Several factors contribute to the design of a successful and accurate assessment.  Table 2 summarizes the key factors, resulting from lessons learned over the years:

Table 2.  Keys to a successful assessment [48]

Factor	Detail
Identify the Users	Every element of an assessment should be designed to collect information for a specific user. The potential users should specify their data needs during the design phase. For example, health workers need certain types of information that will only be useful in certain formats, usually tables, while a procurement officer may need more quantitative or statistical data.
Identify the Information Needed To Plan Specific Programs	Too often, assessments collect information that is incomplete or of little value for planning relief programs or specific interventions. In many cases, information is anecdotal rather than substantive; in others, valuable time is wasted collecting detailed information when representative data would be just as useful. Determine what information is vital, what method is best to obtain this information, and how much detail is necessary for the information to be useful.
Consider the Format	It is important to collect, organize, and present the data in a form useful to analysts and program planners. The results must be presented in a format that makes the implications very clear so that priorities can be set quickly. By applying baselines and standards to the presentation, key relationships can be quickly noted. For example, daily death rates in a displaced person (DP) camp should be calculated and compared to the international standard of 1.0 deaths per 10,000 per day.
Consider the Timing of the Assessment	Timing may affect the accuracy of an assessment because situations and needs can change from day to day. Various types of assessments need to be timed to collect the necessary information when it is available and most useful. Relief needs are always relative but, as a general rule, initial surveys should be broad in scope and should determine overall patterns and trends. More detailed information can wait until emergency operations are well established.
Determine the Best Places to Obtain Accurate Information	If the information must be obtained from sample surveys, it is important that the areas to be surveyed provide an accurate picture of needs and priorities. For example, carrying out a health survey in a medical center would yield a distorted view of the overall health situation, because only sick or severely malnourished people would be in the medical center.
Distinguish Between Emergency and Chronic Needs	Virtually all developing countries have longstanding chronic needs in most, if not all, sectors. It is important to design an assessment that will distinguish between chronic needs. Attempts should be made to acquire baseline data, reference data, and/or recognized and accepted standards in each sector. The surveyors must differentiate between what is normal for the location and what is occurring as a result of the disaster, so that emergency food aid and health care can be provided to those most in need. (It should be remembered that assessments may bring to light previously unrecognized or unacknowledged problems in a society. Thus, the data collection system should be careful to structure the information so that critical data such as health status, etc., can be used for long term planning.)
Assess Needs and Vulnerabilities in Relation to Capacities	Needs are immediate requirements for survival. Vulnerabilities are potential areas for harm and include factors that increase the risks to the affected population. Vulnerabilities create unequal levels of risk between groups. Needs are assessed after an emergency has occurred, whereas vulnerabilities can be assessed both before and during the emergency. Needs are expressed in terms of requirements (food, water, shelter, etc.); vulnerabilities are expressed in terms of their origins (physical/material, social/organizational, or motivational/attitudinal). The antidote to needs and vulnerabilities are capacities. Capacities are means and resources that can be mobilized by the affected population to meet their own needs and reduce vulnerability. Preventing a widening of the emergency in which today's vulnerabilities become tomorrow's needs.
Use Recognized Terminology, Standards, and Procedures	Assessments will invariably be carried out by a variety of people operating independently. To provide a basis for evaluating the information, generally accepted terminology, ratings, and classifications should be used in classifying and reporting. The use of standard survey forms with clear guidelines for descriptive terms is usually the best way to ensure that all information is reported on a uniform basis.

Conclusion

In almost all emergencies, nutrition is in danger, as people flee their homes, crops are destroyed, communication and transport become difficult, and the social structure of society is altered.  In the effort to provide relief to those affected by emergencies, there is a need for data on the numbers affected and on the extent of the nutritional emergency. 

By observing the list of references cited in this review, important turning points in nutritional survey philosophy are evident:  (a) 1950s – early 1980s (key literature/papers referenced.  These were the “standards” at the time); (b)  1980s – mid 1990s – attempts at manuals bringing greater standardization, although key papers were still cited;  (c) after 1995 – the push toward simplified and internationally “expert agreed” standards and protocols for use in the field.  The use of these manuals is now reflected in published literature (after 1995) of nutritional assessment experience in disaster/humanitarian assistance relief field work.

For the present, anthropometry will continue to be used for monitoring the health and well-being of populations vulnerable to food insecurity and famine.  But there can be no neat formula for judging the risk of death associated with any given rate of malnutrition because of the synergism between malnutrition and disease.  The mortality risk associated with a given prevalence of malnutrition can be judged approximately by taking into account those public health factors that determine exposure to disease and provide some protection.  These include the health environment (water, sanitation, crowding) and access to health services (health facilities, essential drugs and vaccines, immunization coverage, vitamin distribution).

To estimate the need for increased food supplied, the nutritional status of the affected population is important information.  Yet, those who are in charge may lack the expertise to give reliable information.  It is hoped that this literature review will serve as a primer to quickly paint a picture of the state of the art where nutrition surveys and their use are concerned.

References

1.      Toole MJ, Waldman, RJ:  Refugees and displaced persons: War, hunger, and public health.  JAMA, 270: 600-605, 1993.

2.     The Management of Nutritional Emergencies in Large Populations (revised edition), WHO, 1995.

3.     Sample Size Determination in Health Studies – A Practice Manual.  S.D. Lwanga and S. Lemeshow, WHO, Geneva, 1991.

4.     Measuring Change in Nutritional Status, WHO, Geneva, 1983.

5.     An Evaluation of Infant Growth, Nutrition Unit, WHO, Geneva, 1994

6.     Physical Status: The Use and Interpretation of Anthropometry – Report of an Expert committee, WHO, Geneva, 1995

7.     Field Guide on Rapid Nutritional Assessment in Emergencies, WHO, Regional Office for the Eastern Mediterranean, 1995

8.     Rapid Health Assessment Protocols for Emergencies, WHO, Geneva, 1999.

9.     Conducting small-scale nutrition surveys – A field manual.  Food and Agriculture Organization of the United Nations, Rome, 1990.
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11.   Gomez, F. et al.  Morbidity in second and third degree of malnutrition.  J. Trop Pediatr, 2: 77-83, 1956.

12.   Manual for Nutrition Surveys.  US Government Printing Office, Washington, DC, May 1957 (developed by the Interdepartmental Committee on Nutrition for National Defense).

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17.   Arnhold, R.  The arm circumference as a public health index of protein-calorie malnutrition of early childhood.  XVII.  The quac stick: A field measure used by the Quaker Service Team in Nigeria.  J. Trop. Pediat. 15: 243, 1969

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31.   National Center for Health Statistics.  NCHS growth charts, 1976.  Monthly Vital Stat Rep, 25(3) Suppl: 1-21, 1976.

32.   Miller, DC et al.  Simplified field assessment of nutritional status in early childhood: practical suggestions for developing countries.  Bull of WHO, 55, 79-86, 1977.

33.   DeWinter, ER.  Measuring weight gains relative to standard weights for age.  J. Trop Pediat Environ. Child Health, 23(3): 111-118, 1977.

34.   Miller, DC et al.  Simplified field assessment of nutritional status in early childhood: practical suggestions for developing countries.  Bull. WHO, 55(1): 79-86, 1977.

35.   WHO.  The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years.  Bull. WHO, 55: 489-98, 1977.

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37.   WHO.  A growth chart for international use in maternal and child health care.  Guidelines for primary health care personnel.  Geneva WHO, 1978.

38.   Cole, TJ.  A method for assessing age-standardized weight-for-height in children seen cross-sectionally.  Ann. Human Biol., 6(3): 249-268, 1979.

39.   Trowbridge, FL et al.  Sensitivity and specificity of arm circumference indicators in identifying malnourished children.  Am. J. Clin. Nutr., 33(3): 687-696, 1980.

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(accessed November 2000)