1. Kakuma Nutrition Survey November 2012 Training Day 1

2. Today’s schedule  Introduction of coordinators, supervisors, and survey team members  Overview of the survey  Survey objectives  Survey schedule  Survey teams Roles and responsibilities  Skills for good interviewing  Malnutrition  Anthropometry  6-59 months section  IYCF section

3. Snapshot question  What is a nutrition survey?

4. Definition of a survey  Collection of data from a specific population at a single point in time.  Allows for: Providing data on prevalence Providing information on the actual situation Gathering diverse data

5. Objectives of a survey  Evaluate scope and severity of a humanitarian crisis  Determine needs of a new programme  Advocacy  Evaluate already existing programmes

6. Kakuma nutrition survey objectives Among the refugee population residing in Kakuma camp this survey aims to  estimate the prevalence of malnutrition among children 6- 59 months;  estimate anaemia levels among children 6-59 months and women of reproductive age (non-pregnant);  estimate period prevalence of diarrhoea in last 2 weeks among children 6-59 months;  assess coverage of measles vaccination in children 9-59 months;  assess coverage of vitamin A supplementation and deworming in last 6 months in children 6-59 months;  assess IYCF practices among children 0-23 months;  assess global coverage and use of mosquito nets;  investigate household food security;  assess water, sanitation and hygiene situation;  estimate coverage of the selective feeding programme.

7. Schedule for the survey 13 th Nov Tuesday Pilot test 14-15th Nov Wednesday / Thursday Recoding of ODK questionnaires (if required) 16-23th Nov Friday-Friday Field data collection 8 – 9 th Nov Thursday/Friday Training on objectives, sampling, questionnaires 10 th Nov Saturday Training on android phones 11-12 th Nov Sunday/Monday Practical training, standardisation anthropometry and anaemia

8. Snapshot question  What are the characteristics of a good nutrition survey?

9. A nutrition survey should:  Be conducted by a competent team  Have clear and precise objectives  Provide reliable data and a clear image of situation  Be relatively simple to execute  Use standard methods to collect data  Use simple, robust questionnaires and software  Results are available on time to be able to intervene and react

10. Team roles WEIGHT HEIGHT ASSISTANT MEASURER HB CHILD IYCF WOMAN WASH MALARIA FOOD SECURITY Team of 5 One team leader – any of the above roles (except HH questionnaire) ‘Individual’ questionnaires ‘HH’ questionnaires

11. BREAK

12. Snapshot question  How would you define a household?

13. Snapshot question  How would you define a household?  A group of people who live together and routinely eat of the same pot.

14. Kakuma nutrition survey components  Measurements Anthropometry Anaemia  Questionnaires Household questionnaires  WASH  Mosquito net  Food security Individual questionnaires  Women  Children 6-59  Children 0-23  Other: HH enumeration  Cluster control sheet  HH listing form (paper record of Hb, anthro etc.)

15. Skills for good interviewing  SMART video  Translation

16. Children 6-59: Objectives  To measure the prevalence of acute malnutrition in children aged 6-59 months.  To measure the prevalence of stunting in children aged 6-59 months.  To determine the coverage of measles vaccination among children aged 9-59 months.  To determine the coverage of vitamin A supplementation and deworming in the last six months among children aged 6-59 months.  To determine the two-week period prevalence of diarrhoea among children aged 6-59 months.

17. Main indicator: acute malnutrition  Marasmus Excessive thinness, “wasting”” Low weight compared to height/length Resulting from a recent or rapid weight loss or incapacity to gain weight Reversible through improvements of life conditions  Kwashiorkor Presence of bilateral oedema Weight and appearance can be quite normal Often following weaning, and 18m – 2.5y Causes remain uncertain

18. Marasmus

19. Marasmus: signs and synptoms  Severe weight deficiencies and growth problems  Deterioration of adipose and muscular tissue  Growth retardation  Behavioural problems  Infections and diarrhea  Anorexia  Hypoglycemia  Hypothermia

20. Kwashiorkor

21. Kwashiorkor: signs and symptoms  Bilateral edema  Eyebrow and nail alterations  Hepatic hypertrophy  Variable weight for height deficiency  Moon face  Behavioural problems: children who are sad, fearful, closed onto themselves  Hair may be depigmented and broken  Oropharyngeal mucous atrophy

22. Stages of acute malnutrition Global acute malnutrition (GAM) = MAM and SAM together Moderate acute malnutrition (MAM) = moderate wasting Severe acute malnutrition (SAM) = severe wasting or/and bilateral oedema

23. Intervention cut-offs and benchmarks Severity of the situation Prevalence of wasting (- 2 Z-score) Acceptable< 5 % Poor5 – 9 % Serious10 – 14% Critical≥ 15 % Classification of malnutrition (WHO 2000)

24. BREAK

25. Introduction to equipment  Height board  Scales  MUAC tape

26. Children - spot question  What is anthropometry?

27. Children - answer  Anthropometry: anthropometry is the study and technique of human body measurement. It is used to measure and monitor the nutritional status of an individual or population group.

28. Snapshot question  Why are the 6-59 months the most targeted population in anthropometric surveys?

29. Children 6-59 months  Nutrition status indicates severity of situation in whole population  In growth period  Particularly vulnerable to disease and food shortage  Considered to be most vulnerable to nutritional stress  Easier to measure Equipment less bulky Possible to undress them when taking measurements  Generally at home  Stakeholders are used to this type of data and appropriate response  Lots of expertise in surveys for this age group  Anthropometric indicators and measures are internationally recognised

30. CHECKLIST: 1)Questionnaire and pencil on clipboard on floor 2)Assistant on knees 3)Measurer on knees 4)Hands cupped over child’s ears; head against base of board 5)Assistant’s arms comfortably straight 6)Line of sight of child right angle to board 7)Child flat on board 8)Hands on knees or shins; legs straight 9)Feet flat against footpiece CHILDREN <87 cm

31. CHECKLIST: 1)Questionnaire on floor 2)Assistant on knees 3)Measurer on knee 4)Right hand on shins, heels against back and base of board 5)Left hand on knees; knees together and against board 6)Heel against board 7)Calf against board 8)Line of sight right angle to board 9)Hand placed on chin 10) Shoulders level 11) Hands at side 12) Head, back of shoulders and bottom against board 13) Headpiece rested firmly on head CHILDREN >87 cm

32. CHECKLIST: 1)Ensure weight at zero before mother steps on scales 2)Mother steps on; centrally placed feet 3)Measurer puts weight of scales to ZERO 4)Mother handed baby 5)Weight measured If child able to stand straight and understand instructions not to move while on the scale, child can stand on the scale by himself or herself. Measurement of weight with electronic scale

34. CHECKLIST: 1.Locate tip of shoulder and tip of elbow 2.Place tape at tip of shoulder 3.Pull tape past tip of bent elbow 4.Mark midpoint 5.Don’t pull tape too tight or too loose; gently touching all round MUAC

35. Diagnosing oedema CHECKLIST: 1.Moderate thumb pressure 2.Tops of feet or just above the ankle – inside of leg 3.Pressure for 3 seconds 4.If Oedema: a pitting remains for at least a few seconds 5.If both feet have oedema child can be recorded as so

36. Exercise: Find the errors

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44. BREAK

45. Children 6-59months  Talk through questionnaire

46. Children – tips to note  Always measure the weight before the height as children often get agitated with height measurements.  If there is more than one eligible child in the household, measure the less ‘difficult’ child first.  Explain the procedure to the mother and ask the mother’s authorisation to undress the child.  To avoid the scales wobbling when placed on uneven ground, they should be stood on a flat wooden board. The height/length boards can be laid flat and used for this purpose.

47. Local event calendar – 15 mins  Exercise

48. Referral exercise – 15 mins  Exercise

49. ENA for analysis

50. Plausibility checks Digit preference And much more!

51. IYCF  0-23 months Infant = <12m Child = 12m+  Measures breastfeeding practices Initiation of breastfeeding Exclusive breastfeeding for <6m Continued breastfeeding at 1 and 2 years Introduction of solid, semi-solid or soft foods Consumption iron rich foods Bottle feeding children 0-23m

52. IYCF  Interviews with the mother or main caregiver  TIPS! Invest time in the assessment of AGE  Don’t round up or down  Don’t complete on a child of 24 months Ask questions exactly as written  E.g. ‘yesterday, during the day or at night’ for 24 hour recall Clear broth – it’s a water based liquid Use local brand names for products

53. Women 15-49 years  Anaemia for non-pregnant Including lactating  Pregnancy ANC enrollment Receiving Iron-Folate