s role should be passive and shouldnot dominate the discussion.

Focus groups are composed of people withcommon characteristics such as age, sex, socialor economic background. Interaction is bestwithin a small group of participants rangingfrom six to twelve persons. Every participant isencouraged to express views. The type ofresponse generated from the discussionsdetermines the quality and interpretation ofresults.

In-depth interviews

This is an exchange between the interviewerand the respondent that allows investigation ata greater level of detail. The interview probesfor feelings, attitudes, opinions and views. Itrequires the interviewer to be skilled in thequestioning technique so as to elicit therequired response.

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Both the interviewer and the participant worktogether in a relaxed setting, a conversation iscreated by making participants talk freely onan identified topic.

Observation

It involves watching people and events to seehow something happens rather than how it isperceived. This is called direct observation. Innutrition studies, one can observe child caringpractices or child feeding practices in a givenhousehold over a period of time withoutinterviewing that family.

Direct observation can be used to confirminformation that respondents may provide onthe same matter. Observations are useful forovercoming contradictions provided ininterviews by respondents.

In most observation sites such as the healthfacility, the researcher should prepare a list ofthings to observe. What is seen or heard willgive meaning and new insights into a nutritionalissue being investigated. The observationprocess should be discreet.

Documentary evidence

This involves analyzing existing material for aspecial purpose such as the creation of adatabase. Content analysis can be used todetermine a trends analysis in nutritional statusover a period of time, examine food patternsand habits across communities, food andnutritional policy, cultural beliefs and practicesconcerning food consumption.

Case study

The study concentrates on the history and the‘story’ of a specific individual or situation.Factors that contribute to malnutrition of anindividual child in a refugee camp wouldconstitute a case study. The case must beunderstood in its own context. However, byundertaking a number of such studies, sometrends might be identified or furtherinvestigation might be prompted.

Basic steps in qualitative data analysis andinterpretation

• Data organization: To analyze qualitativedata, the researcher should first review the

research questions or objectives. Theprocess begins by reading and fullycomprehending the field notes. As theresearcher reads and transcribes fieldnotes, the researcher should watch out foremerging themes. Such themes can bedisease prevalence, infant feeding habits,commonly consumed foods and foods inseason.

• Displaying data and establishingpatterns: The researcher should examinedata layout more closely. What patternsare emerging from the relationships?Which ideas are related?

• Data analysis and interpretation: Theresearcher requires analytical skills. Thesedevelop with guidance and experience.Data analysis involves sieving informationto establish relationships betweenconcepts. For instance, relationshipsbetween morbidity and nutritional statusin a community. Interpretation involvescommunicating essential ideas of the studyto identify connections and links withmajor themes. It is processing of findingsto create connections and gaps.

• Triangulation of the qualitative andquantitative data is done duringinterpretation. Triangulation is theintegration of two methodologies to givedata an in-depth and richer meaning. It isusually after establishing the nutritionalstatus of a population, that linkage is madebetween the prevalence of malnutritionand causal factors in the community.

• Intervention programme data:Consideration of the supplementary andtherapeutic feeding data (whereveravailable) is important to monitor theincidence of malnutrition. Special focusis made on the new admission and re-admission rates as well as the places oforigin of the malnourished cases. Detailsof the age categories to facilitateestablishing the vulnerable populationgroups are needed.

• Report Writing: It is both a descriptive andnarrative account of the nutrition situation.The report states the problem, significanceof the study, objectives, methodologies,findings and consequently,recommendations. Appendix 7 provides ageneral format for report writing.

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Water is the only food for these teenage girls, during the long hours of herding (photo by FSAU)

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Analysis and interpretation of nutrition data iscarried out in a systematic manner in order todevelop an understanding of such questions as:

• What is the population’s nutritional status?• Is the current nutritional status acceptable

or not• Is the situation improving or deteriorating?• What are the key factors influencing the

current nutritional status?• Which interventions are most appropriate

in protecting or promoting better nutrition?• Under the prevailing circumstances how

is the nutritional status expected to evolveover the coming months?

• What is the likely situation in theneighbouring areas (i.e. extrapolation)

Notes

The sources of nutrition information aresurveys, rapid assessments and health facilitydata. Each of these data sets should beanalyzed in the context of the season inwhich it is collected as this will influencee.g. food supply, disease patterns and wateravailability. Additionally, reference should bemade to past nutrition information for thestudy area so as to avail a clear indicationon whether the nutrition situation hasimproved or deteriorated over time.

Nutrition surveys provide the most accuratedata and the results can be seen as relevant forthe population with similar characteristics.While manual analysis can be used to generatedescriptive statistics, EPIINFO is useful for bothdescriptive and inferential detailed analysis.

Health facility data is mainly from a self selectedgroup and attendance will be influenced bymany factors e.g. disease outbreaks, quality ofservice and availability of drugs. Though notrepresentative, the data is useful in indicatingtrends in nutritional status.

Rapid assessments data gives an indication ofthe situation during critical periods and whensurveys are not possible.

No single source of data is used in isolation.Triangulation of information is carried out for abetter analysis of the situation.

The term ‘study’ is used to refer to the varioussources of data in this chapter.

Steps in data analysis andinterpretation

a) Collate relevant data.b) Establish links and associations among

the various variables and the nutritionalstatus, considering all data collected.

c) Identify areas requiring interventions.d) Prepare study findings/results.e) Discuss findings with study population

and partners.

A Collate relevant data

Gather the historical data for the area orpopulation. This includes baseline informationand previous surveys or assessments data. Pastrelevant background information includingmorbidity data, food security information andtrends in malnutrition as reported in healthfacilities. This information helps identify trendsand whether the nutrition situation is improvingor deteriorating.

B Establish links and associations of thevarious variables and the nutritional status.

Analyze and interpret both qualitative andquantitative data. The causes of malnutritionvary from one population to another hence theneed to define the specific factors thatcontribute to nutritional status in eachpopulation. Statistical analysis of nutritionsurvey data can be used to determine the links/associations while this is not possible for rapidassessments and health facility data. Furtherlinks between qualitative data and the resultingnutritional status can also be established guidedby the conceptual framework. (figure1)

Socio-economic and political environment.

• What is the estimated population size andhow is this distributed among the variouslivelihood or food economy groups? Isthere a particular group that is moreaffected than any other?

• How do the macroeconomic factors likeinflation rates, money supply andemployment levels affect food security?

• How does the current situation affect tradeand food marketing activities (locally,

5 Analysis and intepretation of the nutrition situation

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Milk market (photo by FSAU)

nationally, regionally) for instancesanctions, ban on exports, restrictions onmovements of traders?

• How do the cultural attitudes influencewhat people eat, own or the socialinstitutions.

• What is the security situation in the area?

Food security situation.(Food availability and access)Type, quality and quantity of food available.

• The food economy group of the populationplays a vital role in guiding this process.For instance in the case of an urban

population that mainly relies on purchasesto obtain food, determining the prices andavailability of food in the markets isimportant. In the case of an agro pastoralpopulation that mainly relies on its ownproduction for food, determining whetherthere was good harvest over the seasonsand if sufficient food stocks were availableat the time of the survey is important.

• Weather conditions determine if goodharvests will be realized, if pasture andwater supply is good hence influencinganimal production.

• Interpretation should take into accountavailability of food stocks and anestimation of how long these would lastthe families.

• Seeds availability and pests, rodents anddisease infestation on crops influencefood availability.

Access to food

• Food access is influenced by purchasingpower. Definition of income availabilityand the proportion spent on food items iscrucial especially for urban populations.In the case of agro pastoral and pastoralpopulations that also need to purchase

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certain foodstuffs to supplement theirproduction, it is important to establish theselling prices of their products or theirterms of trade.

• Availability of foods in markets atunaffordable prices can limit food access.

• Logistical or geographical obstacles tomarkets and insecurity can limit accessto food

• If families harvest or obtain food but theysell or use the bulk of it to settle past debtsthere is need to analyse if the balance issufficient to meet their needs over a givenperiod.

• Estimating the quantities of food eaten byfamily members can help define ifmembers are meeting daily foodrequirements or not. In the case ofchildren, frequency of meals per day isimportant and more than threenutritionally balanced meals per day arerecommended.

• Coping strategies in times of stresscontribute to food access in Somalia. Thenormal means of accessing food for a givenpopulation may be constrained at a giventime but since the people have viablecoping strategies, their access to food maynot be limited.

• Establish if there is a change in copingstrategies from the normal

• The prevailing food security situationcould guide in predicting future nutritionalstatus for instance if low malnutrition ratesare reported in times of relatively poor foodsecurity, the nutritional status is expectedto deteriorate in the future.

• The analysis may coincide with a seasoncharacterized as a hunger gap and with apossibility of improvement if the seasonalvariables get better.

Health and sanitation.

• Nutritional status and diseases are closelylinked. A high incidence of importantchildhood illnesses (those that have strongassociations with nutritional status likemeasles, diarrhoea, ARI and malaria) priorto or around the period of analysis willinfluence nutritional status.

• A disease outbreak or high diseaseincidences in a given area willcompromise nutritional status.

• Understanding seasonal trends in diseasecontributes to the analysis.

• Does the community have access toquality health services and is the healthservices seeking behaviour positive?

• Immunization is the safest way to protectchildren from immunizable diseases likemeasles and poliomyelit is. Onceimmunized, bodies are more able tofight diseases. If the immunizationcoverage is low, the population is morevulnerable to outbreaks ofcommunicable disease. Understandingthe factors that contribute to a high orlow immunization coverage rate guidesin defining possible interventions; it isindicative of the level of contact withthe formal health services, the qualityof those health services and ultimatelythe extent to which the populationchooses to use the health services.

• Supplementation of certain micronutrientsis usually undertaken among certainpopulation when deficiency is suspectedand when foods rich in thesemicronutrients are not readily available.In Somalia, vitamin A supplementationis usually done on a regular basis. Highvitamin A supplementation coveragecould indicate a low likelihood ofvitamin A deficiency.

• Poor sanitation practices predisposepopulations to illnesses like diarrhoea andmalaria which in turn contribute tomalnutrition. High proportions of thepopulation without access to cleansanitary facilities could account for a highdiarrhoea incidence.

• If a large proportion is relying on a cleansource of drinking water, there is need todetermine if this is sustainable or not.

• Hygiene practices in homes, aroundwater points and when handling foodscan explain certain disease outbreakslike cholera.

Care practices for mothers and children.

• A child’s health and nutritional well beingdepends on the type of care that childreceives. Poor care practices willcontribute to a deterioration in nutritionalstatus. For example a lactating mother wholacks good care might not have enough

32

Children recovering from severe malnutrition in a therapeutic feeding centre (photo by FSAU)

milk or even adequate time to breastfeedher child while an expectant motherwithout good care will most likely deliveran underweight child.

• Low birth weight and poor childcarepractices (breastfeeding, weaning, feedingfrequencies) are likely to contribute to poornutritional status.

Food consumption

• Both quantity and quality of foodconsumed are important in determiningthe well being of an individual. The bodyrequires certain amounts of the variousnutrients on a daily basis for propergrowth. A limitation in any of these willhave negative consequences on anindividual’s nutritional status.

• In most cases, people will consume thefoods that are readily available to themfor instance among the pastoralcommunities, the quantities of milkconsumed during the good seasons ishigh unlike in the lean seasons.

Food utilization by the body

• For certain foods/nutrients to be betterutilized by the body, they need beconsumed in combination with others. Forinstance, for the body to utilize fat-solublevitamins, fat consumption is important.Vitamin C helps the body to absorb iron.Likewise, some foods inhibit theabsorption of other foods. [Consumptionof tea (containing tannins) soon after mealsinhibits iron absorption.]

Mortality

• This indicates a crisis. It marks the highestlevel of deterioration of life andlivelihoods. A low malnutrition rate whilethe under five mortality rate is high doesnot essentially mean that the nutritionalstatus of the population is good. It ispossible that some of the severelymalnourished children died prior to thesurvey hence the low malnutrition rates.

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Livelihood assets:

These define the context, options andconstraints available to households andindividuals in their livelihood strategies.Analysis is undertaken at the zonal and/orhousehold level, with consideration made toprivately and public owned assets (or capitals).

• Physical Capital:This defines the basicinfrastructure and producer goods neededto support livelihoods. (e.g. transportation,shelter, water supply and communications)

• Financial Capital. This refers to thefinancial resources people use to achievetheir livelihood objectives; and flows andstocks that contribute to consumption andproduction. (e.g. flows of cash income,livestock holdings, credit)

• Human Capital: These are the skills,knowledge, ability to labour and goodhealth that together enable people topursue different livelihood strategies. (e.g.the amount and quality of labour available,skills and health status.)

• Social Capital are the social resources fromwhich people draw, in pursuit of theirlivelihood objectives. (e.g. networks andconnectedness, relationships of trust)

• Natural Capital are the natural resourcestock from which resource flows andservices useful for livelihoods are derived.(e.g. land, trees, pasture).

C Identify areas requiring interventions

• Interventions that contribute positively to thenutritional status include adequate healthservices; availability of clean and reliablewater sources; income generating projects;education facilities; seed distributionprogrammes and veterinary services. Ifpresent, are they accessible to all andsustainable?

• Are certain factors contributing negativelyto the nutritional status for example lowknowledge on nutrition-related issues, lackof sanitation facilities; inadequate healthservices; low immunisation rates, lowvitamin A supplementation coverage andinsufficient food. Have these beenaddressed at all? If yes is it sufficiently so?

• Which interventions require immediate orlong term response

• Recommendations on interventions need tobe guided by the analysis and ideally not bythe focus of particular organizations.

D Prepare study findings

• Prepare study results highlighting theimpor-tant findings.

E Discuss study findings with studypopulation

• Share the main study findings with thestudy population and partners.

• This discussion will provide an openingfor more comprehensive and longer termcommunity based analysis of issues thatcan be addressed more efficiently andeffectively by the community themselves.

Case studyA case study on Bulla Hawa Nutrition Surveyin Gedo region undertaken in October 2002 ispresented to illustrate data analysis andinterpretation.

Gedo is the most chronically food insecureregion in Somalia, partially explained byrecurrent drought and insecurity incidences.Consequently, the acute food insecurity andhuman suffering was manifested by theunacceptably high global acute malnutritionrate of 37% (using <–2 Z-score cut-off) in theDecember 2001 Belet Hawa nutrition surveyaccompanied by high mortality. Theseprovoked significant humanitarian responses.Both food aid (general and selective feeding)and basic healthcare services in the districtwere supported by CARE and Gedo HealthConsortium (GHC) amid serious insecurity.Following the relatively good 2002 GUseason, it was felt that food security andnutritional status might have improvedalthough the effect of recurrent insecurity andthe diminished asset levels in households wasnot clear. Implementing organisations andthe Humanitarian Response Group of theSomalia Aid Coordination Body (SACB)therefore, recommended a repeat survey inthe district which was undertaken in October2002. Some of the survey results are aspresented on the table.

34

Indicator No. %

Children under five years screened during the survey 907 100

Global acute malnutrition – W/H <-2 Z-score or with oedema 195 21.5 (CI: 18.9%-24.5%)

Severe acute malnutrition– W/H <-3 Z-score or with oedema 20 2.2 (CI: 1.4%-3.4%)

Global acute malnutrition – W/H in Z-Score (<-2 Z-score) or 71 26.6presence of oedema in agro-pastoral villages

Global acute malnutrition – W/H in Z-Score (<-2 Z-score) or 77 21.0with oedema in Belet Hawa town including IDP village

% of children with diarrhoea in two weeks prior to the survey 234 25.9

% of children with ARI in two weeks prior to the survey. 186 20.6

% of children with malaria in two weeks prior to the survey 212 23.4

% of children that received Vitamin A within last six months 797 88.1

% of children immunised against Measles 621 72.0

% of children from displaced households 95 10.5

Substantial food aid (that is, both from generaldistribution by CARE and GHC/UNICEF’sselective feeding programme), harvests fromrelatively good 2002 Gu rains andaccompanying migration of some livestock,more aggressive/improved health serviceprovision (manifested by improved measlesimmunisation and vitamin supplementation),and relatively low incidences of common childillnesses (compared to 2001) played a key rolein explaining the significant improvement innutritional status since the December 2001nutrition survey. In addition, the use of bushproducts increasingly provided a significantincome source to most households in thedistrict. The survey reveals that with apopulation of about 65,000 residents (WHO2002) in Belet Hawa, the relief food servicesdistributed between December 2001 andOctober 2002 was capable of providing about70% of the daily food requirements to allindividuals assuming minimal losses and useof all the rations within the district.

Continued limited food availability and the almostconstant insecurity; poor childcare/feedingpractices and high disease incidences, allcontribute to the persistent poor nutritional statusof the population in Belet Hawa District. Thesignificant statistical association between theobserved malnutrition and diseases like diarrhoeaand malaria confirms that disease prevalence is

still a major problem that calls for continuedsupport to comprehensive health and nutritionintervention programmes.

About 27% of the children fed once or twice aday. The overwhelming majority of the children(99%) included in the survey were notexclusively breastfed in their first six monthswhile nearly 98% received foods other thanbreast milk in their first three months of life.Mothers reported having to travel increasinglylong distances in search of water (especiallybefore the Gu 2002 rains). Some responses tolimited food access like collecting bushproducts leads long separation from their youngchildren further compromised childcare.

Both the survey and other FSAU food securityinformation indicate significant shifts inpeople’s livelihood patterns in recent years withmany more households now categorised as‘urban’ and fewer as ‘pastoralist’. Purchasesand food aid were the main food sources whilecasual work and sale of bush products werethe dominant income sources. Borrowing andfood aid reliance ranked highly as copingstrategies.

Recommendations following the survey includeadequate general ration and selective feedingconcurrent with continued support to thehealth, livestock and water sectors as immediate

35

responses. Income generating activities are alsokey to revive the Belet Hawa economy. Animprovement on the security situation in the

region will also work positively for the BullaHawa population.

Bibliography

Action Against Hunger (2000). Basics of Nutrition and General Food Distributions.

Action Against Hunger (2002). Training Manual on Nutrition Surveillance.

African Medical Research Education Foundation (1994). Community Nutrition For Eastern Africa.Anne Burgess & others. AMREF. 1994.

Cogill. B, (2001) Anthropometric Indicators Measurement Guide. Food and Nutrition TechnicalAssistance. Washington DC.

Emergency Nutrition Coordination Unit (2001)Training Manual on Emergency Nutrition Assessmentin Ethiopia.

Food Agriculture Organization of the United Nations (1993): Food and Nutrition in Management ofGroup Feeding Programs. Rome, Italy.

Food and Agriculture Organization of the United Nations (1990). Conducting Small Scale NutritionSurveys. A Field Manual. Food and Agriculture Organization of the United Nations. Rome.

Food Security Analysis Unit (2002). Nutrition Surveillance in Somalia.

Food Security Analysis Unit (2002). Nutrition surveillance Training Guide Notes.

Gibson, R.S (1990). Principles of Nutritional assessment.

Young, H. (1992). Food Security and Famine. Assessment and Response. Oxfam Practical HealthGuide No. 7.

Young, H and Susanne, J. (1995). Nutrition Matters. People, Food and Famine. An IntermediateTechnology Group Publication.

Hubbard, M. (1995). Improving Food Security. A Guide for Rural Development Managers. An Inter-mediate Technology Group Publication.

Lee, RD; Nieman, DC (1995). Nutritional Assessment. 2nd Edition. Morsby.

Lusty, T & Pat, D. (1984). Selective Feeding Programs. Oxfam Practical Health Guide. No. 1. OxfamPrint Unit. United Kingdom.

Nutrition Working Group (1999). Nutrition Survey : Recommendations for Somalia. February 1999,Nairobi.

Rosalind S. Gibson: (1990). Principles of Nutrition Assessment. Oxford University Press.

Save the children (2001). The Household Economy Approach. A Resource Manual for Practitioners.Save the Children, UK.

World Food Program (1998). Food and Nutrition Handbook. Rome, Italy.

World Health Organization (1995). Field Guide On Rapid Nutrition Assessment in Emergencies.World Health Organization Regional Office for the Eastern Mediterranean. Geneva.

World Health Organization Regional Office for the Eastern Mediterranean. Geneva.

World Health Organization (1999). Management of Severe Malnutrition: A Manual for Physicians andOther Senior Health Workers. WHO, Geneva.

World Health Organization (2000) Management of Nutrition in major Emergencies. Geneva.

36

A nutrition survey enumerator measuring height of a child (photo by FSAU)

37

Height measurement

A child aged 2 years (24 months) and above ortaller than 85 cm should be measured whilestanding.

1. Place the measuring board on a smoothlevel, flat hard surface preferably againsta wall, tree or a doorpost.

2. Remove shoes, sandals, socks, headgearor any other heavy items.

3. Assist the child stand with its backagainst the measuring board. Ask theassistant to help keep the child calm andcomposed

4. Position the child with bare feet together.Check on the position of the heels,buttocks, shoulders and back of the headtouching the board.

5. Hold the chin so that the child is lookingup straight

6. Adjust the headpiece so that it is level7. Lower the headpiece until it is firm on

top of the head. Press gently to ensurethat it’s in contact with the head.

8. Read the child’s height to the nearest0.1cm.

9. Record the reading immediately.10. Remove the headpiece and repeat

the instructions once more.*Note that in weight for height, children<5years or those whose measurements arebetween 65 and 110cm are considered.

Length measurement

Children less than two years old or childrenwhose length is shorter than 85 cm should bemeasured lying on their back.

1. Where the child is <2 years old, usehorizontal measuring board.

2. Lay the child on the measuring boardwith the top of the head pressed firmlyagainst the fixed ends .

3. Make sure the child is lying flat in thecentre of the board.

4. Hold knees straight and bring themovable footboard firmly against theheels so that the feet are at right angles.

5. Check the child’s position.6. Read and record the length to the nearest

0.1 cm.Always note that measurements and reading aretaken twice.

Weight measurements

Rope for hanging scales, Measuring sling,Plastic pants

1. Ensure that the Salter scale is hooked ontothe ceiling or a tree branch and that thescale is stable and hanging freely. Thescale should hung on a strong support.

2. Always adjust the ‘scale to zero’ withweighing pants hanging on the scalebefore weighing the child.

3. Request the mother to undress the child.She should remove as many clothes aspossible.

4. With the mother’s assistance, put thechild into the weighing pants.

5. Gently lower the child onto the Salterscale while the mother holds the baby.

6. Read the child’s weight. Ensure that thechild is hanging freely and not holdingon to anything.

7. Read the weight to the nearest 0.1 kg.8. Repeat the procedure of reading and

recording the child’s weight. Record theaverage of the two measurements.

9. Gently remove the child from the scale.Do not lift the child by the straps orweighing pants.

Appendices

Appendix 1

Procedure for taking weight, height/length and MUAC measurements

Body measurement Type of equipment

Height/Length Height or length boards (cm); Head block, Foot piece

MUAC MUAC tape

Weight Salter scale (235), plastic pant, rope

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A nutrition survey enumerator measuring length of a child (photo by FSAU)

Mid Upper Arm Circumference (MUAC)measurements

In young children, the target group is usuallythe age group12 -59 months.

• Request the mother to uncover the child’sleft arm as far as the shoulder.

• Bend the arm and place the lower armacross the stomach.

• Find the tip of the bone at the back andtop of the shoulder with your fingertips andmark it with a pen.

• Mark the second spot at the tip of theelbow.

• Measure the distance between the twomarked spots while standing behind thechild and divide this measurement by two.

• Using a MUAC tape, wrap the tape aroundthe arm at the midpoint between theshoulder and the tip of the elbow.

• The tape should be comfortably crossedover from 0 mark.

• Take the measurement to the nearest 0.1cm where the tape crosses at 0.

• Record down the data on the data entryform.

• The entry form should bear the followingdetails: child’s sex, age, presence ofoedema, and MUAC measurement.

To determine a child’s age various methodscould be followed:

• Examining the documentary evidence ofbirth date such as Road to Health Cardfrom the MCH Centre.

• Where such evidence is missing, estimatedate of birth using parent’s estimates orlocal event calendars.

39

Appendix 2

Sources of error in taking anthropometrical measurements

Common errors Solution

1. All measurements

Restless child Postpone measurement. Involve parent in procedure.

Inaccurate reading Training and retraining stressing accuracy.

Recording Record results immediately after taking measurements andconfirm record.

2. Length/Height

Incorrect method for age Use length only when child is <2 years old

Foot wear/headgear Remove

Head not in correct plane, Correct technique with practice and regular retraining.child not straight, knees bent, Provide adequate assistance. Calm the child.or feet not flat on floor

Child not straight along Parent or assistant should be present.board and foot not parallel Don’t take measurements while the child is struggling.with movable board

Sliding board not firmly Settle child. Correct pressure should be practiced.against heels/head Move head board to compress hair.

3. Weight

Scale not calibrated to zero Recalibrate after every measurement.

Child wearing heavy clothing Remove or make allowances for clothing.

Child moving or anxious Wait until child is calm or remove cause of anxiety.

4. MUAC

Child not standing in Position subject correctly.correct position

Mid arm point Measure midpoint carefully.incorrectly marked

Examiner not level with Correct techniques with training, supervision and retraining.subject, tape around the arm Take into account cultural practices for example. wearingnot at mid point, tape too of armbands.tight/ too loose

40

Traditional method of processing cereals before cooking (photo by FSAU)

Appendix 3

An Example of a 24-hour dietary recall checklist

Name of person interviewed ..........................................

Date ...............................................................................

Date & Day of week.......................................................

Name of interviewee ......................................................

Food Type Breakfast Lunch Supper In-between snacks Amount/portion Which foods

& Beverages eaten and why? foods are not

1.

2.

3.

4.

*Note also that main ingredients in mixed dishes should be identified.

41

Basic statistical concepts

Variables

These are items for which data is sought e.g.name, level of education, age etc. variables arecategorized under the following two groups;

Qualitative variables: these are variables whosevalues are descriptive and cannot be quantifiede.g. sex of a child (male/female), householdsource of income (remittances, sale of animals,diarrhea in last two weeks (yes/no) etc. Thesevalues do not compare numerically.

Quantitative variables: these are variableswhose values arise from counts ormeasurements expressed numerically. Forinstance weight of a child, age of a child,household size, height of a child etc.

Steps in Data Analysis:The first step in quantitative data analysis is tosummarize data to make it easier to understand.The commonly used tool in summarizing datais through use of frequency distribution.1 Frequency Distribution: Frequencies are

counts of different values of a particularvariable e.g. finding out how many of thesurveyed children are boys and how manyare girls. A set of all frequencies occurringvalues is called a frequency distribution.It comprises of counts, percentages andcumulative percentages. The frequencydistribution gives a general picture of thevalues of the variable. Summaries canfurther be made through use of averagevalues (central tendency) and other spreadvalues (measures of dispersion).

2 Measures of Central Tendency (Mean,Mode and Median)Mean: This is the sum of the values of avariable divided by the number of values(n).Median: This is the value that divides thedistribution in half when the values areeither arranged in ascending or descendingorder. It therefore becomes the middlevalue in the distribution.Mode: this is the most frequent valueamong all values in a variable.

3 Measures of DispersionRange: The difference between the

minimum and the maximum values of allvalues to a variableStandard Deviation: this is measure ofdispersion around the mean of values. Itgives an idea of how the different valuesof a variable disperse from the mean value.It has the unit of values of the variable andthe square root of the variance.

4 Determining Nutritional StatusNutritional indicators are developedthrough comparing a child’smeasurements to reference measurements.The reference data has been developedfrom the children of the same age, weightand height respectively. Results ofnutritional status are expressed as,• Standard deviation scores (Z-Scores)• The percentage of the median or

Percentiles

Standard Deviation Score (Z-Score)

• Are measures of the distance of how farthe child’s measurement e.g. a child’sweight is from the median weight of thechild of the same height in the referencedata. The distance is expressed in standarddeviation. Its computed as follows:

Weight-for-height = Observed – reference medianZ-Scores weight weight

Standard Deviation of thereference population

• Z-scores has greater compatibility with theNCHS/WHO reference values andsuitability for selecting malnourishedchildren irrespective of height

• Z-scores are particularly useful fordetermining differentials in malnutritionrates

• Z-scores Involve a complex process incalculation

• Z-score relies on fitted distribution ofindices across age and height values Ifa child’s SD score falls outside thenormal range (-2 and +2), then thissignals a deviation from the norm in thenutritional status

• Has a greater capacity to determineproportion of malnourished cases.

Appendix 4

42

Percentage of the Median

Demonstrates the child’s anthropometricalmeasurement as a percentage of the expectedvalue of the reference population. It is the ratioof a child’s weight to the median weight of achild of the same height in the reference data,expressed as a percentage. For instance,assuming that the median weight of thereference data for a particular height is 10 kg,then to say that the child is 80% weight forheight suggests that the child is 8 kg.

Percentage of the median is calculated asfollows:

% of the median = Actual weight of thechild being measured X 100

Reference weight of the child

The usefulness of the percentage of the medianis that its widely used in the field than SD scores.Besides it is typically used for admissions intofeeding centers.

Also, these calculations are easy to understand,calculate and interpret given that tables ofreference values are readily available

Determination of Population’s NutritionalStatus

A child’s body measurements are comparedwith the reference values by calculating eithertheir percent of the reference median or bycalculating their standard deviation scoresIn the theoretical perspective of normaldistribution, the mean is normally equal to themedian and also to the mode i.e.mean=median=modeIn such a distribution, about 70% of subjectswill lie within1SD about the mean, 95% within2SD and 99% within 3SD about the mean.Normal distribution therefore refers to thedistribution where individual measurements aresymmetrically distributed around the mean (itnormally takes the bell shaped curve as isshown in the box.)Normally, the child’s nutritional status isdetermined by her/his weight compared to astandard child with the same heightStandard median weight for each heightmeasure of children has been developed andused as reference data for determination ofnutritional status for by the United StatesNational Centre for Health Statistics (NHCS).The reference population data has been

recommended by the World HealthOrganization.This reference data is based on basic tenetsof a normal distribution. For instance, if achild falls below –2SD or 80% then that childis considered to have a negative deviant ofthe 5% minority for that height group. If achild’s weight on the other hand falls below-3SD or about 70%, then it is a negativedeviant of the 1% minority for that heightgroup and as a consequence considered asseverely malnourished.

Confidence Intervals

The nutritional status developed from samplesonly gives a rough estimate of the situation inthe general population. However when thesample is selected through some randommethod, then we can use properties ofdistribution to describe the general population.For example, a 95% confidence interval aroundthe sample estimate will imply that we are 95%confident that the interval contains a truepopulation measure. So, a prevalence of 12.5%(CI: 10.8% -14.1%) will mean that at least wecan be 95% confident that the true populationprevalence is between 10.8% and 14.1%.

Inter-relationship Between AnthropometricData and Other Variables

Further statistical analysis mainly usinginferential statistics is normally performed torelate anthropometric data to other variablescollected during survey e.g. sex of the child,age groups of the surveyed children, householdsources of income, food economy groups,disease prevalence, breastfeeding and infantfeeding patterns etc.

When conducting this kind of analysis,statistical tests such as chi square analysis,analysis of variance (ANOVA), regressionanalysis and other statistical investigations arecarried out. This is normally an advanced levelof analysis and requires assistance by astatistician in order to help determine the typeof analysis that is suitable for the data collected.

Significance tests are performed. These arefacilitated through use of computer packagesas manual packages are time consuming andrequires even more statistical expertise.

Always consult a statistician before embarkingon this type of analysis.

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Technical Terminology

Household food access is determined byseasonality patterns e.g. the main food cropproduced may not be sufficient to meet thehousehold needs at all times. Amongst pastoralcommunities, milk production varies withrainfall and availability of grazing lands. Further,opportunities for employment, migration,availability of fish and wild foods are oftenhighly seasonal. In addition, household income& expenditure may vary according to seasonthus affecting food consumption patterns.

Household Economy - the sum of ways inwhich the household produces food and nonfood items (assets, livestock, land) for its ownuse and also how households obtain non fooditems by exchanging production and labor.

Vulnerability - the extent to which a householdis affected by a defined event or risk - whateverthe risk of that event occurring. For example ahousehold might be regarded as vulnerable toa defined level of crop failure if this wouldreduce its income by, say, 50%, even if cropfailure in that area were rare. Vulnerability canbe reduced by having greater diversity ofactivities to reduce degree of exposure to anyone risk, and greater range of coping options.

Shock or Risk - events with potentiallyadverse consequences for the household .Shock or risk is unpredictable and out ofhousehold’s control. Can be natural or man-made, slow or rapid-onset.

Effect of a shock (or shocks) on a household inany location will depend on ;

• The magnitude of the shock (scale/severity/duration)

• The “normal” household economy• Opportunities to compensate for loss of

income• Choices that the household makes &• Degree of market dependency

Risk Minimization - Strategies employed toreduce the anticipated exposure to risk e.g.storage of crops, pesticide use, splitting herds,castrating male animals, planting drought-resistant crops and maintaining goodrelationships with other people/groups/populations.

Expandability - Refers to how much extra foodand income can potentially be obtained if thehousehold needs to increase access to incomeor food and reduce expenditure by:

• Expanding existing food and incomeoptions of households

• Additional food and income generatingoptions and

• Reduction in spending to “minimum” levels

Coping Strategies - are the ways in whichhouseholds try to make up in some activitieslosses suffered in others.Understanding coping strategies helpsdetermine an appropriate response. Copingstrategies change as stress continues. Earlycoping strategies are highly reversible (e.g.short-term dietary change) and require a lowcommitment of domestic resources. There arealso irreversible coping strategies which involvea high commitment of domestic resources (suchas productive asset sales, or out-migration).Some examples of coping strategies include:food reduction, increased labor, consumptionof wild food, migration, sale of assets, reducedexpenditure patterns and splitting householdmembers amongst relatives.

Cost of Coping - include financial, time,social costs.

Opportunity Cost - the hidden cost ofexpanding an activity. For instance, increasingcasual labor for other people will implyneglecting ones own land. This will have long-term consequences since it will affect foodproduction the following year. Similarly, takinga child out of school might imply receivingadditional cash for food in the immediate termbut , it will result in the loss of potentially higherearnings and social benefits in the future.

Distress Strategies - are strategies employedwhen coping mechanisms fail, e.g. Eatingbudgeted stores, or wild foods that wouldn’tnormally be eaten and which may bedetrimental to health. Slaughter/sale ofl ivestock to unsustainable levels -jeopardizing future livelihoods. Detrimentalnon-economic or social costs – for instancewomen who respond to a shock by becomingcommercial sex workers.

Appendix 5

44

Adaptive Strategies - The continuation of ashock, or series of shocks, forces the householdto adapt its old way of life into a new one. Thusthe economy becomes new or different. e.g.pastoralists who “drop out of” pastoralism orpermanent migration to a new location

Health - A state of physical, social, mental andpsychological well-being and not just theabsence of disease

Morbidity - ill health or disease.

Immunization - is a process of inoculatingattenuated or live organisms into the body inorder to stimulate production of antibodiesagainst a particular disease. All children underfive years of age are susceptible tocommunicable diseases, many of which canbe preventable through vaccination. Somaliahas developed an Expanded Program forImmunization (EPI) addressing vaccinepreventable diseases such as tuberculosis,diphtheria, tetanus, poliomyelitis, and measles,that follow recommendations of WHO.

Nutrients are the constituents of food orsubstances that the body uses for variousfunctions. They can be either macro- ormicro-nutrients.

Macronutrients are food nutrients that arerequired by the body in large quantities. Theycomprise the bulk of our diets and include,proteins, carbohydrates and fats. proteins areused for building body tissues; carbohydratesfor producing energy

Micronutrients are substances needed by the bodyin very minute quantities for growth, developmentand maintenance of a wide variety of bodilyfunctions. They include iron, iodine, Vitamin A,Vitamin B Complex, Vitamin C and Zinc.

Nutrition surveillance - is the process ofmonitoring changes in the nutritional status ofa population or subgroup on a regular andtimely basis. Nutrition surveillance involvesdata collection, processing, analysis,interpretation and communication. Nutritionsurveillance is an important process duringnormal and emergency situations.

The Food Security Assessment Unit (FSAU)supports nutrition surveillance activities inSomalia and aims to provide timely andappropriate information on the nutritional statusof the population along with possibleexplanations for potential or real change.

Nutrition - The subject of nutrition is concernedwith how people stay alive and well byconsumption of food. It includes how peopleobtain their food, how it is processed, handled,prepared, shared, eaten and with what happensin the body- how it is digested, absorbed andused by the body to contribute to good health.

Nutrients - Nutrients are small parts of foodthat the body uses for various body functions.

• Proteins- for building body tissues• Carbohydrates -for producing energy• vitamins and minerals- for fighting

infections

Nutrients be classified into macronutrients andmicronutrients for sources see appendix 8.

Macronutrients - The foods that we consumecomprise of the some major food nutrients,which comprise the bulk of our diets, and theyare known as macronutrients. Examples ofmacronutrients include; proteins, fats andcarbohydrates as well as water. Ideally, thesenutrients supply all the energy requirementsneeded by the body. In addition, macronutrientscomprise the bulk of our diets. It is wellestablished that about 80% of our food intakeis composed of macronutrients. In order for thebody to discharge its normal functions it needs,proteins, carbohydrates and fats.

Micronutrients - These are substances neededby the body in very small quantities for growth,development and maintenance of differentbody functions. They comprise of vitamins andminerals. The important vitamins are vitaminA, the B vitamins, C, D and E while importantminerals include iron, zinc and iodine. VitaminA helps the body resist infections and to keepall the cells on the surface of the body healthy

Malnutrition - Malnutrition may be defined asa state in which the physical function of anindividual is impaired to a point where sheor he can no longer maintain adequateperformance in such processes as growth,pregnancy, lactation, physical work, resistingand recovering from disease” (Pacey andPayne, 1985).

Under Nutrition - Malnutrition should not beconfused with under nutrition, which refers toreduced overall food intake in relation to therecommended daily dietary nutritionrequirements.

45

Inadequate dietary intake Disease

Inadequatehousehold foodsecurity

Inadequatematernal andchild care

Insufficientservices andhealthy

i

Formal and non-formal institutions,political and ideological superstructure,Economic structure, potential resources

Malnutrition anddeath

Appendix 6

UNICEF’s Conceptual Framework showing the causes of malnutrition

Appendix 7

Format for Nutrition Assessment Reports

Executive summaryIntroductionSurvey/ assessment justificationBackground informationMethodologyResults and analysisConclusionRecommendationAnnexes (e.g. of tools and references)

46

Appendix 8

Micro-Nutrients: Functions and theconsequences of deficiencies

Definition of micronutrients - Micronutrientsare nutrients that are essential for healthygrowth and development but required only insmall amounts. Micronutrients play veryimportant roles in the body. They affect adultproductivity, resistance to illness, educationalachievement (cognitive impairment), childsurvival and maternal health.

Important micronutrients - Iron, Vitamin A,Iodine, Vitamin C and Zinc

Iron - Iron helps to make blood, particularly inthe production of haemoglobin, the protein inred blood cells that carries oxygen. Iron alsohelps to make essential enzymes that enablethe brain, muscle, and immune systems tofunction properly.

Iron deficiency - Low levels or lack of iron inthe body leads to iron deficiency. Severe lackof iron leads to iron deficiency anaemia (IDA).Iron deficiency is the most common nutritionaldeficiency. Young children and pregnantwomen suffer high rates of IDA. The mainsymptoms are pallor, fatigue, brittle fingernails,sore tongue, and brittle hair, shortness of breath,unusual food cravings, low blood pressure,rapid heartbeat, low immunity, headache,decreased appetite, severe menstrual pain andbleeding and disturbed sleep.

Dietary sources of iron - Some of the sourcesinclude meat (spleen, kidney and liverespecially), chicken, fish, eggs, dried fruits,legumes (beans, peas), cocoa and cocoaproducts and dark green leafy vegetables.Cereals (maize, rice and wheat) containmoderate amounts but since they are consumedin large amounts they provide most of the iron.It is also obtained from iron cooking pots.

Vitamin A - It is essential for vision, growth andskeletal development. Assists in maintaininghealth skin and mucous membranes, protectingthe body’s major organs, enables properfunction of most body organs, assistsmaintaining health skin and mucousmembranes and provides optimum immunefunction.

Vitamin A deficiency - Low levels or lack ofvitamin A in the body leads to vitamin Adeficiency (VAD). The main symptoms ofvitamin A deficiency are: eye symptoms (eyeblindness, inflammation of the eye,inflammation of the cornea, eye lesions, anddry eyes), skin symptoms (rough skin, dry skin),decreased immunity (frequent infections ofcommon diseases like diarrhoea and measles)and loss of appetite as well as growthretardation in children.

Dietary sources of vitamin A - Some of the mainsources include breast milk (especially thecolostrums), animal products (cheese, butter,egg yolk, milk, meat specially liver and kidney,and oily fish), green vegetables (carrots,pumpkins, parsley, amaranth, spinach, sweetpotato and cassava), fruits (mangoes, papayasand tomatoes), yellow varieties of sweet potato,yellow maize, red palm oil and fortified foodslike margarines, vegetable ghee and dried milk.

Iodine - The body needs iodine for normalmental and physical development. Iodine isessential for the function of the thyroid gland,which is responsible for development. Iodineis also essential for foetal development.

Iodine deficiency - The main symptoms aregoitre (enlargement of thyroid gland),protruding eyes, hypothyroidism (fatigue,weight gain, weakness and depression) andhyperthyroidism (weight loss, rapid heartbeat,and appetite problems). IDD (Iodine DeficiencyDisorders) in pregnancy causes dwarfism andcretinism (severe mental retardation, stuntedphysical growth, enlarged head and deafness)to the newborn.

Dietary sources of iodine - The main sourcesof iodine are sea fish, milk, seaweed, greenvegetables grown near the sea (especiallyspinach), iodated salt and fresh water(depending on area).

Zinc - Zinc promotes normal growth anddevelopment. It promotes wound healing,maintains a healthy immune system and helpsprevent diarrhoea in young children.

Zinc deficiency - Main symptoms of zincdeficiency are slow growth in children, hairloss, various skin lesions, peeling skin, slowhealing of wounds, frequent and recurringinfections, severe diarrhoea, poor appetite, lossof taste and smell, fatigue, and sterility in males.

47

Dietary sources of zinc - Zinc is readilyavailable in breast milk for the young children,vegetables, seafood, meats (including chickenand fish), eggs and whole grain cereals andlegumes.

Vitamin C - Vitamin C (also called ascorbicacid) is essential for healthy teeth, gums andbones. It helps to heal wounds, produce redblood cells, build immunity and fight bacterialinfections. Vitamin C helps to form collagen,the ‘cement’ that holds tissues together. VitaminC enhances the absorption of iron in the body.Vitamin C deficiency leads to a disease knownas scurvy.

Vitamin C deficiency - Main vitamin Cdeficiency symptoms includes bruising, swollenor painful joints, bleeding gums, nosebleeds,fatigue and weakness, easily gets colds,anaemia, poor digestion, scurvy (skin thatbruises and bleeds easily, bleeding on fingertips,old scars and internal bleeding, nose bleeds,soft swollen purple gums, bleeding gums, toothdecay, hair and tooth loss, bones that easilyfracture, swollen and painful joints, slowhealing wounds and fractures, loss of appetite,weakness, fatigue and irritability.

Dietary sources of vitamin C - The main sourcesinclude fruits (like kiwi fruit, oranges,grapefruits, lemons, strawberry), vegetables(amaranth, spinach, broccoli, cabbage andgreen pepper) and various leaves (e.g. baobab).Young maize, sprout cereals and pulses as wellas plantains and bananas also contain fairamounts of vitamin C.

Calcium - Calcium is the most abundantmineral in the human body. The body requirescalcium in relatively larger amounts than theother micronutrients. Calcium is used forbuilding bones and teeth and in maintaining

bone strength. Calcium is also used in musclecontraction and blood clotting.

Calcium deficiency - Main calcium deficiencysymptoms are weak teeth that easily fall out,lack of sleep, premenstrual cramps, high bloodpressure, large forehead, sunken chest,protruding chest, osteoporosis (bones easilyfracture due to minor falls i.e. bones breakunder their own weight), hump in the back,curvature of the spine, rounded shoulders,losing height (becoming shorter) and inabilityto hold the body upright.

Dietary sources of calcium - Breast milk forthe young children, milk and milk products likecheese and yoghurt, bread (added to white flourby law), finger millet, small saltwater and bonesof fresh water fish (e.g. sardines and sprats) andhard water. Dark green vegetables and pulses(beans and peas) have small amounts ofcalcium.

Vitamin D - The major function of vitamin D isto maintain normal blood levels of calcium andphosphorous. Vitamin D helps the body toabsorb calcium; helping to form and maintainstrong bones.

Vitamin D deficiency - Lack of vitamin D canlead to calcium deficiency. Vitamin D preventsrickets in children (soft bones that bend inabnormal way, bowed legs) and osteomalaciain adults (weak bones, bone pain, spinal bonepain, pelvic bone pain, muscle pain, muscleweakness, bowing legs and fractures) which areskeletal diseases that result in defects thatweaken bones.

Dietary sources of vitamin D - Egg yolk,fortified foods like margarine, cheese, milk,butter, fish liver oils, liver are good sources ofvitamin D. Meat and fish contribute vitamin Din small amounts.

48

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Figure 5 Somalia: Nutrition status trends (1999-January 2005)

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