How to conduct a rapid nutrition assessment - Health Systems Trust

How to conduct a rapid nutrition assessment - Health Systems Trust




A Guide for Health Districts

and Sub-Districts

in South Africa




A guide for Health Districts

and Sub-Districts in South Africa

Developed by:

Public Health Programme (University of the Western Cape)

Initiative for Sub-District Support (Health Systems Trust)

Eastern Cape Department of Health

Written by: Mickey Chopra & David McCoy

With Assistance from: David Sanders & Ellen Piwoz

Cover design by the Academy for Education Development

Photo Credits: UNICEF and HST


This product is one of the outputs of an initiative spearheaded by ISDS and PHP in

partnership with the Mount Frere Health District and the Eastern Cape Department of Health.

It is part of a series of training guides and resource materials that are being put together by the

University of the Western Cape, the Health Systems Trust, Sustainable Approaches to Nutrition

in Africa and the Academy for Educational Development. We would like to thank Thandi

Puoane, Lesley Bamford, Susan Strasser, Jon Rohde, Wendy Hall and Rina Swart who have all

assisted through discussions and debates.

This Publication is

ALSO available on the Internet

Commissioned and Published by Health Systems Trust

Health Systems Trust Tel: (031) 307 2954

401 Maritime House Fax: (031) 304 0775

Salmon Grove


Victoria Embankment


Durban 4001

ISBN: 1-919839-09-7

August 2000

The publication of this document was funded by a grant provided by the Henry J.

Kaiser Family Foundation and the European Union (through the National

Department of Health)

Designed and printed by The Press Gang, Durban - Tel: (031) 307 3240


It is with pleasure that I welcome the publication of this guide for health

and nutrition workers in South Africa. Conducting a district-wide or sub-district

assessment of malnutrition together with the resources available to remedy the

situation must be one of the first steps for any district or sub-district health team

in South Africa.

This guide also emphasises the importance of team-work, inter-sectoral

collaboration and local ownership in conducting a Nutrition Situation Assessment.

I hope you will enjoy using this guide, and that it will contribute towards a

more effective response to the problems of malnutrition.

Nobahle Ndabula

Deputy Director: Nutrition

Eastern Cape Department of Health.


Designing and implementing comprehensive nutrition programmes within districts is

one of the most important challenges facing district teams in South Africa. The first activity in

this process is the collection of relevant information upon which to base planning decisions.

The purpose of this guide is to provide health district nutrition workers with the steps

and information necessary to complete a participatory NSA within the framework of the

district health system. It will go through a framework and give examples of where and how

information can be collected.

This guide is meant for health district PHC workers who are motivated to implement an

integrated nutrition programme. The key members of a district health team responsible for

managing and conducting a NSA include:

❖ INP Coordinator

❖ MCH Coordinator

❖ Environmental Health Coordinator

❖ Clinic Supervisors

❖ Senior School Health Nurse

❖ Senior Health Promotion Officer

❖ District Health Information Officer

❖ Doctor/ Nurse in charge of paediatric ward.

The guide is based mostly upon experiences of doing a similar exercise with nutrition

teams in two poor health districts: Hlabisa in KwaZulu-Natal and Mount Frere in the Eastern

Cape. It is broken up into the following sections:

Section 1:

Section 2:

Section 3:

The background to, and reasons for, performing a NSA.

The steps that need to be completed in performing a NSA.

The type of information that needs to be collected and suggestions about

how this can be done.


Section 1: Introduction......................................................................................... 1

1.1 The Integrated Nutrition Programme.......................................................... 1

1.2 Why do a Nutrition Situation Assessment?................................................... 3

Section 2: Steps in Conducting a Nutrition Situation Assessment 4

Step 1: Identifying a district nutrition team ............................................................ 4

Step 2: Build a common vision for the district health nutrition team ....................... 6

Step 3: Establish the framework for the NSA ........................................................... 6

Step 4: Identify what information is already available and what information

is still required ............................................................................................. 8

Step 5: Designing the tools and methods for Information Collection ....................... 9

Step 6: Collect the information ............................................................................. 10

Step 7: Analyse information and write a report...................................................... 10

Step 8: Disseminate the Information...................................................................... 10

Section 3:

Information for Conducting a Nutrition Situation

Assessment...................................................................................... 11

LEVEL 1 ................................................................................................................ 11

1.1 The Geography and Mapping of the Health District ....................... 11

1.2 The Community Composition (Demography) of the

Health District................................................................................ 12

1.3 Socio-Economic Profile.................................................................. 12

1.4 Community Resources / Structures ................................................ 13

LEVEL 2 ................................................................................................................ 13

2.1 Household Food Security ............................................................... 13

2.2 The Physical Environment .............................................................. 15

2.3 Care ............................................................................................... 16

LEVEL 3 ................................................................................................................ 17

3.1 Nutrition Services .......................................................................... 17

3.2 Health and Illness Profile ................................................................ 21

LEVEL 4 ................................................................................................................ 22

4.1 Nutrition Status.............................................................................. 22

FURTHER READING ............................................................................................. 23

Appendix 1:

Sample Observation Checklist for Assessing Growth

Monitoring and Promotion ............................................................................ 25

Appendix 2:

Sample Checklist for Assessing Common Infant Feeding

Practices in the Community ......................................................................... 26

Appendix 3:

Example of a scoring system for targeting individual

schools within a district or sub-district ................................................. 27

Section 1:


1.1 The Integrated Nutrition Programme

In South Africa more than 2 million children suffer from malnutrition. It is an underlying

cause in more than one in three of all childhood deaths in sub-Saharan Africa. It is also associated

with reduced academic performance, physical outputs and earning capacity. Malnutrition

therefore affects all sectors – health, education, welfare, agriculture and labour. Malnutrition is

an important reason why so many of the poor are caught up in the vicious cycle of poverty and

poor health.

Malnutrition is not just the result of a lack of food or ill health but the sum of many

different causes. This can be shown by the framework of causes of malnutrition drawn up by

UNICEF (figure 1). Whilst malnutrition usually presents to the health sector, many different

sectors need to be involved to prevent malnutrition.

Traditionally nutrition interventions in South Africa have been vertical and food based.

The main emphasis has been on giving food handouts accompanied by standard nutrition

messages, which are often inappropriate or irrelevant. The deficiencies of these programmes

have been recognised in the new national Integrated Nutrition Programme (INP).

The INP has outlined a comprehensive approach to address the underlying socioeconomic,

environmental, educational and health related causes of undernutrition. The major

aim of the INP is to shift from a reliance on feeding programmes to providing more

comprehensive community and facility based nutrition interventions.

The INP also proposes an interactive and participatory process of problem assessment

and analysis, followed by action, to be adopted at all levels. The INP is divided into three broad

areas of activity:

❖ A health facility-based nutrition programme, incorporating the Protein Energy

Malnutrition (PEM) Scheme, nutrition education, growth monitoring and promotion,

the management of infectious diseases (including parasite control and diarrhoeal disease)

and the in-patient management of severe malnutrition.

❖ A community-based nutrition programme (CBNP), which includes the Primary

School Nutrition Programme (PSNP). It aims to strengthen household food security,

improve knowledge and behaviour about nutrition, support the care of women and

children, and promote a healthy environment, especially access to clean water and

effective sanitation.

❖ A nutrition promotion programme, which focuses on improving communication,

advocacy and appropriate legislation in support of good nutrition.


Figure 1: The UNICEF conceptual framework




dietary intake






Food Security


Maternal and Child


Insufficient Health

Services & Unhealthy




Inadequate Education

Resources & Control

Human, Economic & Organisational

Political and Ideological Superstructure



Economic Structure

Potential Resources


1.2 Why do a Nutrition Situation Assessment?

Performing a nutrition situation assessment (NSA) is an important first step in

implementing the INP. It serves to:

❖ be the first step in the triple A cycle (Assessment, Analysis and Action) of the INP.

❖ be an advocacy tool, by persuading policy makers and funders of the problem of

malnutrition and the validity of your implementation plans.

❖ assist in the future monitoring and evaluation of the INP.

❖ assist in the development of a district health system (a NSA would fit into a broader

district health situation assessment).

❖ pull together the different members of the district health team to work towards a

common plan of INP implementation.

❖ bring together a multi-sectoral team and increase their appreciation of the need for

all sectors to fight malnutrition (especially the Departments of Education, Welfare,

Agriculture and Water Affairs).

Furthermore, conducting a NSA in a participatory manner can:

❖ be an educational process for both the district nutrition team and the community as

they come to realise the causes of malnutrition and set about combating them; and

❖ promote the participation of different community groups (in particular, women, poor

people, young people) and thereby contribute to community empowerment.


Section 2: Steps in Conducting a

Nutrition Situation Assessment

The steps for conducting a NSA are outlined below:

1. Identifying a district nutrition team

2. Build a common vision for the district health nutrition team.

3. Establish the framework for the NSA

4. Identify what information is already available and what information is still required

5. Designing the tools and methods for information collection

6. Collect the information

7. Analyse information and write a report

8. Disseminate the report.

Step 1:

Identifying a district nutrition team

Because malnutrition has many causes, the solution to nutrition problems involves different

people, programmes and institutions. This makes the process of “teambuilding” to be of crucial

importance – it is worth the investment in time to get people, programmes, departments and

organisations to understand and trust each other. However this is not easy and it is important

not to wait until you have full participation from everybody before starting. Quite

often as other sectors see you asking relevant questions and engaging with communities, they

will want to join in.

To start this process, an inventory of the organisation and institutions that are working

locally or supporting local activities related to child health, nutrition and welfare should be

drawn up. These can include government departments such as Education, Health and Agriculture,

as well as NGOs involved in development work. Box 1 illustrates an exercise, which can be

used to identify the important role-players in a district.


Box 1: Identifying Key Role Players

At the first meeting of the district nutrition team, a map of the district was shown to

everybody present. They were asked to point out where they were based and what

child health, nutrition and welfare activities they were involved in within the district.

The team then discussed other role players in the district who were not at the meeting,

and ended up by developing the following table:

Role-players Location Nutrition related Activities

Health Sector

Nutrition Co- Mary Theresa Hospital PEM Scheme, Creche Feeding, PSNP


PSNP co-ordinator Based in Mt. Frere Providing school meals, school nutrition

education and school gardens

Maternal & Child Mary Theresa Growth Monitoring and Promotion,

Health Coordinator Hospital

Nutrition education, PEM scheme,

Immunisation services

EHOs Sipetu Hospital Hygiene education and toilet building

projects in numerous communities

Health Promotion Mary Theresa Hospital General health education campaigns in


the district



Growth Monitoring and Promotion,

Nutrition education, PEM scheme,

Immunisation services

Growth Monitoring and Promotion,

Nutrition education, PEM scheme,

Immunisation services, Management of

severe illness such as severe malnurtition

and diarrhoea

Other Sectors

Education Circuit Mt. Frere PSNP; The 4 A’s programme


Agriculture In all parts of the Community garden and poultry

Extension Officers district. projects; 4 A’s School Programme

Welfare Mt. Frere and Sipetu Income generating projects; grants

NGOs Isinamva Income generating projects, community

health worker project

Mvula Trust

Water and sanith~ion projects in all parts

of the district


Step 2:

Build a common vision for the district

health nutrition team

All the relevant local people and institutions should then be invited to a meeting or

workshop where the problem of undernutrition, the importance of a multi-sectoral and

participatory approach to tackling the problem can be discussed and agreed. The meeting

should aim to set up and strengthen a nutrition task team whose first task is to conduct a

participatory NSA for the district. Box 2 shows the aims of such an initial meeting in Mount


Box 2: Aims of First Nutrition Workshop, in Mount Frere

1. To introduce the various role players working in Mount Frere and Region E to each

other and to share what they are doing

2. To share the results of national and local surveys showing the prevalence and

impact of malnutrition in the region.

3. To perform a mapping exercise of the district in order to share information about

nutrition related activities and projects in the district

4. To develop a common understanding of the causes of malnutrition.,

5. To motivate for the need for multi-sectoral collaboration

6. To form a regional and district integrated nutrition team which can perform a NSA

and then a “health district” based INP.

If it is not possible to organise a workshop or meeting then visiting key individuals such

as the agricultural officer, education officer and other maternal and child health workers to

explain what you are going to do and how they might be involved can be a way of getting cooperation

/ collaboration.

Step 3:

Establish the framework for the NSA

After setting up a health district nutrition team, it is necessary to outline the NSA

framework. A useful exercise is to ask the team what information they would require if they

were requested by a district manager to recommend a nutrition intervention.

In the Mount Frere district, for example, the team came up with the following headings:

❖ The geography of the district

❖ The community composition (demographic details) of the district

❖ The socio-economic profile of the district

❖ The health status of the population

❖ The nutrition status of the population.

❖ The environmental health indicators


❖ Important child care practices

❖ Household Food Security

After further discussion it was also decided to add the following:

❖ The quality and coverage of existing child, nutrition and welfare services and

programmes, as they relate to nutrition

❖ The resources available in the district to tackle undernutrition

Drawing up the framework in this way helps to get the team to think about all the

information that is required. The team can also now plan for the collection of data. It is therefore

important that all members of the team understand each part of the framework. This manual

provides a framework which can be adapted to fit the circumstances of a health district, but

which is suggested as a model framework to allow comparisons between different districts.

To make it easier to see what information needs to be collected, the framework can be

rearranged into an information pyramid as shown in figure 2.

Figure 2: Information Framework


























The bottom level of the pyramid represents a foundation of information about community

composition, socio-economic factors, geography and existing resources and structures. It is

important for nutrition planners to know about the community with which they are working

and some of community resources available for nutrition interventions. It can assist in deciding

what parts of the district need to be targeted first and whether there are very different groups

of people within the district.


The next level aims to establish the importance of the underlying causes of undernutrition:

child caring practices, the environmental context and distribution of food at the household


The third level concerns information on ill health and nutrition, and establishes the

existence, coverage, accessibility and quality of nutrition and nutrition- related services. Finally,

at the top of the pyramid is some general information about relevant national and provincial

health and nutrition policies.

Step 4:

Identify what information is already

available and what information is still


The information pyramid can also be used to help decide what data is missing and still

needs to be collected. The main team members can be asked to write down the pieces of

information needed for each part of the pyramid (e.g. clean water, water availability, low birth

weight rate, quality of growth monitoring) and then identify which parts of this information

are already available.

Remember that the main reason for doing a NSA is to assist in making

decisions about appropriate nutrition interventions. The NSA is not designed to collect

all information about nutrition, but about relevant information that can be used to improve the

quality of planning and implementation.

In addition, it must be practical to collect this information. Large community surveys are

expensive and time-consuming exercises, the results of which may not have much bearing on

the planning of interventions. Where possible information which has already been collected,

either by government services or by other organisations, should be identified and collected.

Possible sources of information include:

❖ The National Census

❖ The National Demographic Household Survey and other surveys that have already

been undertaken.

❖ Government department records (e.g. water, agriculture, housing etc.)

❖ Reports of studies done by local universities, research organisations or NGOs

❖ Department of Health accounts showing budgetary expenditures

After this exercise it will be easy to see what information is still required. The team must

then decide about what information it will have to actively collect for itself. Remember that

only information which is needed to help prioritise and plan nutrition interventions should be

collected and that it might not be possible to collect all the information within the given



Step 5:

Designing the tools and methods for

Information Collection

Once the required information has been identified, plans must be drawn up to collect

this information. There are a number of different methods which can be used to collect this

information, some of which are described below:

Key Informant Interviews

Information about certain aspects of nutrition can often be derived by talking to a few

key people who have insight and knowledge about that particular aspect of nutrition.

Such people whose knowledge and understanding can be used to inform planning

are termed “key informants”, and include the following three groups of people:

People who work within the community and have a professional understanding of

the issues: for example, school teachers, clinic nurses and social workers.

People who are recognised as community leaders and seen to represent (a section

of) the community: for example, councillors, church leaders, old women in the


People who are important within informal networks and often play a central role in

local communications: for example, shop-owners, old women in the community,

income generation project leaders.


Some information can only be obtained by actually seeing what is happening with

your own eyes. For example, the actual way in which babies are weighed and growth

monitored. As a member of the NSA team, you may want to find out about the hygiene

conditions in which mothers prepare food for children by visiting local homes, and

observing other aspects of child health care at the same time. Generally it is a good

idea to draw up a checklist of the different things to specifically look out for.

Exit interviews with carers

Exit interviews are interviews of patients or health care users conducted just after they

have used a health service, and is usually designed to assess the quality of care provided

from the user’s perspective. For example, the provision and standard of GMP and EPI

services can be assessed by exit interview.

Record review

Ward registers, clinic registers, the actual case records of in-patients or even the patient–

held Road-to-Health cards of children can all be used in various ways to collect

information to assess various aspects of quality of care.

Routine information

The routine health information system can be used to collect a lot of useful information

that is relevant to nutrition. For example, what proportion of the child catchment

population are immunised? What proportion of babies are low birthweight?


Step 6:

Collect the information

After the tools have been developed and pre-tested you are ready to collect the information.

Tasks must be clearly delegated to appropriate people with a clear timeframe for their completion.

It is important for someone to take responsibility for monitoring the process to ensure

that the data is being collected as planned.

Step 7:

Analyse information and write a report

The findings of the NSA should be presented as clearly and concisely as possible. The

way in which information is presented is very important 1 . This should be done in the form of

a report which will form the basis for planning and evaluating the required nutrition

interventions. The report should allow the “district nutrition team” to:

❖ Identify priority nutrition problems, and their causes

❖ Review the quality and coverage of existing nutrition activities in maternal and child

health services

❖ Review the quality and coverage of existing INP activities in the district

❖ Identify community and public service resources for combating nutrition problems

in the district

❖ Define target groups, set nutrition objectives and identify strategies

❖ Identify indicators for monitoring progress with the nutrition programme

If this is a follow up NSA then important areas of progress or deterioration over the past

year in the district should be identified and reasons for these changes highlighted.

Step 8:

Disseminate the Information

Once the report is finalised, it is important to disseminate it and make it available to key

people. There are many other ways of disseminating the findings of the NSA:

❖ Make short and easy-to-read policy and programme briefs on key findings and


❖ Make oral presentations to key decision-makers, managers, health workers, community


❖ Organise a dissemination workshop for decision-makers, managers, health workers,

community organisations

❖ Write press releases for the local media, including local and / or community media


The wider the dissemination the more chance there is of the NSA leading to meaningful

discussion and actions.


1 The training manual: ‘Integrating Nutrition into Development Programmes’ has a whole section on

these basic skills.

Section 3: Information for Conducting

a Nutrition Situation Assessment

This section reviews in greater detail the type of information required for the NSA, the

sources of information and how to collect it. It is structured according to the information

pyramid discussed in Section 2. Not all the blocks in the information pyramid are equally

important, and this manual emphasises the important information within those blocks.


1.1 The Geography and Mapping of the Health District

A simple map which outlines the boundaries of the health district, the major roads and

rivers, clinics and mobile points, the hospital, the offices for education, agriculture and welfare

and the major settlements is a very useful start. The map can be further improved with information

about the location of the district relative to the nearest towns as well as the physical attributes

of the district (i.e. rural, hilly, state of the roads etc.).

Develop the map in consultation with different sectors as they will have maps with

different sorts of information available. For instance, the Department of Education should have

a map of the schools in the district. By bringing the different sources of information together

the team can build up a comprehensive picture of the activities and resources in a district.

Finally, for specific local communities, community mapping exercises can be a quick and

accurate means to get information about the structure of the community (see box 3). This sort

of exercise can be done in conjunction with local clinics which can use these exercises to help

define their catchment population, or mapping can be done with community groups that may

be involved in district projects. The manual ‘Mapping for Primary Health Care’ from Management

for Sciences for Health has a number of examples of performing mapping exercises.

Box 3: Mapping exercise in Hlabisa

After initial meetings with community leaders it was decided to hold a community

meeting at the local school. To begin the meeting the facilitators asked the community

to draw a map. There were thirty participants of whom about twenty were women.

They readily took up the challenge of drawing a map on the ground using different

colour powders to symbolise the roads and rivers, and stones to mark the various

kraals. They were asked to mark important landmarks in the community. In this way

the team gained useful insights into what the community perceived as important

structures. With little intervention from the facilitators they completed their map after

about an hour. This was then checked by the elderly men and women who had not

participated as fully during the exercise; they picked up a few points which the others

had missed. The facilitators were then able to complete a rapid demographic survey

of the community by asking for information about who lived in the various households

located on the community map.


1.2 The Community Composition (Demography) of the

Health District

The ratio of male to female children and the age distribution of the population (especially

proportion of children under 5) are important pieces of information. However, accurate

information on the demographic structure of the local population can be difficult to get. The

recent census data and the local welfare office should be able to provide some statistics for the

magisterial districts.

If household surveys have been completed in parts of the district either for health, welfare,

education or agriculture, you can use this as a source of information.

1.3 Socio-Economic Profile

A general description of the socio-economic profile of the health district will help to

contextualise the plans for an INP. But getting good quality data can be difficult so it is

recommended that you speak to key informants in the district. Important issues to discuss with

informants would be:

❖ Where are the poorest communities in the district?

❖ What are the main sources of income for families in the district?

❖ What are the main sources of income for women in the district?

How widespread and successful are income generating projects?

❖ Are there seasonal factors for income generation?

Box 4 outlines an exercise which can assist you in answering some of these questions:

Box 4: Investigating different sources of income in Hlabisa

After completing a community map and a walk through the village the facilitator

explained why it was useful to understand the different sources of income in the

community. He then drew a house on the ground. Participants were asked to shout

out the different sources of income coming into their household. These were drawn

and written on pieces of card and distributed around the drawing. The participants

were then given one bean each and instructed to place it on the most important

source of income in their household. The men were given different coloured beans

from the women. Most women and men placed their bean on farming. They stated

that even if pensions or remittances sometimes contributed larger amounts they were

quite often irregular and farming was something they could rely upon. The sale of

vegetables grown in the community gardens was also important for some women,

whereas nearly half the men put down part-time jobs as an important source of income.

This could include working on other peoples farms, putting up fencing and building

kraals. They also mentioned that sometimes they get paid in kind with food rather

than money in some of these jobs.


1.4 Community Resources / Structures

Because an important component of the INP is the development of community-based

interventions, with community involvement and participation, it is important to have a good

idea of the community structures and resources that exist. Some important resources include

informal creches, Church Groups, Community Based Organisations, local GPs etc. Box 5 shows

an exercise which can help to get this information.

Box 5: Finding out about community resources

During a community meeting a member of the district INP team asked a group of

women and men to write down all the organisations that they belonged too or were

active in the area on pieces of paper which had been cut into circles. Once they

completed this she then asked them to discuss the importance of each of the

organisations to the community. They were requested to write the name of the village

on a piece of paper and place all the most important organisations next to the village

name. The next important organisations were then placed a little further back. This

continued until they had built a picture which allowed the team to see which

organisations were present in the area and which ones the community regarded as

most important.


2.1 Household Food Security

A household is food secure when it has adequate access to the food (in terms of quality, quantity,

safety and acceptability), needed for a healthy life for all its members and when it is not at undue risk of

losing such access.

In South Africa, not all households have food security and not all members within a

family have equal access to that food.

Households may not have food security either because they lack physical access to food

and/or they lack the economic resources to buy food and/or because households are unable to

use the food available to them safely and appropriately. To assess household food security we

need to find out about the availability, access and use of food by households. Table 2 provides

a framework for collecting this information.


Table 2: Assessment of Household Food Security

Information needed Source of Method for

information collection

Food availability and access Community mem- Key informant

How do households obtain their food? bers/ Agricultural interviews/

What do they produce? officers Participatory

What do they purchase? Other sources?


Has this situation changed in the last

few years? How? Why?

Production for Household Consumption Community mem- Key informant

What foods are produced by the house- bers/ Agricultural interviews/

hold? How many months do staples last? Officers Participatory

During which months do they eat the


other foods? Do they grow energy-rich


What are the periods of food scarcity?

For which foods?

What efforts do people make to overcome


Food Purchasing Community mem- Key informant

How much of the household income is bers interviews/

spent on food?


What are the foods purchased? Which are


considered as essential?

Which as luxury? Why?

How have purchasing habits changed in

recent years? Why?

Food Use Community mem- Key informant

How many meals do the different house- bers interviews/

holds members eat a day? In which season?


Any snacks in between? Do children eat


differently? How often do they prepare

meals for young children?

How do eating patterns change in times

of scarcity?

How is food obtained in such cases?

If the household had more resources

what foods would they like to more or

more often? What foods are considered

especially good or to be avoided in

certain circumstances?

What was the normal diet for children

20 years ago? If it has changed,

how and why?


Answers to questions such as: “Who is at risk of poor household food security? What is

the nature of the problem? Its severity? Its frequency and periodicity?” will inform the

development of appropriate interventions which can help to target households and improve

the availability of food at a household level.

2.2 The Physical Environment

Important causes of malnutrition include illnesses such as diarrhoeal disease and worm

infections, which are often caused by a poor living environment. An INP needs to be able to

monitor and respond to a number of key environmental health indicators.

Environmental health officers quite often collect information from local communities

about the water supply and its quality, the number of toilets, waste disposal facilities etc.

Environmental health officers are also trained to perform observations to assess the environment

of a community, and the nutrition team can draw upon this expertise. Requesting communities

to indicate on the community maps the position of water sources, the quality of the water and

the number of households with toilets is also a way of assessing the environmental situation.

This method also has the advantage of being able to lead into a community discussion on issues

concerning the environment. Table 3 outlines some of the information that may be important.

Table 3: Physical Environment

Information needed Source of Information Method for collection

% with clean water supply Department of Water Literature review

at home and Forestry Local survey

% with communal taps Local surveys Key informant interviews

% with no clean water supply

% spend more than 30 mins

to get to water supply

% with toilets in households Department of Water Literature review

% with access to toilets and Forestry Local survey

Local surveys

Key informant interviews

% with waste disposal Department of Water Literature review

facilities and Forestry Local survey

Local surveys

Key informant interviews

% with adequate home water Department of Water Literature review

storage facilities and Forestry Key informant interviews

Local surveys

% households with clean Observations Key informant interviews



% villages with no unburied


% taps with proper drainage


2.3 Care

Food and health services are necessary but not sufficient conditions for good nutrition.

The third underlying determinant is care. Care refers to the practices of those who give care to

children, translating the available food and health resources into a child’s survival, growth and

development. Because it is women who are usually responsible for providing child care, the

care provided to women is also important.

Even when poverty causes food insecurity and there is limited health care, enhanced

child care and affection can optimise the use of existing resources to promote good health and

nutrition for women and children. Breastfeeeding is an example of a practice that provides

food, health and care simultaneously.

Through assessing the common child care beliefs and practices the nutrition team should

be able to determine the need for certain health promotion and nutrition education services.

Table 4 outlines some of the information that may be of importance.

Table 4: Assessment of Care Practices

Information needed Source of Method for

information collection

Breastfeeding and complementary feeding

Proportion of children exclusively breastfed Carers of children Clinic surveys at

at 3 months

3 rd immunisation

Proportion of children breastfed on demand Carers of children Clinic surveys at

3 rd immunisation

Average age when a)liquids b) milk and

c)semi-solids are introduced

Community mem- Key informant



What types of foods are they given, and Community mem- Key informant

how are they prepared and fed to children bers/Health interviews

under 2? How many times a day?


At what age is breastfeeding discontinued?

Are any high energy foods given (e.g. peanut

butter, oil, margarine etc.)?

Community mem- Key informant



Community mem- Key informant



Psycho-social stimulation

Do adults supervise when eating and actively

encourage the children to eat? How? Carers of children Clinic surveys at

3 rd immunisation


Table 4: Assessment of Care Practices (continued)

Information needed Source of Method for

information collection

Hygiene practices

Are resources available in the community to

practice adequate hygiene?

Community mem- Key informant




Are hygiene practices adequate in the Community Key informant

household and community? members/Health interviews/

personnel Observations

Care for women

What is the degree of control of decision Community Key informant

making and finance of women in the members interviews


Are girls valued just as much as boys? Community Key informant

members interviews

Are there any special customs regarding Community Key informant

the care and diet of pregnant and lactating members/Health interviews




3.1 Nutrition Services

The availability of effective and efficient health services can play a significant role in

improving nutrition and reducing the impact of undernutrition. An attempt should be made to

assess maternal and child health services (MCH) in the district.

For instance, good growth monitoring and promotion (GMP) by health workers can

prevent much undernutrition; similarly the proper care of severely malnourished children in

the paediatric ward can significantly reduce the mortality of these children.

The following are a list of priority MCH services that should ideally be assessed as part

of any NSA:


Primary level (clinic/CHC’s/ Hospital OPD)


❖ Management of diarrhoeal disease

❖ Vitamin A / Iron supplementation

❖ Promotion of Breastfeeding

❖ Ante-natal services

❖ Immunisation service

❖ Nutrition education


❖ In-patient management of severe malnutrition and diarrhoeal disease

❖ Nutrition Education

❖ Promotion of Breastfeeding.

In Mount Frere the district nutrition team drew up a checklist of health service activities

they thought were important in performing growth monitoring and promotion. They then

went to a number of clinics and hospitals in the district to perform observations and interviews

using these checklists. They found a number of shortcomings in the performance of GMP.

Their results have helped with designing a training programme to improve GMP in the district.

At Hlabisa district hospital the paediatric team kept a simple record of the outcome of

children admitted with severe malnutrition. They then reviewed the management of these

children. Through changing a few simple things they were able to achieve a five fold reduction

in mortality.

Other services which should be assessed include breastfeeding, immunisation and

management of the sick child.

Assessment of Services

To help a team think about what needs to be measured to assess nutrition services we

need to be sure that the correct things are available and in place (INPUTS) and that these are

combined together (PROCESS), to produce a service (OUTPUTS) which will have an impact

(OUTCOME). For example, to assess the quality of GMP the following table could be drawn



Table 5: Assessing quality of GMP

Information needed Source of Method for

information collection


Adequate number of trained staff

Availability of drugs/food supplements

Functioning scales


Timely and courteous service

Correct weighing and plotting

Appropriate counselling

Correct treatments

Growth monitoring sessions


Improved knowledge of mother about growth

of her child

Increased number of children correctly

weighed and plotted

Increased client satisfaction

Health Staff/Clinic Key informant



Growth monitoring Exit interviews


Growth monitoring Exit interviews



Reduced mortality Provincial Records/ Literature and

Reduced levels of malnutrition Hospital and routine statistics

Increased levels of immunisation coverage clinic records review

Assessment of Nutrition Programmes

South Africa is investing a lot of resources in nutrition programmes. Some of these, such

as the PEM scheme are run by the Department of Health; some such as the Primary School

Nutrition Programme (PSNP) are run in collaboration with other sectors (Education); and

others, such as community garden projects are run in sectors outside of health (Agriculture). It

is important to assess the efficiency and effectiveness of these programmes. The following is a

suggested checklist of what to check for when assessing nutrition programmes in your district.


❖ Whether the programme has clear goals, measurable targets, and whether they are

well understood;

❖ Whether progress has been made towards these targets in the previous 12 months or

so, and if not, why;



❖ The current set of activities and services;

❖ Whether the quality of the service is adequate;

❖ Whether priority groups (i.e. pregnant and lactating women, young children) are

being reached effectively;

❖ Whether monitoring, evaluation and supervision are adequate and if not, what needs

to be done to improve it;

How the activities relate to other services provided in the district.


❖ The personnel available to work in the programme;

❖ Whether supplies and transport are sufficient;

❖ Whether resources (human, organisational, technical and financial) are adequate to

reach the programme objectives;

Once again this information can be collected using a variety of methods. Box 6 shows an

example from Mount Frere.

Box 6: Assessment of PSNP in Mount Frere

The Mount Frere nutrition team decided to assess the PSNP in the district. Because

one member of the team was the district education officer, collecting information on

the aims and objectives, the resources available and the coverage of the programme

was relatively easy. The team interviewed key personnel such as the circuit education

manager, a school principal and a contractor about their knowledge and understanding

of these aims and objectives. Other members of the team drew up an observation

checklist which included such things as the quality of the food, the children’s enjoyment

of the food and the disruption it caused to the class. They then conducted interviews

with a couple of the teachers, the school principals and members of the school

committee asking about their opinions of the programme and any suggestions they

might have for improvements.

They found that the food was quite often stale and not much liked by the children. In

addition, they found that the teachers and community were also dissatisfied since

large amounts of money went to the large bakery in a distant town and the lunch was

not reproducible at home. As a result of the assessment it was decided to explore the

possibility of providing a locally produced lunch. This would then be linked to a school

nutrition education programme and the school garden projects being supported by

the Agriculture department.


Here are some questions that you could ask about the PSNP programme:

❖ What is the basic organisational structure and management of the PSNP?

❖ What schools are targeted and what is the coverage?

How is the food supplied and prepared?

❖ What is the community and NGO involvement?

❖ What are the links to other interventions?

❖ What are the outcomes/benefits of the programme?

❖ What are the plans for the future?

Appendix 3 gives an example of a scoring system that can be used to target the most

needy schools.

3.2 Health and Illness Profile

Illnesses such as diarrhoea, measles, pneumonia, and HIV are important causes of

undernutrition in children. Women who suffer from illnesses during pregnancy or during child

care are also more likely to have undernourished children. Therefore, information on the

frequency and prevalence of common childhood illnesses and women’s health is important.

Table 6: Assessment of Health and Illness

Information needed Source of Method for

information collection

Health Status

Maternal mortality

Infant mortality rate and Under 5 mortality


Ante-natal HIV prevalence

Prevalence of maternal anaemia

National/Provincial Literature review


Childhood Illnesses

Prevalence of diarrhoea Hospital/Clinic Register/Record

Prevalence of pneumonia Statistics Review

Prevalence of severe malnutrition

Prevalence of children with worm infestations

In rural areas, especially, there can be a great deal of seasonal fluctuation in the incidence

of some illnesses; for example, diarrhoea is quite often much worse during the rainy season.

This can have an important bearing on the timing of interventions (e.g. increase our efforts of

giving nutrition messages about feeding during diarrhoea during the rainy season).

Clinic and hospital records can provide very useful information about the incidence of

different illnesses. Once again this can be checked by asking community members of their

opinions about the prevalence and seasonality of different illnesses.



4.1 Nutrition Status

There are several indicators of nutrition status: weight-for-age, height-for-age, weightfor-height,

low birthweight, prevalence of anaemia.

Once again it is advisable for the team to use different sources for this information. If the

clinics and mobile points are reaching most of the community and they have a good data

collection system then clinic and hospital data on the number of children underweight for age,

incidence of low birthweight and prevalence of anaemia in pregnant women can be very


Unfortunately in many districts this information is not very reliable. There have been a

number of very good national nutritional surveys in the last few years which are readily available.

The South African Vitamin A Consultative Group study, for instance, measured the vitamin A

and iron levels and the weights and heights of young children all over the country. The Health

Systems Trust has a publication entitled “The Nutritional Status of South Africans: A Review

of the Literature from 1975-1996” which summarises the results from most of these national

surveys and is available from the HST offices. In addition it is worth trying to find out whether

there have been any local surveys done by universities or the Medical Research Council.

Once again interviewing key informants, such as senior nurses, clinic workers, community

health workers, about the prevalence of severe malnutrition and changes over the recent past

can lead to valuable information about the extent and severity of the problem.

Table 7: Assessment of Nutrition Status

Information needed Source of Method for

information collection

1. What % of young children are National/Provincial Literature Review



2. What % of young children are stunted Surveys from

(low height-for-age)

Medical Research

3. What % of young children are wasted Council, Univer-

(low weight for height)

sities etc.

4. What % of young children have

vitamin A deficiency?

5. What % of newborns weigh less than Hospital/Clinic Record/Case

2,500g? Records Review

6. Are there some areas in the district which

have rates of low birth weight than others?

7. Are these nutrition problems improving Community Key Informant

or getting worse? members/health interviews

8. What geographical areas, communities or workers

ethnic groups are more likely to have

nutritional problems?



McCoy D, Bamford L. 1998. How to conduct a rapid situation analysis: A guide

for health districts in South Africa. (Health Systems Trust.)

Bennett J, Rohde J. 1999. Mapping for primary health care. (Management Sciences

for Health.)

Chopra M, Sanders D, et al. 1999. Kwik Skwiz #22 Improving growth monitoring

and promotion in PHC clinics: Lessons from Mount Frere health district.

(University of the Western Cape and Health Systems Trust.)

Chopra M, Sanders D, Puoane T et al. 1999. Integrated Nutrition Programme

Planning: A training guide for district nutrition managers. (University of the

Western Cape and Health Systems Trust.)

McCoy D, Saitowitz R, Saasa M et al. 1996. Evaluation of the Primary School

Nutrition Programme. (Health Systems Trust.)

Strasser S, Puoane T et al. 1999. Kwik Skwiz # 16: The WHO ten steps – The way

forward for improved care of severe malnutrition. (Health Systems Trust)

Vorster H, Oosthuizen W et al. The nutritional status of South Africans: A review

of the literature.





SITE: ..................................................................................

DATE OF ASSESSMENT: ..................................................

CATEGORY OF WORKER: ............................................

INITIALS OF ASSESSOR:.................................................


Did the service provider:

1. Greet the mother?

2. Ask the mother the purpose of the visit?

3. Ask the mother to remove the child’s clothing?

4. Set the scale to 0?

5. Ask the mother to put the child on the scale?

6. Correctly read scale?

7. Tell the mother whether her child has gained, lost weight

or stayed the same since last weighing?

8. Ask if the child has any health problems since last weighing?

9. Explain the importance of gaining weight for health?

10. Tell mother when to take child for next weighing?

11. Make recommendations regarding child feeding and


12. Stress importance of using locally available energy

dense foods with examples?

12. Explain about exclusive of breastfeeding and good

weaning practices?

13. Explain how to feed children during illness?

14. Explain the purpose of growth monitoring?

15. Ask mother if she has any questions?

16. Explain where to go for growth monitoring services?

Adapted from N. Ndabula A protocol to evaluate the quality of community based growth monitoring and

promotion in the Eastern Cape Masters in Public Health University of the Western Cape





Age Estimated Common reasons for stopping Foods (other than Frequency Common feeding

Group breastfeed breastfeeding before 2 years (or breastfmilk) commonly and amount problems; reasons

ing rate supplementation before 4 months) given fed

2 months Stopping:

up to 4

months Supplementation:

4 months

to 6


6 months

to 12


12 months

to 2 years

Remember to note sources of information.

Taken from: Protocol for adapting feeding recommendations. IMCI initiative WHO/UNICEF 1999







Criteria 0 1 2 3

Proportion of school entrants who are stunted < 5% 5 - 10% 11 - 15% > 15%

State of school (electricity) Grid Alternative None -

Electricity source of


State of school (water supply) Fully Less than 5 One well/ No source

serviced taps for pump in of water on

entire school school

school grounds grounds

Number of children per classroom - 20-10 41-60 >60 or 3 - 6 km > 6 km

Sanitation and toilets One flush One flush Adequate Inadequate

toilet per toilet per VIP sanitation

100 children 100 children latrines

or less or more

School drop-out rate between sub-A and Grade 8 10% >20%


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