Nutrition Guide to Data Collection Interpretation Analysis and Use English (1)

8/17/2019 Nutrition Guide to Data Collection Interpretation Analysis and Use English (1)

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April 2005

NUTRITIONA Guide to Data Collection, Analysis, Interpretation and Use

Food Security Analysis Unitfor 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: [email protected]: www.fsausomalia.org

Design and layout by Jacaranda Designs Ltd.Printed in Nairobi, Kenya


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AcknowledgementsThe 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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ForewordNutrition is about people and the measurement of the nutritional status of a population is one of the 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, there

has 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 understand

nutrition 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 ContentsAcknowledgements ............................................................................. .............................. iiiForeword ............................................................................. .............................................. 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 .................................................................................. 123 Measuring nutritional status ............................................................................... ......... 13

3.1 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 ................................................................................................... 265 Analysis and intepretation of the nutrition situation ................................................... 29

Steps in data analysis and interpretation ...................................................................... 29Case study ................................................................................................................. 33

Bibliography .................................................................................. ............................... 35Appendices .................................................................................. ............................... 37

Appendix 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 the

key 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 of increasing malnutrition are felt in a society bothin the short term and long term. In much of sub-Saharan Africa, measurement (anthropometry) of children under the age of five is the most

commonly 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 amongst

the 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 other

development 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) that

support 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 food

security. 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, analyzing

problems 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 nutrition

Food 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 politicalenvironment, 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 vulnerability

Nutritional 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 of destitution, 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 includingdisplaced and orphans.

2.3 Conceptual framework forunderstanding possible causes of

poor 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 of malnutrition. 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 low

food 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 (productiveland, 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 the

appropriateness 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. There

are 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 of working 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 quality

SanitationFood safety and

quality

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 meets

their 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 of imported food commodities is common.

Food stability

Food stability is influenced by both supply andaccess factors. Seasonal fluctuations inproduction and access are a major feature in

Somalia. There are many incidences of recurrent 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), food

intake 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 urban

centres) 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 strategiesCoping 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 of income 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 ill-health, these

practices include seeking health servicesfrom qualified personnel; access to healthservices; as well as control and treatment of communicable diseases.

The poor health of individuals is normallyassociated with the inability to engage inmeaningful productive activities, and higherexpenditures on treatment at the expense of food 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. A

significant 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 of contamination. 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 place

for 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 of inappropriate 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 of clothing, bedding, contact environment).

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

•Specific care during periods of vulnerability 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) of food 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 of essential 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 of iron, 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 Nutrition

is therefore an outcome of the individual orpopulation receiving and utilizing theappropriate diet. This diet maintains normalfunctions in processes like 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 of the 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 of evaluating 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 an

understanding 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 of the 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 values

of weight-for-height for under five-year-oldchildren are available.• Body weight is sensitive to rapid changes

in 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 of feeding 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 facilities, 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 of underweight 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 of the nutritional status of the child.

• All cases of oedema should be separatedfrom the rest of the respondents during

analysis and treated as severe acutemalnutrition.• Oedema should always be used as a major

criteria 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, urine

and other biological samples. Compared toother methods, biochemical methods of nutritional 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 they

eat. 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 diarrhoea

and 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. Acute

malnutrition 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 of acute 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 micronutrient

deficiencies 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 rather than 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 and

at what frequency. Data on foods consumedassist in the identification of nutrient intake.Interpretation of dietary intake involves use of food 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 of

consumption 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 of consumption could be coded as:

a) ‘Frequently consumed’ - food itemconsumed once a week to many times

a 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 of foods consumed during the previous 24 hours.Asking respondents about their activities during

the 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 particular

nutritional 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 of seasonality, the assessmentshould be repeated at

intervals 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 nutrition

Nutrition 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 of factors 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 of

children under the age of five. Nutritiondata collected from these facilities servesas an early-warning indicator in case of a 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 of acute malnutrition in the facility’scatchment area.

3. Rapid assessments: These are mainlycarried out on an ad hoc basis and areuseful when nutrition information is

urgently 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 of nutrition 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 approaches provide actual statistics on nutritional statuswhile qualitative research methodologies offerexplanations into the actual causes of malnutrition. The use of both approaches isrequired to develop a useful understanding of the 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. In

qualitative 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 expected

between the various groups in thatpopulation

• Access to all populations in the area of interest 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 nutrition

problem, 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. It isimportant to establish a range of variables 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 not

possible 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 of partners. 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%


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Classification of mortality data

Indicator Definition Interpretation

Crude Mortality Rate (CMR) An estimate of the rate at which members of


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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 discussions

of 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 interviewing

key 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 of life 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 TherapeuticFeeding 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 each

by 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 of the 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 of response generated from the discussionsdetermines the quality and interpretation of results.

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.

ObservationIt 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 of things 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 and interpretation

• 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 for

emerging 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 the

incidence of malnutrition. Special focusis made on the new admission and re-admission rates as well as the places of origin 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 of service and availability of drugs. Though notrepresentative, the data is useful in indicatingtrends in nutritional status.

Rapid assessments data gives an indication of the 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 is

important. 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 at

unaffordable 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 if members are meeting daily foodrequirements or not. In the case of children, 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 a

possibility 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 poliomyelitis. Onceimmunized, bodies are more able tofight diseases. If the immunizationcoverage is low, the population is morevulnerable to outbreaks of communicable 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 of vitamin 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 clean

source of drinking water, there is need todetermine if this is sustainable or not.•Hygiene practices in homes, around

water 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 will

contribute to a deterioration in nutritionalstatus. For example a lactating mother wholacks good care might not have enough


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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 childcare

practices (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 will

have negative consequences on anindividual’s nutritional status.• In most cases, people will consume the

foods 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-soluble

vitamins, 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/or

household 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 distribution

programmes and veterinary services. If present, are they accessible to all andsustainable?

• Are certai

Documents

Nutrition Guide to Data Collection Interpretation Analysis and Use English (1)