Rapid nutritional assessment for West Bank and Gaza Strip

Executive Summary
Introduction

In December 2001, the Palestinian Minister of Health requested the USAID West Bank/Gaza (WB/G) Mission to undertake an assessment of the nutritional status of preschool aged children and women of reproductive age throughout the West Bank and Gaza Strip. USAID WB/G accepted this task and added it to the portfolio of the Emergency Medical Assistance Program (EMAP), a cooperative effort of USAID and CARE International (CARE)/American Near East Refugee Aid (ANERA). CARE had a pre-established contractual relationship with Johns Hopkins University (JHU) to provide technical assistance in health. Within that context, JHU developed a comprehensive three component nutritional assessment to evaluate the extent and causes of malnutrition and anemia and to identify areas for strategic programmatic interventions. The assessment contained: 1) a household interview and examination survey; 2) a survey of market places; and 3) a survey of maternal child health (MCH) clinic practices and capabilities. The surveys of the Nutritional Assessment for West Bank and Gaza Strip (NA/WBGS) were field tested and carried out during June-August 2002 by Al Quds University and the Global Management Consulting Group under sub-contracts with CARE.

Objectives

Populations affected by conflict will experience food insecurity and undernutrition. The escalation of the Palestinian-Israeli conflict which commenced September 2000, and increased in intensity during the Spring of 2002, has led to a deterioration of the household economies in the West Bank and Gaza Strip, interfered with food availability and accessibility, and raised the probability of a significant problem of undernutrition. Furthermore, clinics responsible for recognizing and treating undernutrition-related problems face budgetary constraints and travel restrictions for staff and patients. Thus, principal questions to be addressed included:

• What is the prevalence of undernourishment among children (male and female) aged 6-59 months as determined by conventional and internationally recognized anthropometric measures;
  
  
• What is the prevalence of undernourishment among reproductive age women 15- 49 years as determined by body mass index (BMI);
  
  
• What is the prevalence of iron deficiency anemia as determined by hemoglobin measurement amongst these two populations;
  
  
• What is the consumption of selected macronutrients and micronutrients for the women and children as determined by a 24 hour food intake;
  
  
• What is the status of food security at the household level;
  
  
• What is the availability of staple foods in the marketplace and does the market remain continuously functional for these food types; and
  
  
• What are the growth monitoring practices at MCH clinics and do these clinics have the capacity to properly and accurately diagnose, treat, and follow-up cases of undernutrition and anemia?

Each of these questions will be addressed separately for the West Bank and Gaza Strip.

The NA/WBGS will, by means of accepted scientific methodology, inform the Palestinian Ministry of Health, the international and local donor community, and key public health professionals on the state of nutrition in WBGS (see Figure 1). In so doing, the findings should be used to aid in pinpointing areas for targeted interventions and for the thoughtful implementation of short and long term nutritional programs and policies. It should also serve as a baseline for ongoing nutritional surveillance and any follow-on impact studies or further nutritional assessments.

Methods

Through a competitive tendering process, Al Quds University in Jerusalem was chosen to partner with Johns Hopkins University for the household (HS) and clinic surveys (CS). Also chosen was Global Marketing Consulting Group in Ramallah for the implementation of the market survey (MS). Al Quds and Johns Hopkins faculty members jointly designed the questionnaires and jointly trained the data collectors. Likewise, Global and Johns Hopkins personnel jointly designed the MS tool. Field work was carried out under the supervision of the Palestinian partners with Johns Hopkins consultation and was subject to data quality assurance protocols. The Palestinian institutions were responsible for primary data entry, cleaning, and analysis with secondary review carried out by Al Quds University primary investigators and Johns Hopkins University faculty.

Traditionally, women and children have been the most vulnerable groups during periods of food insecurity worldwide. The HS was a representative sample of 1004 households in WBGS, equally stratified between the two regions to ensure greater precision and to reduce sampling error. The sample size was based on required levels of precision and the sampling distribution on the population figures from the official 1997 census carried out by the Palestinian Center Bureau of Statistics (PCBS) and the mid- 2002 population estimates. Clusters were randomly selected by computer from stratified units within urban, non-urban, and refugee camps in all 11 districts of the West Bank and all 5 districts of the Gaza Strip. The 1,004 households yielded 936 children between 6 and 59 months of age (485 males, 451 females) and 1,534 non-pregnant women between 15-49 years of age. The assessment's nutrition parameters included:

• Iron deficiency anemia of women and children by hemoglobin determination and classified by severity using World Health Organization (WHO) criteria;
  
  
• Acute malnutrition of children defined by the ratio of weight for height classified by severity using WHO criteria;
  
  
• Chronic malnutrition of children defined by the ratio of height for age classified by severity using WHO criteria;
  
  
• Undernutrition of women defined by the Body Mass Index (BMI), a ratio of weight for height squared; and
  
  
• Nutrient deficiencies of critical macronutrients (energy and protein) and micronutrients (iron, calcium, vitamins A and E, and folic acid - folate) by a 24 hour dietary recall on the youngest children in the household and their mothers.

Al Quds University developed the 24 hour dietary recall survey adapted for the Palestinian diet. An Al Quds 24 hour recall database of reproductive age women developed in calendar year 2000 provides a basis for comparison in nutrient consumption for this target group. The 24 hour recall for preschool aged children presented here is the first ever such body of information collected in WB/G.

The CS covered a sample of 68 clinics each of which was the most frequently visited for child growth monitoring as reported by the households in each of the clusters of the HS. Investigation of the following parameters included:

• Qualitative recognition, prevalence, and etiologies of malnutrition in the community based on interviews with senior health providers;
  
  
• Prevalence of growth monitoring and malnutrition in children less than 36 months of age by a random sample of 24 clinic records in each clinic;
  
  
• Prevalence of hemoglobin checks and anemia in children less than 30 months of age by a random sample of 24 clinic records in each clinic; and
  
  
• Capacity and adequacy of care in the clinical management and treatment of malnutrition and anemia based on interviews, on-site inspection, and a random sample of 24 children's records in each clinic.

The chart review gave an indication of how well malnutrition and anemia were "discovered" at the health care level in comparison with the HS. (Note: HS is considered the most reliable method for determining the prevalence of malnutrition and anemia in any community.)

While the household component of the NA/WBGS describes the capacity of families to provide food for their own household consumption, the market component (MS) assesses the capacity of the market to supply that food. The MS was a representative sample of 660 retailers and 140 wholesalers stratified by urban wholesale, urban retail, large village and refugee camp, and small village. Specifically, the MS examined:

• Frequencies of major disruptions in the marketplace of staple (non-luxury) food items that contribute to the nutritional intake of the population;
  
  
• Reasons for such disruptions; and
  
  
• Trends in food prices.

"Disruption" was defined as three or more days over the course of a month in which retailers and wholesalers regarded food products in a state of significant shortage (not available as usual or severely diminished in stock) and were unable to replenish them during that three day period.

Summary of Findings

A. Household Interview and Examination (HS)

A nutritional disorder or condition resulting from faulty or inadequate nutritional intake is defined as malnutrition. Acute malnutrition or wasting reflects inadequate nutrition in the short-term period immediately preceding the survey. The ratio of a child's weight to height (or in the case of an infant, weight for length) is the commonly used and most accurate indicator of wasting. Chronic malnutrition, or stunting, is an indicator of past growth failure, thus implying a state of longer term (weeks to months to years) undernutrition. Chronic malnutrition may lead to serious irreversible growth and developmental delays. The ratio of a child's height for age is the most useful indicator for chronic malnutrition.

The difference between the value for an individual and the median value of the population for the same age or height divided by the standard deviation of the population defines the Z score, the conventional statistic measured for acute and chronic malnutrition. The World Health Organization (WHO) has classified the severity of acute and chronic malnutrition based on the U.S. National Center for Health Statistics (NCHS) standards. The measure of greatest interest (and the one most commonly referred to by donor and humanitarian agencies) is that segment of the population below 2 Z score, classified as moderate (between -2 and -3 Z) and severe (below -3 Z) combined. This combination of moderate and severe is applied to both wasting and stunting and is termed global acute malnutrition (GAM) and global chronic malnutrition (GCM), respectively. Table 1 below reflects the distribution of GAM and GCM in the population of Palestinian children ages 6-59 months.

Anemia reflects a decrease in the oxygen carrying capacity of the blood due to a decrease in the mass of red blood cells. Hemoglobin, the oxygen carrying protein of red blood cells is the most useful indicator of anemia. Iron, folic acid, and dietary protein are necessary for hemoglobin and red blood cell production. Iron deficiency in particular is the leading cause of anemia worldwide. Thus, malnutrition or inadequate nutrition can lead to anemia and subsequent impaired learning and growth development (children), low birth weight infants and premature delivery (maternal anemia), fatigue and diminished physical and mental productivity (adults), and decreased immunity from infectious diseases (all ages). WHO classifies the severity of anemia by hemoglobin levels in gm/dl of blood. As in malnutrition, the widely accepted combined categories of moderate and severe, hereafter referred to as global anemia, is most commonly used as an indicator.

• Among children 6-59 months of age, the prevalence of GAM (moderate and severe acute malnutrition) is 13.3% in the Gaza Strip and 4.3% in the West Bank. As a reference, a normally nourished population below -2 Z would be 2.3%.
  
  
• A significant proportion of children are chronically malnourished (< -2 Z) with ratios in Gaza more than double those of the West Bank (17.5% and 7.9% respectively).
  
  
• In Gaza, the prevalence of GAM among low income (< 1800 NIS per month or US$ 390 per month) households was 15.0% compared to 5.0% in high income (¡Ã 1800 NIS) households; in the West Bank, the prevalence of GAM among low income households was 5.0% compared to 3.7% in high income households.
  
  
• The prevalence for global anemia among children 6-59 months of age varies little between the West Bank (20.9%) and the Gaza Strip (18.8%).

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