Part 1: Introduction

1. Introduction

Despite all efforts undertaken both nationally and internationally, poor nutritional status is still a fundamental cause of disease and shortened life-span. Most people are aware that many factors are either directly or indirectly responsible for undernutrition, including insecure food supply, lack of basic education, inadequate health services, deteriorated environment, low income, and inadequate empowerment. The factors contributing to malnutrition vary from community to community. However, poverty is nearly always an underlying factor.

To improve the nutritional status and improve living conditions in communities, it is necessary to determine the nature, magnitude and causes of malnutrition. Anthropometric indices are internationally accepted as nutrition key indicators of populations. Additionally, they have been recommended repeatedly as a suitable key indicator for poverty as well. The use of anthropometric indicators is based on the extensively observed phenomena that a growing child who lacks an adequate intake of food and is repeatedly ill, does not have the body height corresponding to its genetic potential. Furthermore, inadequate food availability, caring capacity, basic education, health systems, housing and environmental conditions have been proven to be underlying causes of inadequate food intake and repeated episodes of diseases. As a result, communities that are not able to satisfy their basic needs adequately generate higher proportions of individuals with inadequate anthropometric indices.

The quality of intervention strategies is closely linked with the quality of the assessment of the situation. Planning methods for interventions, such as ZOPP (Objective-Oriented Project Planning), triple A (Assessment - Analysis - Action) or PMC (project management cycle), provide a structure for gathering and analyzing data that can be used subsequently in monitoring the impact of an intervention. Therefore, if an objective of an intervention or program/project is to raise the nutritional and living standards, appropriate and realistic indicators must be established.

Appropriate planning requires both quantitative and qualitative information. To measure the impact of nutrition-oriented programs/projects, i.e. self-standing nutritional programs/projects and nutrition-related programs/projects, it is necessary to collect quantitative information. Therefore, projects/programs must start with a baseline survey, and such survey must be repeated periodically.

Self-standing nutrition projects/programs are directly targeted for an improvement of the nutritional situation of the population. Nutrition-related programs/projects may belong to the agricultural sector (in terms of producing, processing and storing of food; food hygiene and quality control as well as regional development in rural areas), health care, nutritional security, urban development and urban planning. These programs/projects have objectives related to the particular subject, but the improvement of the nutritional situation is stated as an overall objective or positive impact in program/project planning. Therefore, the program/project should be evaluated as to whether its impact on the nutritional situation is positive, neutral, or negative.

1.1 Purpose and organization of the guidelines

The purpose of the guidelines is to provide guidelines for nutrition surveys. These guidelines should serve especially

to initialize the assessment of the nutritional situation of communities,
to assist in planning and implementing sound surveys, enabling nutrition and public health workers and specialists to formulate appropriate nutrition policy and measures,
to standardize survey methods and techniques, enabling later comparison of data and results from different surveys, projects and countries,
to be used for training of nutrition and public health workers and specialists, and, ultimately
to help to bring about an improvement of the nutritional situation of target groups.

This guidelines does not contain any new methods but describes international standard operating procedures (SOP) for nutrition surveys. If these SOP are used, results from different organizations and projects can be compared. Where SOPs fall short, illustrations from practical experiences of the authors will fill the gap. This guidelines can only provide guidelines for the selection of the variables to be studied; the final survey document must be adapted to the local situation.

This document is not a text book which teaches the inexperienced reader how to organize and implement a nutrition survey. Certainly, there is information available in the guidelines with which some readers are very familiar. However, the pertinent chapter should be read to ensure that the survey is carried out using a consistent standardized method.

This publication has the following structure:

parts
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chapters
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sub-chapters
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sections.

1.2 Objective of a Survey

A survey is a method for collecting information directly from people. Nutrition surveys assist in the planning and implementation of projects by providing objective data that can be used to improve the nutritional situation. The objective of a nutrition survey is derived from the purpose of nutrition-related projects. The survey should

monitor the improvement of the nutritional situation (project objective, overall objective, or positive impact), and/or
guard against the worsening of the nutritional situation (negative side effect).

General objective of a nutrition survey:

The objectives of the nutrition surveys dealt with in this guidelines are the assessment and analysis of the nutritional situation and of contributing poverty factors of risk groups and the evaluation of the nutritional effect of a project/program on the improvement of living conditions.

The following individual activities are part of the process of a baseline survey:

to initiate dialogues among all groups participating in a project (target group, non-governmental organizations, governmental authorities, donors, and project implementation personnel) concerning the living situation of the poor,
to assess the needs of the poor, in particular, about their problems in daily life,
to increase the awareness and sensitivity of the specialists involved in the project and also those responsible for programs designed to improve the basic need situation of the poor,
to reveal the nature, magnitude and severity of the nutrition- and poverty-related problems and their possible causes,
to identify the particularly affected target groups,
to arrive at a causal model (problem tree),
eventually to propose additional smaller in-depth surveys that are necessary to be carried out to diagnose important causes of poverty problems,
to identify the appropriate scope of intervention for the improvement of the poverty situation,
to identify project-defined indicators (poverty-related socioeconomic determining factors) for evaluation,
to determine the impact of project measures on living conditions of the observed risk groups, and finally
to obtain data for cross-sectional comparisons between the country and the project target groups.

The objective of a baseline survey is not to undertake pure research. As the fundamental causes of malnutrition are known, it is unnecessary to gather scientifically supportable proof of a causal relationship for a nutritional problem. A survey should record all possible important variables known from literature to be responsible for nutritional problems. If, for example, no statistical relationship can be identified between nutritional indicators and early weaning in a project area under survey due to the small sample size, the higher percentage of early weaned children should, nevertheless, be included in a problem tree and suitable intervention measures, e.g., nutritional advice, should be considered. Of course, these variables must be tested for their relevance no later than a pilot testing.

To illustrate this even more vividly: if, while collecting data on 500 children, only one case of eye abnormality caused by vitamin A deficiency is discovered - in which case the sampling is indisputably too small to derive a scientifically supportable conclusion concerning this (health) problem - vitamin A deficiency should nevertheless be considered in project planning. This potential cause-effect relationship must then be followed up in greater detail no later than during the first implementation phase of a project or program (orientation phase).

During the assessment of the nutritional situation of a community, a baseline survey provides information about the nutritional problems in individuals. Therefore if, for example, a child is identified as undernourished, the child must be sent to the nearest available health service for further examination. Before commencing a survey, arrangements must be made with the local health service. Many surveys have shown that both communities and health services have been extremely cooperative in adopting such an arrangement.

The objective of a nutrition survey is not only to obtain information on the nutritional situation of a community in a survey area, but this information should be fed back to serve the needs of individuals in the community.

A nutrition survey takes place in 5 steps:

Collection of available information on the nutritional situation and other demographic, socioeconomic and ecological data in the survey region;
Planning and preparation of the nutrition survey;
Implementation of the nutrition survey;
Data processing, evaluation and analysis;
Dissemination of the results of the nutrition survey and preparation for translation into action.

1.3 Target group of the guidelines

As explained before a nutrition survey has several objectives and the guidelines is a tool to reach these objectives adequately. However, it cannot be expected that all there is to know about carrying out a survey can be taught by means of a handbook. It is only able to set guidelines and standardize procedures. These guidelines have therefore been written for an experienced community or public health nutrition specialists who possess already a basic knowledge in nutritional epidemiology and practical experiences in survey technic. It is designed so that the user can extract the relevant sections corresponding to the project types, phase and needs.

The primary target group of this nutrition baseline survey guidelines is the experienced nutrition specialist who plans, implements, and analyzes nutrition surveys.

1.4 Types of surveys

There are four types of nutrition surveys; each is important for a different type of project or a different phase of a project.

In a rapid appraisal of the nutritional situation, information on the nutritional condition of the target community should first be obtained during the planning phase using qualitative methods. Anthropometric data (such as height and weight) are not recorded in this type of survey.
In a rapid assessment, anthropometric data are measured to obtain information on the type of nutritional problems using quantitative methods. However, the sampling selection and sampling coverage do not allow quantitative conclusions to be made concerning the prevalence of nutritional problems that can be generalized for a broader population.

Both types of surveys are suitable for a pre-feasibility study for the assessment of the nutritional situation. One of these two types of surveys should be used for identification of the project during the planning phase.

The baseline survey (for further information, see section 3.1.3.1) gathers information concerning the type, prevalence, reasons and causes of nutritional problems (see chapter 1.2).
The follow-up survey assesses the impact of the project or individual project measures on the nutritional condition of a community (for further information, see section 3.1.3.2).

Complete nutritional baseline and follow-up surveys cover the following areas:

- Felt needs by the community
- Demographic data of the households
- Socioeconomic factors
- Anthropometry
- Signs of malnutrition and disease
- Nutrition and health practices.

Complete nutritional baseline and follow-up surveys should only be considered for a self-standing nutrition project in which the objective of the project is the improvement of the nutritional situation of a community. In nutrition-related projects that are expected to have a positive impact on the nutritional situation or projects with potential negative side effects resulting in the worsening of the nutritional situation, only specific nutritional indicators should be assessed. Data on other aspects, in particular socioeconomic data, should then be taken from a project-specific baseline survey.

1.5 Timing of a survey

The overview in Figure 1 shows how a nutrition and poverty baseline survey and a follow-up survey are integrated into the Project Cycle.

A project starts with a project idea and ends when its main objective has been achieved. This objective, or objectives should be planned jointly by all involved parties including the community. The project lifetime can be subdivided into phases, such as identification, conceptualization and implementation. The baseline survey is an instrument for the development of a project strategy.

Figure 1. Project Cycle for nutrition- and poverty-oriented projects/programs

Project Phase Planning Decisions Instrument

Project idea

Project indentification ¯ Pre-feasibility study (e.g. RAN)

Decision about project purpose

Poject design (conceptualization) ¯ Baseline survey and participatory planning (e.g. ZOPP)

Decision about projects strategy

Project implementation ¯ Follow-up survey and participatory planning (e.g. ZOPP)

Decision about project strategy adjustment

Project redesign and implementation ¯ Follow-up survey and participatory planning (e.g. ZOPP)

Desired project impact

RAN: Rapid Assessment on Nutrition for Community-Based Poverty Alleviation Projects/Programs
ZOPP: Ziel-Orientierte Projekt-Plannung (objective-oriented project planning)

Project Phase	Planning Decisions	Instrument

	Project idea
Project indentification	¯	Pre-feasibility study (e.g. RAN)
	Decision about project purpose
Poject design (conceptualization)	¯	Baseline survey and participatory planning (e.g. ZOPP)
	Decision about projects strategy
Project implementation	¯	Follow-up survey and participatory planning (e.g. ZOPP)
	Decision about project strategy adjustment
Project redesign and implementation	¯	Follow-up survey and participatory planning (e.g. ZOPP)
	Desired project impact