Objectives of this presentation

To introduce the various Nutrition assessment methodologies. To summarise the various steps involved in conducting a individual nutrition assessments and community survey in a given population

Defining a survey?
Surveys give varied information on specific topic depending on the objectives e.g. to determine the malnutrition prevalence rate and mortality in a population. Surveys collect information at single point in time. Surveys are done when baseline data (or midterm, end line etc.) is needed to supplement existing or non existing surveillance data. Factors that trigger health and nutrition surveys include:
1. 2. 3. 4. Food security Economic, weather, harvest predictions Political turmoil Health centre, hospital data

Strengths and weakness of surveys

Strengths If procedures are followed, surveys can give reasonably accurate estimate of prevalence of health condition in population. Can be replicated to evaluate health outcomes. Can be done when other data collection systems (e.g. surveillance) not feasible.

Weaknesses Difficult to assess cause/effect. Difficult to answer why questions. Surveys are expensive and time consuming

Limitations of surveys
Surveys should not be interpreted in isolation. There has to be contextual data that prompted the survey. Cannot be used solely to decide how and which programs to implement. information collected must be triangulated and used appropriately. Cannot give reasons why events occur or why things are the way they are, incidence or trends.

Surveys should therefore be

Be done by a well trained team. Provide information that is reliable and give an accurate picture. Use standard methods for collecting information. Be used with simple questionnaires and easy-to-use computer software for analysis and reporting gives credibility atlthough surveys can be analysed manually also. Be available in time to be useful for the intervention- nutrition surveys results should be released within 2- 4 weeks as situation can change completely within 3 months. Based on the findings, results should be discussed with the community surveyed and if need be, lead to action.

Surveillance
Many people refer to "nutrition surveillance" when they actually mean repeated surveys. However WHO, defines surveillance as systematic ongoing collection, collation, and analysis of data and the timely dissemination of information to those who need to know so that action can be taken-. The most common form of surveillance is collection of data from routine growth monitoring programmes in maternal-child health or primary care clinics.

Steps in conducting a Survey

It is important that the survey team members and the community leaders from the population being surveyed understand the big picture of doing the survey. Each step impact on each other. Each step is as important as the other.
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This is a Simplified, standardized survey methodology in a package easy for emergency situations. S-Standardized M-Monitoring A-Assessment R-Relief T-Transitions SMARTs main goal is to make Nutrition, and mortality surveys as easy as possible for the field staff and as reliable as possible for the decisionmakers.
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What is SMART?

 SMART addresses issues of common interest to many organizations. SMART gives very specific, measurable, accurate, information in the right format, to the right people at the right time, especially in relief and transition contexts. It is a very standardized survey methodology covering data collection, analysis and reporting among organizations conducting nutrition surveys.

Advantages of SMART
SMART is easy and user-friendly, Easy to understand and apply. Once trained, country staff could be self-sufficient and not require external assistance to do the work. Analysis done by one computer program only. SMART data

entry and analysis are enclosed in only one package with one accompanying software called ENA.

The SMART method is not really new: It is based on many established manuals and guidelines. SMART is open for upgrading based on research, experience and current best practises.
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Limitations of SMART
The food secutiry component in SMART is under development although food security is key in interprating nutrition survey results. Although many organisations including UNICEF have accepted and are using SMART, it is yet to be agreed or approved that it is the best practice.

How to assess nutritional status

In measuring nutritional status of a given population, children 6 months to 5 years old and mortality are the key indicators used. Why measure nutritional status under-5? Children in this age group are closely linked with high risk of death, especially in times of crisis. They are still in growth period and particularly vulnerable to disease and food shortage Considered to be the most sensitive to nutritional stress compared to other age groups Their results are used to draw conclusions on whole population.

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Why measure mortality?

It is the most critical indicator of a populations improving and deteriorating health status. Type of information to which donors and relief agencies most readily respond to. ******************* There are acceptable international standards for interpreting mortality and nutrition prevalence. In general, if nutritional status of children under 5 is improving and mortality rates are decreasing or getting back to international standards, most of the humanitarian assistance support systems are probably working.

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Steps in doing surveys Step 1~ Decide whether or not to do a survey

Decision is made and implemented in conjunction and collaboration with government, partner agencies and donors. Key points to consider: Results will be crucial for decision making Results will lead to action Access of affected population

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 Overall objective. E.g. To determine the prevalence of various forms of malnutrition among the refugees in a given population, at a defined point in time. Specific objectives. E.g. 1. To evaluate the nutritional status of children aged 6 to 59 months amongst the Somali refuges in xxxxx district. 2. To estimate retrospective crude and under five mortality rates amongst the refugees in these districts. 3. To understand the underlying causes of malnutrition in the targeted population. 4. To determine the prevalence of anaemia amongst children under fives amongst the targeted population. 5. To make recommendations for the next programme.
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Step 2: Define objectives

Step 3: Define geographic area and population group to be surveyed

Confine survey to area in which you intend to implement a program. Considering homogeneity, the area should corresponds to one or more administrative areas (E.g. a district, location). Areas difficult to access because of insecurity or other factors like very difficult infrastructure could be left out of the survey but must be reported. Nutritional survey: Anthropometric measurements and edema assessments among children aged 6-59 months. Other ages groups depending on the specific agenda: sometimes pregnant and lactating women. Mortality survey: Crude death rate (CDR) assessed for entire population. Age specific mortality rate e.g under 5 mortality rate, infant mortality rates.

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 Meeting the targeted community leaders and local authorities before starting a survey is essential to agree on dates, objectives and how results will be used. Obtain: Map of area Population figures Information on security and access Letters of permission

Step 4: Meeting community leaders and local authorities

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 With the help of community leaders and local authorities, agree on times when people are likely to be present at home. Events to avoid include market days local celebrations food distribution days vaccination campaigns assign adequate time for preparation, literature review, training, pilot testing, community mobilization, data collection, analysis and reporting.

Step 5: Determine actual home visiting timings

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Step 6: Selecting sampling methods

Sampling methods use standard method of selecting the subjects that is designed to eliminate bias and get a representative sample. Every child in the entire targeted population should have an equal chance of being surveyed Sampling is based on the way households are distributed and the population size to be surveyed There are 3 commonly used methods:

1. 2. 3.

Simple random sampling Systematic random sampling Cluster sampling

Exhaustive survey are occasionally done on very small populations (less than 1000 people), where every household can be visited. 1. Simple or systematic random sampling is used. When a list of every household or individual is available. Where the houses are arranged in a systematic way 2. Cluster sampling, the most commonly used, when households are distributed in an unstructured way that does not easily allow all the households to be listed or numbered.
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Systematic random sampling continued...

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Cluster sampling

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Cluster sampling is in two stages: 1. Stage 1: Whole population divided into smaller geographical areas that the population size is known e.g. villages and Clusters are then randomly selected from these units. 2. Stage 2: households are chosen at random from within each cluster area or village. Though larger villages are more likely to be selected to contain a cluster (or more) than smaller villages, the individual households within the larger village are less likely to be sampled than a household from a small village. These effects balance each other so that each household in the whole population has an equal chance of being selected.

 1. 2. 3. 4. 5.

Thirty clusters of thirty children has largely been used, giving a sample size of 900 children.. However with the SMART methodology, smaller sample sizes can be calculated accurately based on: Precision: the higher the precision the more the sample size. Prevalence: What are the expected malnutrition prevalence and death rate? Precision: The longer the recall period the more precise the estimate of mortality. Design Effect (if the survey is to use cluster sampling). Recall period- for the Mortality. These factors are entered into Nutrisurvey to calculate both nutrition and mortality sample size. Use this routinely to calculate the sample size instead of using the same sample size for all surveys as the factors above may change. This reduces the cost and time and eases logistics compared to the 30 X 30 methodology while ensuring the use the minimum sample size that gives adequate results so that the teams are not stressed

Sample size:

Step 7: Gather available information

Population characteristics and figures. Previous surveys and assessments. Health statistics. Food security information. Situation reports (security and political situation). Maps, and anthropological, ethnic and linguistic information.
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Step 8: Decide on additional data

Each additional data collected may limit accuracy of whole dataset and prolongs survey. Need to consider if information can be collected more efficiently in other ways. Additional information must be quickly and reliably obtainable during a short visit to the household.

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Step 9: Obtaining and preparing equipment, supplies and survey materials

Measuring material, scales and height boards are in good condition. Transport, fuel, paper, pens, notebooks, per diem. Copies of questionnaires, forms for referral of malnourished children, etc.

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Step 10: Selecting survey teams

SURVEY SUPERVISOR

TEAM 1

TEAM 2

TEAM 3

TEAM 4 ++

TEAM LEADER

MEASURER 1

MEASURER 2

INTERVIEWER (mortality) or COMMUNITY MEMBER

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Step 11: Training survey team members

Teams can be made of 3- 4 people depending on availability and other logistical factors like if they are to be transported. Adequate formal training of the survey team members before the survey is essential. The same training for each team member is done to ensure standardization of methods. Supervisor must continually reinforce good practice, identify and correct errors and prevent declining measurement standards.
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Managing the survey

Have a supervisor who has overall responsibility for survey planning and implementation. Important not to overwork survey teams. Together with the supervisor, ensure quality of data collected through: 1. Checking with data entry on daily basis. 2. Organize daily wrap-up sessions. 3. Keep record of all important point with team leader. 4. Double-check edema cases.

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