Introduction TO Nutrition Surveillance PDF

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Introduction to nutrition surveillance

Module Units and Time Allocations Unit No 1. 2. 3. 4. 5. 6. 7. Total

Name

Introduction to nutrition surveillance Methods of nutrition surveillance Surveillance information Types of nutrition survey Application of nutrition surveys Program monitoring and Evaluation Emerging issues and trends

Time (Hours) Theory 4

Practical 2

Total 6

6 2 5 7 5

2 5 6 9 5

8 7 11 16 10

1 30

1 30

2 60

Module outcomes a) b) c) d) e) f) g)

By the end of this module unit, the learner should be able to: Recognize the role of nutrition surveillance in nutrition and dietetics Apply the nutrition surveillance principles Develop skills in nutrition surveillance Collect nutrition information and data in nutrition for use in surveillance Use malnutrition and growth monitoring data in nutrition surveillance Conduct programme monitoring and evaluation

1: INTRODUCTION TO NUTRITION SURVEILLANCE 1.1: Meaning of terms DEFINITION OF KEY TERMS AND TERMINOLOGIES Surveillance: It refers to the act of carefully watching someone or something especially in order to prevent or detect an occurrence of a given situation. It can also be defined as a continuous observation of a place, person, group, or ongoing activity in order to gather information: 1|Page

Nutrition surveillance: Definition one: Nutrition surveillance refers to a continuous process and focuses on monitoring trends in the nutrition situation over time rather than providing one off estimates of absolute levels of malnutrition. Definition two: The term can also be referred to as information system. It involves the collection, analysis, interpretation and reporting on information about the nutritional status of populations and most importantly are used to inform appropriate response strategies. It is important to distinguish between the terms ‘surveillance’ as a general activity, and ‘surveillance systems’ as a specific process within this activity. A nutrition surveillance system is: A system, coordinated by a central institution that collects representative primary data at recurrent intervals on indicators of nutrition and the factors that influence them, for making decisions. Objectives of surveillance systems  To aid in long term planning of health and development  To provide input for program management and evaluation  To give timely warning of the need for an intervention to prevent critical deterioration on food consumption

Nutrition surveillance is: Regular and systematic collection of data on nutritional indicators. Monitoring: The term ‘monitoring’ implies recurrent observation. In nutrition this word usually refers to an activity related to evaluating programmes, so is more specific than surveillance. However, the term monitoring is often also used interchangeably with the term surveillance, and in fact surveillance has been defined in terms of monitoring both academically (Bender, 2009 p.386) and in practice: It can also be defined as to watch over nutrition, in order to make decisions that lead to improvements in nutrition in populations Nutrition status: It refers to the physiological state of an individual that results from the relationship between nutrient intake and requirements and from the body’s ability to digest, absorb and utilize these nutrients. It can also be defined as the health status of an individual as influenced by the intake and utilization of nutrients in the body 2|Page

Poor nutritional status: It is the inadequate intake/use of nutrients to meet the body’s requirement for energy, growth and maintenance. Therefore, a malnourished individual has a poor nutritional status Screening: It refers to application of rapid tests, examinations or other procedures to sort out apparently well persons who probably have malnutrition or disease from those who probably do not have malnutrition or the disease. Screening- Nutritional screening is the process of identifying characteristics known to be associated with nutrition problems. Its purpose is to identify populations, sub-groups or individuals who are malnourished or at nutritional risk. Four different methods are used to collect data used in assessing nutritional status:    

Anthropometric assessments e.g. weight, height and MUAC Biochemical assessments e.g. Laboratory tests for urine and blood Clinical assessments e.g. Hair texture and colour, skin condition etc. Dietary assessments e.g. 24 hour recall, food frequency records

Screening procedures  The population comprises of apparently health members is subjected to a screening test.  The screening test negative are allowed to go home depending on the nature of the disease in question but in some special cases everybody whether negative or positive may be subjected to diagnostic test.  The screening test positive are subjected to a diagnostic test to confirm their status. Those who are diagnostic negative are allowed to go away while diagnostic positive cases are subjected to an intervention  The screening test is then repeated after some regular prescribed interval Purpose of nutrition assessment i. ii. iii.

To accurately determine nutritional status To identify current and potential nutritional and medical problems To monitor changes in nutritional status during national policy changes, fortification programs, nutrition intervention or the course of a chronic or acute illness Nutrition assessment is important because acute and chronic malnutrition can be identified. The methods for nutrition assessment will be covered in detail in topic three.

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Characteristics of a good surveillance system The following are characteristics of a good surveillance system: • Capacity to act on information. First and foremost, the system must be able to act on information produced, whether in terms of a well-organized response to the rising nutrition problem or of managers using the information to make better medium- and long-term decisions. • Standard case definitions and reporting protocols. These allow correct and timely documentation and reporting. • Basic and sound investigation methods. These use appropriate analysis and interpretation techniques. • Adequate laboratory support. Appropriate actions require accurate detection. Cases detected in the field may require more sophisticated laboratories for confirmation of the diagnosis. • Efficient communication systems. Information and feedback must be passed on quickly. • Cost-effective resource use. The system must focus on priorities to keep nutritional problems under control and also, where appropriate, on cooperation to save duplication of effort. • A network of interested people. The surveillance system is only as good as the people who operate it. Geographic coverage: The geographic coverage of most surveillance systems tend to vary to some extent. While these systems are supposed to be national in scale, only 9 of the 13 systems collect data in all/nearly all sub-national regions. Other systems target sub-national areas of heightened vulnerability to food insecurity or are sub-national at the moment with future plans to expands to national coverage. 2.0: Methods of Nutrition Surveillance 2.1: Nutrition Surveillance methods Various criteria can be used to establish nutrition surveillance systems. A decision on the best approach to adopt will depend on:  the objectives  resources,  Environment and capacities available.

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The following are the main methods used for surveillance/types of nutrition surveillance i. ii. iii. iv. v.

Large scale national surveys Repeated small scale surveys Clinic based monitoring Sentinel site surveillance School census data

In an emergency setting additional sources are also used:

 Rapid nutrition assessments  Rapid screening based on mid upper arm circumference (MUAC) measurement either exhaustive community screening or screening groups of children to provide an indication of a problem  Selective feeding programme or services statistics monitoring (monitoring the use of services such as health facilities) NB: There is no single prescribed method for nutrition surveillance systems in emergencies. What often occurs is that a variety of nutrition information sources are used depending on the context, what is appropriate, available and feasible. It is best to use representative data collected from the population. LARGE SCALE NATIONAL SURVEYS National level representative population based surveys, such as the demographic and health surveys (DHS) or the United Nations Children’s Fund (UNICEF) multiple indicator cluster surveys (MICS) are generally conducted every three to five years. Nutrition information is collected with regional and national level prevalence estimates of wasting, underweight and stunting reported Large scale national surveys are not appropriate to conduct in an emergency setting given the scale and the frequency of these studies. Regardless of that, they are a useful baseline for comparison of estimates of acute malnutrition at regional levels as well as other health and nutrition indicators such as immunisation coverage, care practices and mortality (death) data.

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Information from large scale national surveys is available at DHS or MICS website and is stored with National Bureau of Statistics for DHS or UNICEF for the MICS reports. National level surveys using the standardized monitoring and assessment of relief and transitions (SMART) method can also be conducted. Repeated small scale surveys/ Repeated nutrition surveys Small scale random sample nutrition surveys are the most common method used to assess the nutrition situation in emergencies. Nutrition surveys are designed to provide representative point prevalence estimates of rates of acute malnutrition of children six to 59 months in a given population. Mortality rates can provide a good picture of the severity of the situation. In addition, information to assess the underlying causes of acute malnutrition is collected such as public health status, immunisation coverage, food security and care practices. Small scale surveys are frequently used as a source of information in emergency nutrition surveillance systems. Clinic based monitoring/ Data from health clinics Clinic based monitoring of the nutritional status of children is one method that can be applied both in emergency and non emergency situations. During the 1970’s and 80’s, heath centre based growth monitoring was established in many developing countries as a component of health information systems (HIS). However, over time the efficiency and effectiveness of growth monitoring has been questioned in the absence of parallel development programmes, as a method to reduce high rates of malnutrition in young children. In an emergency, information from established HIS can be very useful and often may be the only available information about nutrition in the early days of an emergency. In most cases growth monitoring refers to measuring underweight or weight for age. Children who attend maternal and child health clinics (MCH) are measured on each visit and their weight for age plotted on a chart, while health staff document the results in a register. Ideally the data from these registers is collected at a more centralised level where it is compiled into a larger register, analysed and the results and recommendations reported back to the district and health centre level. However, one of the main challenges of such systems is the lack of timely centralisation, analysis and reporting. 6|Page

While the information can provide a picture of the level of underweight children in a given community, there tends to be a bias towards younger children (below one year of age) who attend the MCH clinic for immunisation purposes. then older children do attend, they are generally sick, which can also bias the data. A further potential bias is toward populations who can actually access the health centre. Those communities who are far from the clinic will not be represented in the sample. In many emergency settings, NGOs establish links with a local MCH clinic in order to provide training, equipment and incentives to MCH staff to routinely assess the nutritional status of all children who attend . This can be a useful way of monitoring the nutrition situation as well as identifying acutely malnourished cases who can be referred to the nearest appropriate selective feeding programme. Sentinel site surveillance/ Community based sentinel site Sentinel site surveillance refers to the monitoring of purposively selected communities or service delivery sites, such as a health centre, in order to detect changes in context, programme or outcome variable. Communities are purposively selected for a number of reasons, such as vulnerability to food insecurity in times of stress. Sentinel sites can range from health centres, to villages, to districts. Sentinel site surveillance can be technically sophisticated with large scale assessments at site level or as simple as community based monitoring of a few key indicators. The objectives are to monitor the trends in the nutrition situation in these identified vulnerable areas in order to provide early warning. Community based surveillance also has the potential advantage of empowering the community, being relatively low cost and is particularly useful in emergencies where insecurity prevents representative sampling. School census data Nutritional indicator monitoring is occasionally undertaken in schools. The usual form of measurement is height for age (a measure of stunting). children are often measured through censuses that are carried out every two to three years. The method has been used to identify high risk populations with poor health, 7|Page

malnutrition and low socio economic status. The main strengths of this method are that it is both cheap and provides very good population coverage. It can, however, be easily confounded by external factors such as a reduction of attendance rates so that the data cannot be extrapolated (generalized) to the general population. Although this type of information is not useful in detecting nutritional changes during an emergency, it may serve as a useful baseline indicator for assessing attendance rates. Attendance rate can be seriously affected by a shock and be an indicator of food insecurity where children, particularly girls, are taken out of school in order to support the households to access food. Rapid nutrition assessments Rapid nutrition assessments are conducted to get a quick snapshot of the nutrition situation. Depending on the context, different indicators can be used such as weight for height or MUAC. Agencies have developed a variety tools which can be modified according to the context and the type of information considered appropriate to collect. Although the information may not always be representative and thus not statistically valid, the results from a rapid assessment, even of a small sample of children, can provide a basis for determining whether a more detailed assessment is required to establish the actual prevalence of acute malnutrition or whether an emergency response is required. For this reason rapid assessments are an important source of information especially at the onset of an emergency to determine the magnitude and severity of a crisis. See module 7 for more information about rapid nutrition assessments. Selective feeding centre statistics/ Data from feeding programs admissions In large scale nutrition emergencies a component of the response will be selective feeding for acutely malnourished children. These usually include therapeutic care for the severely malnourished and supplementary feeding for moderately malnourished cases. See modules 12 and 13 for more information. In selective feeding programmes, statistics are collected on admissions, cure rates, defaulter rates and case fatality rates. These indicators provide a measure of programme quality as well as act as a source of information on the trends in acute malnutrition. By including these indicators in a nutrition surveillance system they can provide useful information of the most vulnerable groups (by profiling the type of 8|Page

individual admitted i.e. children under two years of age, adolescents, their location etc). They can also help identify the underlying causes of malnutrition such as morbidity (illness) patterns. Monitoring the trends in admissions and assuming reasonable coverage and access can provide additional information on seasonal trends in the nutrition situation (i.e. during the rains pre harvest the numbers of cases admitted to the feeding programmes may increase). One challenge is that NGOs have established different admission criteria for selective feeding programmes making it difficult to compare data between centers. However, monitoring rates of cure, case fatality and defaulting can still contribute to an understanding of the nutrition situation. OBJECTIVES OF NUTRITION SURVEILLANCES  Describe the population’s nutritional status, with particular reference to defined subgroups who are identified as being at risk.  Monitor nutrition programs and to evaluate their effectiveness.  Raise awareness about nutritional problems  Provide guidance to health-related local intervention programs  Enable predictions to be made on the basis of current trends in order to indicate the probable evolution of nutritional problems  To describe the nutritional status of the population, with particular reference to defined subgroups that are identified as being at risk  To monitor nutritional programmes and to evaluate their effectiveness

Surveillance Information 3.1: Importance of nutrition surveillance information 3.2: Principle users of surveillance information Considering there are there are many factors leading to malnutrition and there is a close relationship with socioeconomic status, the potential users of nutrition surveillance information are found in many sectors. Even though, it sounds unrealistic to expect nutrition to play a critical role in decisions on overall resource allocations, nutrition surveillance can be used to analyze policies for nutritional consequences, to suggest alternative policy options and eventually to assess their nutritional effects.

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There is an advocacy role for long-term nutrition surveillance to reinforce other similar methods trying to detect the fundamental causes of malnutrition. However, surveillance probably has the most potential for bringing about policy changes favorable to nutrition with reference to specific, selected issues. These issues may often be less fundamentally related to the basic causes of malnutrition, such as the inequitable distribution of resources, but in reality decisions on them have a better chance of influencing nutritional status. Some of the principles users of the surveillance information include: Stakeholders of food and nutrition surveillance data (5) Table 2 summarizes the important stakeholders of food and nutrition surveillance data

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Types of Nutrition survey Meaning of terms What is a survey? Most of us are familiar with surveys and are likely to have participated in several of them in the past. A common type of survey frequently done in humanitarian emergencies is a nutrition survey of children less than 5 years of age. In such situations, surveys are used to provide a snapshot of the health and nutritional status of the population or coverage of relief programmes. The technical names for these are cross-sectional surveys. Cross sectional survey: It refers to the collection of data at a single point in time from a specific population. What is a nutritional survey? It refers to a method of obtaining information regarding the nutritional status of a population or a subgroup. Such information is collected by using various methods such as questionnaires, interview schedules, and etc to a representative sample of a population. Mostly surveys are esse...