HND 309

NUTRITION SURVEILLANCE
Introduction
Nutrition surveillance or information systems (the terms are used interchangeably here) collect,
analyse, interpret and report on information about the nutritional status of populations and most
importantly are used to inform appropriate response strategies. Nutritional status is a well-
recognized outcome of human welfare. Over the past 20 years, methods for collecting
information on nutritional status have been standardized with the result that rates of acute
malnutrition have become one of the most common and reliable indicators used in emergencies.
This module is heavily focused on emergency/humanitarian surveillance systems. However,
similar principles are used for those systems used in development contexts. Therefore, this
training module, and the principles within, is relevant for any scenario regardless of the state of
population for which information is required.

Nutrition surveillance systems vary significantly and will depend on the context / type of
emergency and information required, as well as the capacity of staff and other resources
available.

The biggest challenge for all nutrition surveillance systems is to ensure effective linkages
between information and action. Recent experience has highlighted varying degrees of success
with a variety of nutrition surveillance systems. However, issues such as reliability of data,
timeliness of reporting, effective and efficient links to action and sustainability remain a
challenge. A further challenge is the interpretation and presentation of findings. Similar levels of
acute malnutrition have different significance depending on the context and unless the
underlying causes of malnutrition are understood an appropriate/effective response may not be
provided.

Objectives
The objectives of a nutrition surveillance system depend on context. These include the following:

 Advocacy. This is used as a means of highlighting an evolving crisis

 Identification of appropriate response/intervention strategies. In emergencies these
may include non-food as well as food assistance to address the underlying causes of
malnutrition. In development scenarios, this may include nutrition education and
activities directed to increasing diversity of food production food access. Both
emergencies and development settings may also require micronutrient supplementation
programmes.
 Triggering a response. Nutrition surveillance systems provide a trend analysis focusing
on the magnitude of change. This may trigger a more in depth assessment that in turn
may lead to response.
 Targeting. Nutrition information can help target areas that are more at risk or in greater
need of assistance,
 Identification of malnourished children. Most forms of surveillance will identify
acutely malnourished children.

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Methods
The following are the main methods used for surveillance:
 Large scale national surveys
 Repeated small scale surveys
 Clinic-based monitoring
 Sentinel site surveillance
 School census data

In an emergency setting additional sources of data can be obtained from:

 Rapid nutrition assessments
 Rapid screening based on mid-upper arm circumference (MUAC)

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. Representative data are most easily understood and
interpreted. This type of data is therefore the most desirable for a nutritional surveillance system.

Which population groups should be monitored?

In emergencies, acute malnutrition, especially wasting, among children 6 to 59 months is usually
taken as a proxy indicator for the general health and wellbeing of the entire community.
However, in certain contexts information on the nutritional status of adolescents, adults or the
elderly may also be valuable.

What indicators should be monitored?

A number of standard indicators are used to assess the nutritional status of the population and the
underlying causes of malnutrition. These include:
 Anthropometric (body measurements to assess nutritional status) measurements
 Clinical and biochemical indicators of micronutrient deficiency diseases
 Indicators to assess the underlying causes of malnutrition such as care practices, health
status, water and sanitation, and food security indicators such as dietary diversity.

Information on other indicators may also be relevant such as mortality (death), population
displacement numbers and shelter conditions

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Data collection
Factors that have to be considered include:
 Frequency of data collection
 Identification and capacity of enumeration staff
 Access to data collection areas by enumerators

Analysis of data
There are a variety of computer programmes that can be used to analyse nutrition and related
data. These include Nutrisurvey (ENA) software and EpiInfo. The quality of data needs to be
maintained at a high level in order for it to be credible / provide an accurate representation of the
population.

Interpretation of data
The following should be taken into account when interpreting data:

Rates of acute malnutrition in relation to thresholds for response. A number of classification

systems have been developed around which particular emergency interventions should be
initiated. In addition, more specific nutrition ‘decision trees’ have been developed to indicate
when selective feeding programmes should be started.

Trends over time and seasonality. Nutrition data must be interpreted in relation to pre-
emergency levels of malnutrition and normal seasonal patterns.

Underlying causes of malnutrition. The relative importance of food, health and care as
nutritional risk factors need to be identified so that appropriate responses can be prioritized.

Relationship between malnutrition and mortality. The relationship between mortality and
nutritional status is not clearly defined. In some cases it is strong and in others it is weaker.

Challenges of nutrition surveillance systems

Sustainability is one of the biggest challenges, i.e. to ensure continued effectiveness of the
system after the initial donor support has been withdrawn. One of the main reasons surveillance
systems fail is that national or local governments are unable to provide the level of resources
needed to maintain a system. When establishing a nutrition surveillance system it is essential to
consider and plan for long-term sustainability, especially in areas where there is a high likelihood
of protracted crisis. Ideally, if a system proves to be effective and sensitive to monitoring change
over time, there should be no difficulty in justifying long-term resource provision to maintain a
system that provides accurate early warning that in turn can trigger a rapid, geographically
targeted response. This is likely to be more cost-effective than mounting a full-scale wide-
spread humanitarian response to a nutritional emergency.

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Institutional issues, such as where the system should be located within decision-making bodies
and how it links with existing early warning systems or health information systems, can also be
problematic. The challenge for many information systems is that they rely on a range of
information sources that cut across several government ministries including health, agriculture,
education and even the bureau of statistics. This means that no one ministry takes responsibility
for the management of the system while its utility may be under-valued. Over time it may
therefore be abandoned. In some countries where there are recurring humanitarian emergencies
a specific department, bureau or high profile (and well-funded) project may be established with
responsibility for disaster management and response. This institution is likely to manage the
surveillance system and takes responsibility for the information generated by it.

Linking information to action is of paramount importance. The collection of data that is not
linked to action is pointless and unethical. Therefore, nutrition surveillance systems should be
designed to maximize the likelihood of response, where needed. This requires: an analysis of an
optimal institutional location for the system, consideration of channels for disseminating
information, and a forum in which the analysis will be presented. Furthermore, involvement of
decision makers in the design and development of an analytical framework for using the
information will strengthen credibility of the system and, as a result, the likelihood of response
where necessary.

Key messages
1. Before establishing a nutrition surveillance system, be clear on the objectives and what the
information will be used for. Consider the availability of resources, staff capacity, sustainability,
environmental factors and response capacity.
2. Review and map existing nutrition information sources (indicators collected, frequency of collection,
target population) to prevent duplication and, where possible, ensure linkage or integration with
existing information systems.
3. Review and map existing sources of relevant non-nutritional information sources and how they can
complement and provide data to explain changes in nutritional status. Define a minimum set of core
indicators that relate to nutritional status and provide an understanding of the underlying causes of
malnutrition.
4. Design the surveillance system on the basis of context and recognise that in some contexts, several
data collection methods and analytical tools may be appropriate.
5. Ensure adequate training and supervision of enumerators for data collection.
6. Include simple quality checks to assure reliability of data.
7. Consider contextual issues when interpreting the data: seasonality, population movement, morbidity
patterns, and historical trends in nutritional status.
8. Ensure triangulation of information with data from other sources.
9. Ensure information is presented in a timely and accessible manner to decision makers and to the
community.
10. Establish triggers to determine when more detailed nutrition assessments are necessary.
11. Consider how the information from the surveillance system will link to action or response.
Information is meaningless unless it is used appropriately.
12. For longer term systems in emergency prone areas, consider sustainability issues from the outset.

nutritional surveillance or community nutrition consists of three distinct components. They are:
Nutritional surveillance consists of three distinct components. They are:
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A) CommunityDiagnosis
B) Developing an Action Plan
C) Evaluation of Action
.
Community diagnosis, help to identify the problems. After identification of the problem, suitable
plan of action needs to be formulated to resolve the problem.

B. Developing an Action Plan

It is evident that problems often have several causes. Hence, the community must decide on
different actions to take in solving them. Deciding on which actions to take, will depend on the
kind of problem, its causes and the reasons behind the behaviours which cause it. Working out an
action plan will involve:
• understanding and stating clearly what you want to achieve
• deciding on the activities and materials you will need
• identifying the people you will need
• giving jobs or tasks to people • putting the whole plan into a time frame, which shows when the
activities will start and end.
To ensure that the action plan is effective, evaluation is necessary.

Evaluation of Action
Evaluation should be based on the views of every one who were involved in planning and in
carrying out the activities. We may carry out evaluation either verbally or in writing. However,
we should write down the result carefully, so that we have a record of what happened. Our notes
will also help us, plan and carry out future programmes more effectively.
Evaluation must be done:
• from point of view of different members (e.g.,the community worker, community members,
other community workers, people from outside etc.)
• clearly and frankly, and
• completely giving both strong and weak points.
Why evaluate?

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If at the beginning of a plan or activity, we have a clear idea of what we want, evaluation will
help us find out, whether we have succeeded. For example, if we wanted to see fewer children
becoming malnourished, we need to know at the beginning what are the bad practices which help
malnutrition to occur, also other causes. The plan of action to be followed will be aimed at
changing these practices and correcting the other causes. Evaluating the results will show,
whether the bad practices which cause malnutrition are fewer and if there are more of the right
behaviours, which keep people healthy. Remember, it may take some time for the results of an
activity to show, depending on the kind of health or nutrition problem, which is being dealt with.
Evaluation is also important because:
• we can find out which actions will gain results and which will not,
• we can avoid repeating mistakes and help others to avoid the mistakes we have made.
• we can save time and money by not carrying on unsuccessful activities.
• we can gain satisfaction by showing results.
Asking questions like- What things went well? Why did they go well? What new behaviours
have people learned? How can they use these behaviours to solve other problems? - will help us
and the community to evaluate and learn from a plan or activity. If the results were not what we
expected, we should also try to find out why?
Answering the following questions will help us and the community to plan better activities and
programmes in the future, to improve the status of community nutrition.
• Were there any problems in carrying out the activity?
• Did each person involved, know what to do?
• Could each person do, what he had to do?
• Did each person do, what he had to do?
• How did he do it? .• Were the right kinds of activities chosen?

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