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    9 views66 pages

    Who TRS 593

    Uploaded by

    Labiba Tasnim

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    © All Rights Reserved
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    The rpert coting the colectve vont of an inernatonat rap sfenperts and docs mor neces rprses the detent, WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES No. 593 METHODOLOGY OF NUTRITIONAL SURVEILLANCE Report of a Joint FAO/UNICEF/WHO Expert Committee WORLD HEALTH ORGANIZATION ISBN 92 4 10580 8 (© World Healt Orgniation 1976 Pubcon ot he Wed Hels Orguintin enjoy copyright protton inacode ance with the povione of Proven! fof the Unvral Copyright Comenton. For fips ot reproduction or wanton of WHO pbiation in prr ino, appaton shouldbe madeto he Divison of Pableatins an Translation, World Heal Organ {aton, Gener, Switarlan. "The Wort Heath Orasation welcome ach oP “The designation emploed andthe pesataion ofthe materiel n this publation oot imply the exrestion of any option whatever onthe pat the Se fie World Health Organza oncering he lo sas fy cosy ery, Sty ov aca ofa ts ethort, or conerning te San of Rents ot Stores “The meation of metic companies oF af erin manufctrr’ product oes ot na hat hy read ren ye Wort Hs Oris a bretrence to ther of sir store tht ae net meio Ersrs td omiions ‘Scpid the nes of propriary prod dang by ial cates CONTENTS 12 Geral objectives of survelanse « . Specie objectives fs eftions eee Ea 2 ‘The nature ofthe mtitonl problems ensigention and desripton of groups ats 7 rte ton of aul store 0 formation of working hypothesis ‘Sources of data fr itl snesent 7 Indctors fr ws in mteitina sarees a a3 aa as 311.2 “Cyto points” and tape ive 7 311.3 Charts of indestors relied to metsurements andthe 2.14 Characteristics of insestors elated tthe sample 43.1.5 Operational ch “The slnicans of causality inthe choice ofndcatons = “These of agra andsocicesonomichariabes inspec nvitona Suevellane stems 3.2.1 The importae ofthe food soppy rem 3.3.2 Saggeted instore 5.3.3 A simple lst of agicurl and ssiosconemic indicators 2:34 The problem of gba instore Heath and sitar indicators ofthe nuiiona status of te population Sours of ta for srvellance 7 3.5.1. ata cole by state and meeorolopial agencies of the 3.5.2. Data colton the wil operation of the Balhae: 313.3, Data collected by agricul ervees 5.5.4 Requements for atonal data sources ‘Plening and development of srellance stems Base principles : esto setae Steps inthe ergy of a areas system: bepbesse 4.3.4. Summary of preliminary prosedures 4s 4.3.3. Design of report fomat and qustioaaies a 43.4. Design of data collection aster a 4.3.3, Reporing tinetble a 43.6 Implementation of fed operation 5 6 ss - e 4.7 Data procesing ° 5. Neds for friar research s 5.1 Canal elationshipe 7 a 5.2 Signieance of heat ndctors 2 5.3, Operaonalssereh 8 6 Summary snd recommendations 2 [Annet 1. Exampit of know relationships in food supply an mtion .. . 56 Annet 2. Selected socioeconomic ndcatore @ JOINT FAOJUNICER/WHO EXPERT. COMMITTEE ON THE "METHODOLOGY OF NUTRITIONAL SURVEILLANCE. MeD.G.R, Bela, Schoo of Development Studs, University of Fast Ani, "Norwich, Eland Profesor R. Basing, Hed, Deparinent of Nutitn, Instat of Pac Heth “roa, Zagreb, Yaron ri. Cones, Anite Protein, Graduate Schoo! of Pubic and Iernationat ‘Airs and Gradante School af Pubic Heath Univers of Pasha, Pi thr, PA, USA Profesor M. ret, Profesor‘ Human Esology, Univenty of Rome Institute ‘of Antropalogy, Rowe, aly ‘Br 1 Bagi Saleh, Director General Static: Depertnent Mla of Hea, Kartoum, Sudan De M, Gebre Medhin, Diector, Etopian Notion Iie, Aduis babs, Eiiope Dr C. Gopalan, DitstorGenersl, Indl Council of Medial Research, New Deis tna rb Mie, National Centr for Health Statist, Department of Healt, ‘Edacaton and Welfare, Rockville, MD, USA (Rapporteur) Profenor D. 8 Selif, Protez of Pubic Health and Pediatr, and Meas, ‘Dnuion of Populstion, Family and Ineraational Health, Sebo of Public Health, Unberaty of California, Lat Angler, CA, USA. be J. Kevany, Senior Lestrc, Department of Soclal Meine, University of usin, Dubin, Leland (Rapporteur) eT. N. Maleskima, Dietor, Tanzanian Food snd Netien Cee, Dus Srna, United Repu of Tanzania Me. Rs Payne, Reaer in Apoled Natsion, Departent of Human Notion, Landon School of Hypene and Tropical Mdisine, London, Eopend ‘Proesor VE, Sith, Chairman, Deparment of Ezooomi, Niki State Ua "ety, Bast Lansing, MI, USA (Pie Choma) [Dr ¥. 5. Solon, Exot Director, Natron Cente of te Pollplaes, National Nutri Cosel Maka, Rul, Piippines Profenor PV. Subbatne, Honorary Profesor of Biomety, Depattment of Bio ney, Satara Ausociaton forthe Calsvation af Sint, Poot din ‘rofsor J.C. Watelow,Profesior, Department of Human Natron, London ‘Sto! of Hygen and Tope! Metin, London, England (Chaban) Represents of ober Orgaiations Unite Neon ‘Switzerland i Dr I Beghia, PAHO Mecical Ofcer, Itt of Nutrition of Cental Americ Dr M. Mar, Chief Nuttin, WHO, Gene, Switzerand Dr BM, DeMacyer, Medial Ofcer, Nutrition, WHO, Gener, Switzeriand Dr M. Guzman, PAHO Seas, Instat of Nutton of Cotal America and Panama, Gunemals De R.W. Hay, Techical Adviser, Food and Nutrion Suvelance, UNICEF DeW. Kell, Medal Oficer, Nuttin, WHO, Geneva, Switertand (Serta) eM. H. Lent, Nuvition Offer, Food Pokey and Nation Divison, FAO, De P. Lunven, Chis, Natron Policy and Programmes Service, Food Poy an ution Dstion, PAO, Rome Dr J. B. Mason, Nuteion Ofer, Food Policy and Nutition Division, FAO, De RD. Nari, Acting Ditetr, Satis Division, FAO, Rome iM. Z. Nichaman, Chie, Preventable Distr and Nation Activity, Cte, {oe Disease Cont, Alt, GA, USA (Temporary Ade) Dr LJ. Teply, Senior Nutonst, UNICEF, New York, USA. 41, INTRODUCTION Surveillance of the nutritional status of populations has become subject of inereasing concern to both national governments and tecdnical agencies in the fields of food, agriculture, and heath, and the World Food Conference in Rome in 1974 made a specific recommendation * for the coordination of surveillance activities of international agencies and ‘emphasized the need for & collaborative approach to planning inthis rea “The aim of this report is to provide guidelines on the nature of a surveillance system onthe methods for setingt up, and onthe principles Tor its operation. Although the Committee recognized that many of the fundamental causes of global malnutrition lie in the weakness of con- temporary social organization, afield outside its terms of reference, it ‘considered that technical guidance on systems by which nutritional prob- lems can be characterized and quantified would increase social awareness ofthese aspects and contribute to their solution, Surveillance is not an isolated activity, but goes hand in hand withthe formulation and execution of policy. At the outset a dilemma has to be faced : on the one hand, itis impossible to develop an eficient system of collecting information without knowledge of the purposes for which the information isto be used. On the other hand, problems cannot be ‘defined and polices formulated i the absence of information. Initially, any programme of surveillance and any definition of policy can only be based on the information that 1S available and on the objectives that appear to be important at that time, However, surveillance must produce feedback, which may be expected to modify the policy and the system it= self, and lead to redefinition of objectives. Only experience can show how the information collected is relevant, and thus the ways in which the surveillance system needs tobe modified. For these reasons the proposals ‘made inthis feport represent only a stating point for surveillance ativ= itis. ‘An obvious dificulty in specifying systems of surveillance isthe very reat diversity between diferent countries in conditions and available Fesources, ‘The Committee has been particulatly concerned with the surveillance of nutritional problems in developing countries, but this * Replaion V8, rcommend hat obs triton! saneilaae sper, te cuted by FAO, WHtO sou UNICEF fo monitor the food and nutiton ‘Souons of be dkadcatapssaroup a be population at sy and to provide 8 ‘rethod of pie and permasentsuctinent of alata whish aloes food one ‘inpionpttrs sed nrionl tar should not be taken to imply that surveillance is considered unnecessary Jn developed countries. However, the system of surveillance may be diferent in these diferent situations. Surveillance is a matter of great urgency in countries where the food supply and nutritional status of vulnerable groups is marginal and where ‘malnutrition may be endemic. In many regions there i a constant threat that unusual variations in environmental factors may induce disaster situations in which malnutrition eaches epidemic proportions ‘Where these conditions exist the administrative and technical frame- work for colletion, transmission, analysis, and presentation of data is usually deficient and poorly utlzed by bodies responsible for planning ‘and making decisions. As a consequence, the need for action is rarely anticipated and the disposal of resources, when committed, is often waste- ful. Similarly, action to reduce the frequency and severity of both acute episodes and chronic situations requites longer-term planning, which gain will only be effective when its based on adequate information, ‘Thus surveillance is seen as providing at one and the same time an carly warning system for nutritional disasters and a method of monitor- ing tends ina situation of chronic deprivation Global surveillance, ab recommended in Resolution V.13 of the ‘World Food Conference, must be based on integration of information systems operating atthe national and local levels. Consequently, action rected towards establishing a global system must be initiated at these local levels and must concentrats on developing and improving systems of information as far as may be realistic for each country, There= fore, surveillance information should, whenever possible, be analysed and. presented in such a way that international comparisons and global fore- ‘casts can be made 1.1 General objectives of surveillance Surveillance should provide ongoing information about the nutitional conditions of the population and the factors that influence them. This information wll provide a basis for decisions tobe made by those respon- sible for poly, planning, and the management of programmes relating to improvement of food consumption patterns and nutritional status. ‘Countries difer in their requirements for planning, their needs for information, and their sources of data, Although a single design for all surveillance systems is nether feasible nor desirable, some principles, ‘examples, and characteristics of systems are presented in this report, 1.2 Spectie objectives [Nutritional surveillance is a continuous proces, that should have the following specific objectives : (1) To describe the nutritional status the population, with particular reference to defined subgroups who are identified as being at risk. This will permit description of the character and magnitude of the nutrition problem and changes in these features, @) To provide information that will contribute to the analysis of causes and associated factors and so permit a selection of preventive ‘measures, which may oF may not be nutritional ) To promote decisions by governments concerning priorities and the disposal of resourees to meet the needs of both normal development and emergencies. () To enable predictions to be made on the basis of current trends in order to indicate the probable evolution of nutritional problems. Con- sidered in conjunetion with existing and potential measures and resources, ‘these will assist in the formulation of policy. (5) To monitor nutritional programmes and to evaluate theit effec: tiveness. 1.3, Definitions Its impo in this report. ‘Surveillance, from the French “surveiller means to watch over with great attention, authority, and often with suspicion. By contrast, the ‘word “ survey is used in this report to refer tothe collection of inform: ation at a particular point in time. ‘Thus a surveillance system may indicate the need for special surveys of particular problems. Assessment isthe appraisal of available information to offer prelim- inary description of the nutrition situation in # country Evaluation isthe process of reaching a judgement, on the basis of clearly defined criteria, about the success of any operation. This includes considerations of effectiveness and efficiency The word monitor also implies an ongoing or continuous activity. It is used in this report to describe an activity that is more specific than surveillance. Thus to monitor rainfall may be a part of surveillance Surveillance is based on the regular colletion of data, These data are analysed to give indicators of present of future change of nutritional nt atthe outset to specify the way in which terms are used ° status, The types of information from which indicators can be devised ‘over a broad range, and the classifications used throughout this report fare intended to be illustrative rather than comprehensive, These types of information can be grouped in a number of Ways, and a classification based on causal sequence, from level A to level D, could be ‘A Ecology: demography: nrasrutre B Resources: production © Income comupuion 5 Hea at Under these headings, further categorization of subjects can be iusrated as follows: Level A: Beology : meteorology, land, water, vegetation. Demography Infrastructure: communications, community services. Level B: Resources nd production: agricultural production, livestock, food imports expors/stocks, fu! “Level C: Income and consumption : market data, income, food con- sumption. Level D Health status: nutritional status, disease patterns “This report considers firs, in section 2, the information essential for ‘the design ofa nutritional surveillance system : what the nutritional prob Tems are; who suffers from them ; where, when, and why; and finaly, ‘what data sources are already available that could be utilized for nut tional surveillance. "The report then considers the indicators for nutritional surveillance (section 3). These indicators are derived from measurements, and have certain required characteristics (3-1). Some indicators are predictive, thers ae indieators of nutritional outcome, Both can be used together for national and global surveillance. The choice of indicators determines the selection of sources for the collection of information ; these data sources should complement each other (3.5) ‘The next step is the planning and development of the nutritional surveillance system itself (section 4), The basic practical principles for Such a system are presented (4.1), the institutional struture is outined (4.2), and the necesary steps are reviewed for implementation (sample ‘design, definition of output, data collection, reporting timetable, im- plementation of operation, and data processing) (4.3) 0 ‘The report concludes with recommendations for future research (section 3) and for implementation of national and international nutrition surveillance systems (section 6). 2, INITIAL ASSESSMENT ‘fore a system of nutritional surveillance can be designed for any ‘country there must be an initial assessment ofthe situation in that country. ‘This assessment should include as far as possible information of four types — type, extent, and timing of the nutritional problems, = identification and description of the groups particularly at risk, — reasons for the existence of malnutrition, = existing sources of data on which a surveillance system could draw. ‘Where no information is available, the fist steps in setting up sur- veillance wll have to be based on analogy with counties in which there fre similar socioeconomic and ecological conditions. At the next stage (qualitative information may be obtained from reports of cases of mal- ‘utstion in hospitals and spot surveys, This qualitative information may indicate what the nutritional problems are. At a more advanced stage data may be available from representative surveys that will give a quanti= tative answer to the questions “Who is malnourished ?" * Where?" “How many” and providing some information on“ Why?”". This progression in knowledge is illustrated by the history of the protein- energy malnutrition problem: in many countries, the situation has im proved from one in which the problem Was not even recognized to & Situation in which there are reports from hospitals, and sometimes com- munity studies of prevalence, severity, and eausal factors. 2.1. The nature of the nutritional problems In developing countries the deficiencies most likely 10 occur ate of energy (calories), protein, and iron. Vitamin A deficiency is very common in some countries, but notin all. Other deficiencies that may be of public health importance are of iodine, B-vitamins, vitamin D, and vitamin C. A preliminary assessment should attempt to pinpoint the deficiency states ‘that ae most provalent and most serious. There may, of course, be other kinds of deficieney that are not of proven public health significance, but ‘these must be regarded as subjects for research rather than of surveillance. " In developed countries the situation is rather different; in addition to the possibilty of some undernutrition, there are the additional prob- Jems of overnutrtion, such as obesity and the dietary factors implicated in cardiovascular diseases. "The assesement should include some estimate of the relativeimportance of the different nutritional problems. It should provide information, ‘where possible based on adequate sampling, about those people in whom the problem is most serous. It is also useful to distinguish groups at risk by the time pattern of the nutition problem that affects them, the ‘main categories being : cyclical incidence, as with yearly. hungry seasons" random incidence, as with famines associated with variable ‘ainfall; and chronio incidence, usually associated with extreme poverty in both rural and urban context. ‘At the same time a check should be made on the possibility of the incipient appearance of eongitions that did not previously exist (oF had not been recognized), and foran increase inconditionsthat were previously luncommon. Examples are the increasing prevalence of obesity in some developing countries, and the re-emergence of rickets in a developed country. 2.2 Identification and desriplon of groups at risk ‘The process of identification and description should start by answer ing the question “ Who is at risk”. This is essentially a selection pro- ‘cedure, narrowing down the description to identily, as precisely as information allows, the group() to be considered. As examples, a group at risk in a particular country might be desribed as: preschool children living in certain district, io an area of that district in which the mean Annual rainfall sles than 600 min, whose food is derived mainly from Iivestock or, the infants of recent urban immigrant families who are ‘unemployed, in a certain town. "An approach to defining these groups is presented below in a theee- fold classification + (@) Biological situation — age group. = physiological status, e.g, pregnant women — exposure to infectious disease and other health factors. (@) Physical situation — rural or urban — ecological zone : -g., savanna, desert, rain forest, et. 2 = type of food source: e., settled subsistence farming, pastoral Subsistence, market = geographical region — Sanitary environment and pattern of endemic disease. (6) Socioeconomic and cultural situation = ethnic or cultural group = socioeconomic status, e., income group, cultivated tand per family, income source, livestock holdings per family _— access to and utilization of health services. ‘The accuracy with which groups at rsk canbe identified and described depends in the frst instance on an analysis of existing information. ‘Additional information might be needed and should be obtained by conventional survey methods as necessary. However, the information

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