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Famine in the Horn of Africa Over the Last Decade. Paul B Spiegel MD, MPH 1 Peter Salama MBBS, MPH 2 Susan Maloney MD, MPH 1 Albertien van der Veen, MSc 3 1 CDC , 2 UNICEF, 3 WHO. Somalia 1991-92: Background.

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Famine in the Horn of Africa Over the Last Decade

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Famine in the Horn of AfricaOver the Last Decade

Paul B Spiegel MD, MPH1

Peter Salama MBBS, MPH2

Susan Maloney MD, MPH1

Albertien van der Veen, MSc3

1 CDC, 2 UNICEF, 3 WHO


Somalia 1991-92: Background

  • Drought, civil unrest, collapse of government, destroyed infrastructure led to many deaths among Somalis during 1992

  • Difficult to provide aid due to insecurity

  • In absence of health care infrastructure, health status of population described through epidemiological studies which influenced how aid was provided


Somalia 1991-92 : Results

  • 23 surveys evaluated which had defined pop. and apparent systematic methodology*

    • Extensive methodological differences

    • 12 (52%) not reproducible

    • Units of measurement and denominator estimates inconsistent

    • 8 of 16 (50%) surveys examining mortality assessed cause of death

* Boss, L. P., Toole, M. J., and Yip, R. Assessments of mortality, morbidity, and nutritional status in Somalia during the 1991-1992 famine. Recommendations for standardization of methods. JAMA. 1994: 272(5); 371-6.


Somalia 1991-92: Results cont

  • 0 of 11 surveys examining morbidity provided case-definitions

  • Of 16 surveys examining nutritional status, variety of definitions of malnutr. and measurement methods used

    • 3 (19%) - MUAC only

    • 10 (63%) - Referenced wt/ht data using % of reference of median

    • 4 (25%) - Presented data using z-scores


Somalia 1991-92: Recommendations

  • Define clear study objectives

  • Use standard sampling and data collection methods

  • Ensure precise written documentation of objectives, methods, and results


Ethiopia 1999-2000: Background

  • Ethiopia subject to recurrent drought and food insecurity exacerbated by civil strife

    • Crises generally involve massive excess mortality and population displacement without formation of discrete camps

  • Prior to crisis of 1999-2000, eastern and southern regions of Ethiopia subject to 3 successive years of drought


Ethiopia 1999-2000: Background cont

  • Beginning in 1999, data from early warning systems in many regions of Ethiopia indicated rapidly deteriorating food security and nutrition situation

  • More than 10 million people estimated to need food assistance during peak of crisis in early 2000


Ethiopia 1999-2000: Mission

  • Members of IERHB/CDC seconded to UNICEF as Nutrition Technical Advisors June-Sept. 2000 at request of OFDA

  • Terms of Reference:

    • Co-ordinate and identify gaps

    • Provide technical assistance

  • WHO sent Nutritionist with whom we collaborated closely


Regions of Ethiopia

Region


Zone

UNDP


WFP Cereal Allocation in April 2002 vs. Requirements by Woreda


<5 Nutrition Surveys in Ethiopia, Jan.-Jun. 2000

Global Acute Malnutrition (GAM)

0-9%

10-19%

20-29%

30-39%

40+%

N=38


Ethiopia 1999-2000: Evaluation

  • Evaluated 125 nutrition surveys from Nov. 1998-Jun. 2000 by 14 different NGOs

    • RHA*: 16 (13%)

    • Cluster: 109 (87%)

      • 42 surveys part of early warning system with different aim and cluster methodology

      • 67 surveys were “intended” to provide useful data to direct programs

    • Only 5 surveys (4%) recorded measles vaccination coverage

* RHA= rapid health assessments using convenience samples


Evaluation of “Intentional” Surveys

  • Valid (i.e. representative):

    • >30 clusters

    • PPS

      and

  • Precise:

    • >10 children per cluster

1. Binkin N, Sullivan K, Staehling N, Nieburg P. Rapid Nutrition Surveys: How many clusters are enough? Disasters 1995; 16:97-103.

2. Sullivan KM. The effect of sample size on validity and precision in probability proportionate to size cluster surveys, Society of Epidemiologic Research, Utah, 1995


Categorization of Cluster Surveys (N=25)

No. of Clusters

No. of Children /Cluster


Valid and Precise Cluster Surveys7 of 67 (10.5%)

No. of Clusters

No. of Children /Cluster


<5 Nutrition Surveys in Ethiopia, Jan.-Jun. 2000

Global Acute Malnutrition (GAM)

0-9%

10-19%

20-29%

30-39%

40+%

N=38


<5 Nutrition Surveys in Ethiopia: Jan-Jun 2000

Global Acute Malnutrition (GAM)

0-9%

10-19%

20-29%

30-39%

40+%

Valid and Precise: N=2 (5.3%)


USAID Funding for Ethiopia 1999/2000

1999 2000

Development Assistance

Food $ 32,264,600$ 36,200,741

Non-food $ 38,214,000$ 42,677,000

Total $ 70,478,600 $ 78,877,741

Humanitarian Assistance

Food $288,968,022$ 82,956,723

Non-food $ 11,740,022$ 1,350,700

Total $300,708,022 $163,185,164

Grand Total $371,186,622 $163,185,164

Source: USAID Ethiopia office 9-01


Problems with Surveys

  • Methodology

    • Sample size inadequate (clusters and/or children)

    • Non-probabilistic sampling

      • Not proportional to population size

      • Targeting of drought-affected areas within woreda

      • Choosing children most malnourished

    • Always include measles vaccination coverage


Problems with Surveys cont

B. Survey Analysis:

  • Nutrition indicators (ER setting)

    • Wt/Ht z-scores for children <5yrs

    • 95% CIs using C-sample in EpiInfo

    • Ensure include edema as cases of severe malnutr.

  • Measles Immunization coverage

    • Report % recorded on imm. card vs. verbal+card


Problems with Surveys cont

C. Survey Reporting:

  • State objectives and detailed methodology

  • State results clearly with units, including:

    • Sample size and number of clusters

    • Number of household refusals or absences

    • 95% confidence intervals (+/- DEFF)

  • Interpret results and compare to baseline data or data from previous surveys if available

  • Make recommendations (underlying causes)


Recommendations

Options for NGOs:

  • ?Make sampling methodology simpler

  • Improve training manuals

  • Ensure field staff appropriately trained

  • Send “HQ staff” to do surveys

  • Co-ordinate with 1-2 “survey NGOs” in field

  • Provide survey form templates with programs for data analysis


Recommendations cont

Options for policymakers/donors:

  • Be wary of data/reports provided by NGOs

  • Have technical persons available (in country vs. contactable elsewhere) to interpret surveys

  • Field personnel appropriately trained who make decisions based on survey results


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