In emergencies, food and nutrition security are often severely threatened and urgent action is required to ensure that all members of the community have access to adequate food. Those who are malnourished require nutritional rehabilitation. The extent of malnutrition has important implications for an emergency response. It influences decisions on the content and transfer mechanism of food assistance (in-kind or cash based interventions) and the requirements of selective feeding programmes.
Ideally following the multi-sectoral needs assessment for refugee emergencies (NARE), a more detailed initial rapid assessment of the nutrition status of refugees should be conducted as soon as possible. The nutrition assessment is normally part of the health needs assessment. It should collect secondary data on and related to nutrition, assess acute malnutrition, and screening of key infant feeding practices. Assessments should be carried out by sectoral technical experts with appropriate qualifications and relevant experience.
A more comprehensive nutrition survey should be undertaken as soon as feasible and no later than 3-6 months after an emergency starts. This assessment should evaluate the nutrition status of the population as a whole and should follow UNHCR's Standardised Expanded Nutrition Survey (SENS) guidelines.
Underlying policies, principles and/or standards
Sphere, Food security and nutrition assessment standard 1.2: Nutrition assessment. Nutrition assessments use accepted methods to identify the type, degree and extent of undernutrition, those most at risk and the appropriate response.
Where people are at increased risk of undernutrition, assessments are conducted using internationally accepted methods to understand the type, degree and extent of undernutrition and identify those most affected, those most at risk and the appropriate response.
UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 3. This requires an emergency response to provide up-to-date information on, and analysis of, food security and nutrition, enabling programming to be both appropriate and based on need.
Good practice recommendations
An initial rapid nutrition assessment should be carried out at the start of an emergency, to establish the nutrition status of refugees and confirm the existence or threat of a nutrition emergency. It should estimate the number of people affected, quantify immediate needs, the availability of local resources, and the need for external resources. The initial rapid assessment will then guide the need for a more in depth assessment to determine medium to longer term needs and approaches.
The assessment should be coordinated and supervised by an experienced nutritionist or public health officer. It should collect secondary data on and related to nutrition, measure acute malnutrition, and screen key infant feeding practices.
Objectives of an initial rapid nutrition assessment
- To provide information on the nutrition situation in the country of origin and country of asylum (secondary data).
- To measure the prevalence of acute malnutrition in children aged between 6 and 59 months, based on mid-upper arm circumference (MUAC) and bilateral oedema (primary data collection).
- To assess key infant feeding practices, specifically breastfeeding of infants younger than 6 months (primary data collection).
- To identify cultural habits among the refugee population that might affect their food preferences and intake, for example whether the population is vegetarian or pastoralist with high meat and/or milk intake (secondary data, key informants).
- To identify characteristics of the refugee population that might influence the effectiveness of coping strategies or early interventions, such as animal husbandry or farming skills (secondary data, key informants).
- To identify specific vulnerabilities, for example that women eat last (secondary data, key informants), older people etc.
- To assess national and local capacity to lead or support the response (key informants, observation).
A situational analysis will help to establish whether the nutrition situation is deteriorating or stable, whether groups in the community have specific needs, and whether community members have specific skills or resources that can help prevent deterioration of the situation. Situational analyses should review the state of nutrition before the emergency, as well as eating habits and livelihood practices.
Where nutrition is a concern, it is usual to assess the prevalence of acute malnutrition in children aged between 6 and 59 months. Acute malnutrition reflects more recent changes in dietary intake and infection and provides an indication of the nutritional status of the whole population. Acute malnutrition among children aged between 6 and 59 months is assessed on the basis of weight-for-height or weight-for-length (WFH) indices, MUAC, and signs of bilateral oedema.
It is important to identify infants younger than 6 months who are not being breastfed. If an infant is not being breastfed or is having breastfeeding difficulties, the mother or caregiver and the child should be referred immediately to a health centre for further assessment and support.
Relevant secondary data is often available and can be complemented by interviewing key informants. Key sources of secondary data include:
- Statistical offices in the country of origin or country of asylum.
- UNHCR's databases and reports.
- Other UN agencies, notably UNICEF and WFP.
- NGOs that work in the area of origin or area of asylum.
- Key informants working in the refugee affected areas.
- Key informants from among the refugees, with an age, gender and diversity lens.
During the assessment, information should be collected from as many different gender, diversity and age balanced sources as possible. The information should be triangulated.
Primary data collection should be undertaken in places where nutrition situation is a concern. Acute malnutrition and infant feeding practices can be assessed by nutrition and health workers in reception centres or other first points of contact with the population.
In a rapid nutrition assessment, the indicators of choice to measure acute malnutrition are MUAC and oedema. MUAC is quick to perform and effectively predicts risk of death in children aged 6 to 59 months. Based on a single measurement, it requires no heavy equipment, is used with the same cut-off for both boys and girls, and can be undertaken by low-skilled staff given training and supervisory support.
Instructions for MUAC and oedema screening:
- All children aged between 6 and 59 months should be screened for MUAC malnutrition and bilateral oedema at the reception centre during registration or at other first points of contact.
- To assess MUAC, measure the circumference of the left upper arm at the mid-point between the elbow and shoulder, to the nearest millimetre, using a standard MUAC tape.
|MUAC measurement||Malnutrition status|
|<125mm (yellow and red)||Moderateand severe|
|≥115mm and <125 mm (yellow)||Moderate|
- To assess bilateral oedema, apply gentle thumb pressure to the tops of both feet of the child for a period of three seconds and observe the presence or absence of an indent.
- A child with bilateral oedema is always classified as having severe acute malnutrition.
Instructions for infant screening:
- Every refugee family that has an infant younger than 6 months should be screened at a reception centre during registration or at another first point of contact.
- Based on a short questionnaire on feeding practices, screening should establish whether the child is being breastfed, whether the mother is present, and (where applicable) what foods the infant receives instead of breastmilk.
- Every infant younger than six months who is not being breastfed or has breastfeeding difficulties should be referred to a health centre for further assessment and support.
Infants younger than six months may be at risk of acute malnutrition if breastfeeding has been disrupted (for example, because the child is separated from its mother, or the mother has died, or the child is only partly breastfed). Among infants younger than 6 months, acute malnutrition is assessed using visible signs of wasting and bilateral oedema. Social criteria (an absent mother, inadequate breastfeeding) can indicate a heightened nutritional risk.
Presentation of results
The findings of an initial rapid nutrition assessment should be reported using the MUAC screening report template. Take care when presenting MUAC results. Make clear the nature of the sample, because this determines how representative it is. (Were all children measured, for example, or only those likely to be undernourished?) Make sure that MUAC results are not conflated with the prevalence of GAM (which can only be measured in terms of weight-for-height and oedema). MUAC does not provide a formal threshold for assessing the state of nutrition in the whole population. However, rapid nutrition assessments can show where immediate interventions are needed.
Considerations for practical implementation
- The findings of an initial rapid nutrition assessment should guide the level and type of nutrition support (for acute malnutrition, infant feeding, etc.) that are offered in transit centres and /or where refugees will settle.
- MUAC results will often show lower levels of under-nutrition than weight-for-height.
- An initial rapid nutrition assessment is a preliminary estimate. It should be followed by a more comprehensive nutrition survey as soon as the situation allows, and no later than 3-6 months after an emergency starts. The comprehensive survey should assess the nutrition status of the population as a whole and should always follow the UNHCR's Standardised Expanded Nutrition Survey (SENS) Guidelines.
- Rapid nutrition assessments should be continual: all arriving children should be screened for acute malnutrition and breastfeeding support. Screening activities should also continue after the first MUAC screening report has been produced. In the same manner, the comprehensive nutrition survey may be followed by simpler weekly reports on the prevalence of MUAC malnutrition.
- In situations where under-nutrition is a concern, screening for acute malnutrition on arrival should be coupled with regular mass MUAC screenings in refugee camps or communities, to monitor nutrition levels.
Resources and partnerships
Initial assessments should involve several agencies and partners and are multisectoral. It is important that UNHCR leads this process in refugee emergencies.
- A trained UNHCR public health officer.
- An experienced nutritionist from UNHCR and / or a partner organisation.
- Community outreach workers to work in camps and the community; nutrition/health assistants to staff reception centres and contact points.
- The key technical partners are: Ministry of Health, international and/or national NGO partners (international and national )(implementing, operational, potential and already on ground), UN agencies WHO, UNICEF (for child and maternal health, vaccination, and linkages to nutrition and WASH), UNFPA (reproductive health), and WFP (links to nutrition and food security)..
- Standard MUAC tapes.
- Infant screening questionnaire.
UNHCR Public Health Section, Division of Programme Support and Management (DPSM). At [email protected].