Health assessment and the link with Nutrition This presentation ia approximately 30 minutes Module 08

Learning Objectives Understand the important links between Health and Nutrition Understand the importance of joint or coordinated Health and Nutrition assessments Understand the importance of coordination in humanitarian assessment generally Be aware of the different types of Health assessments that are required during an emergency and the links with Nutrition Be able to plan and participate in a Health assessment which includes Nutrition 1

* Undernutrition Inadequate food intake Disease Conceptual framework on causes of undernutrition Underlying causes Immediate causes Basic causes Formal and informal infrastructure/ political ideology/resources Inadequate food intake InadequatePublic Health Household food insecurity Disease Undernutrition Poor social and care practices 1 *

The link between Undernutrition and Health WHO estimates that undernutrition contributes to more than one third of all child deaths 0-59 months 1

Link between Undernutrition and Health The major causes of excess morbidity and mortality in emergencies are: acute respiratory infections, diarrhoeal diseases, malaria (where prevalent), measles and undernutrition In complex emergencies or in earthquakes, violent trauma/physical injury is a major cause of morbidity and mortality Emergency nutrition programming includes prevention (e.g. micronutrient supplementation), promotion (e.g. optimal IYCF practices) and treatment (e.g. Management of SAM and MAM) each of these components is provided through the health system, at both facility and community levels, by a variety of health and nutrition workers Both Health and Nutrition staff should ensure that nutrition and health assessments include both areas 1

Link between Undernutrition and Reproductive Health Maternal health and nutrition significantly impact the health, wellbeing and nutritional status of infants Inadequate provision of reproductive health care contributes to excess maternal and neonatal morbidity and mortality in emergencies Inadequate diet in pregnancy contributes to poor uterine growth, low birth weight (LBW) and subsequent suboptimal child growth and development Malaria in pregnancy increases the risk of miscarriage and LBW 1

Link between Undernutrition and Gender Based Violence Gender based Violence includes sexual violence such as rape, sexual abuse, sexual exploitation and forced prostitution; domestic violence; forced and early marriage; harmful traditional practices; and trafficking. The consequences of GBV are: Physical => unintended pregnancies; unsafe and complicated abortions; Sexually Transmitted Infections, including HIV; and Urinary Tract Infections Psychological => anxiety disorders, fear, increased substance abuse, sleep disturbance, eating disorders, sexual dysfunction and suicide Social => stigma, isolation and rejection, loss of women’s potential income, interrupted education of adolescents and homicide (e.g., honour killings) These consequences all impact negatively on the nutritional status of infants and young children 1

Link between Undernutrition and HIV Humanitarian crises (displacement, food insecurity, poverty) increase vulnerability to HIV and negatively affect the lives of people living with HIV Services may be disrupted resulting in lack of access to VCT, condoms, PMTCT, treatment of opportunistic infections and ART as well as nutritional support The impact of an emergency on mothers and other carers living with HIV may impact their ability to provide optimal nutrition and care for children and subsequently affect the nutritional status of those children. 1

Availability and capacity for provision of health services in emergencies Essential health services are priority health interventions (curative, preventative and promotional) that are effective in addressing major causes of excess morbidity and mortality Sphere outlines the health systems requirement in line with WHO health system model with 6 functions: Health service delivery Human resources Drugs and Medical supplies Health financing systems Health information management system (HIS) Coordination 1

Availability and capacity for provision of health services in emergencies Sphere outlines the essential health services in emergencies under the six most important areas: Communicable diseases (including outbreaks) Child health Sexual and Reproductive health Injuries Mental health Non-communicable diseases. 1

Sphere Core Minimum Standard 3 - Assessment The priority needs of all people affected by disaster are identified through a systematic assessment of the context, risks to life with dignity and the capacity of the affected people and relevant authorities to respond.   1

General principles and guidance on Assessments in humanitarian crises (all sectors) Assessment is an organized and collaborative process Comprise various types of information and collection methods, with validated information To be conducted in consideration of the following: people’s security needs and vulnerability factors of special groups positive community strategies Joint planning, information sharing and good multi-cluster coordination and cooperation are essential in conducting any type of coordinated assessment since all sectors/clusters link and influence each other. 1

Recurring problems in assessments Duplication and gaps in assessment – too much data collected from the same people and places in easily accessible areas, remote areas are not visited Assessment data are not sufficiently shared the lack of compatible methodologies and formats make the results difficult to compare and analyse The capacity to collate and analyse data and communicate the results is limited the analysis is incomplete and arrives too late to be useful Potentially useful resources (baseline data etc) that were available prior to the disaster are insufficiently used Rapid multi sector assessments try to gather too much information about a variety of sectoral and cross cutting issues Lack of clarity about who will do what and where during assessment following a disaster event 1

Quiz “We have an emergency here, there have been 44 deaths.” Is this a useful statement in an assessment report? It could be 44 deaths over the last 3 months, or 44 deaths yesterday. It could be 44 deaths out of a population of 100,000 or it could be out of a population of 100.   Always express deaths as CMR and/or U5MR. Show the first 2 sentences first and ask the question. Then show the last 2 bullets to provide the answer 1

Health assessment in emergencies Mortality is measured through crude mortality rate and under 5 mortality rate CMR should always be below one death / per 10,000 pop / per day (presented as: 1.0/10,000/day) U5MR should always be below 2.0/10,000/day CMR that is double the pre disaster baseline indicates a significant public health emergency Mortality is measured using health system data and other sources (camp managers, religious leaders, etc) or through retrospective mortality surveys (often associated with nutrition surveys) 1

Health assessment in emergencies Morbidity is measured through prevalence (number of cases per number of people at a given time) and incidence of diseases (number of new cases per number of healthy people during a determined period) Where possible data on incidence rates of major diseases should be disaggregated by age and sex. Health risks should also be assessed including pre-existing health problems; and current risks such as absence of health service delivery, potential outbreaks, poor infant and young child feeding and care, risk of sexual violence micronutrient deficiencies 1

Health Assessment Tools An Initial rapid assessment tool (IRA) was developed collaboratively by the Health, Nutrition and WASH clusters. The tool includes an Aid Memoire, an Assessment Form, a Guide and a Data Entry and Analysis Tool. The final version IRA developed in 2009 has an 11 page assessment form with 6 sections Standardised Monitoring and Assessment of Relief and Transitions (SMART) is an inter-agency tool whose main goal is to make the survey process (carry out, analyse, interpret and report) as easy as possible for the field staff and as reliable as possible for the decision-makers. 1

Health resources and services available An assessment of the health system is required to determine the capacity of the system and to identify major constraints in the delivery of and access to health services Assess the 4 different levels of the health care system: household/community level; health post; health centre; hospital MOH capacity should be assessed at various levels to adequately support the health response in terms of: technical capacity; logistical capacity; and coordination skills Assessments can be carried out through mapping exercises that aim at highlighting the availability and performance of the health system, and access to services by the affected population 1

Health assessment in emergencies Other specific useful assessments are Knowledge, attitudes and practices assessments (KAP) Infant and young child feeding practices assessment Reproductive health assessment Mental health and psychosocial assessment 1

Key Messages A variety of health assessments is undertaken during various phases of an emergency to assess health status and risk for the affected population; availability and capacity of services; and health system performance  Assessment is a process not a single activity event. Initial and Rapid Assessments provide the basis for subsequent in depth assessments that deepen understanding from earlier assessments Coordinated multi-sector assessment and analysis of an emergency-affected population is essential to identify the health and nutrition status of the population and potential risks and to prioritise programming interventions Important assessments to make in an emergency include: Crude Mortality Rate (CMR) and Under-Five Mortality Rate (U5MR) as these are indicators of the overall health status of a population 1

Key messages (2) Morbidity trends in the emergency-affected population, including the main changes in morbidity from the pre-disaster situation, to provide an understanding of the main health risks Provision of child health care services and reproductive health care (RH). Children’s access to basic services for prevention and treatment of infections will have a positive impact on nutritional status while adequate RH services will have a positive impact on both maternal and child health and nutritional status. Furthermore, many of the nutrition interventions will be implemented with/through these services. Gender based violence, mental health and psychosocial issues will also impact the nutritional status of infants and young children and should be assessed Health assessments are conducted using a variety of qualitative and quantitative methods. The selection and mix of methods used depends on the type of information required.   1