An investigation of anthropometric training by NGOs

By Naomi Tilley

Naomi has just completed her MSc in Public Health Nutrition at the LSHTM. A qualified nurse, she has previously worked with MSF in Ethiopia and Sudan.

A recent cross-sectional study reported in Field Exchange¹ investigated weighing scales used in emergency nutrition programmes specifically for infants less than six months old. The purpose of the study was to see which type of scale was used in emergency nutrition programmes and the type of scale that would be most appropriate. In response to the deficiencies identified, the University of Southampton is developing weighing scales for field conditions suitable for children 0-5 years. While this will improve capacity to assess young infants accurately and precisely, this outcome will also depend on the competency of the measurer. If the staff that are undertaking the anthropometric measurements have limited training and standardization, the measurement error could continue to be significant.

MUAC measurement in Malawi

The aim of this project² was to investigate anthropometric measurement training in nutrition programmes. The main objectives were:

• To investigate the level, depth and frequency of training provided by a sample of nongovernmental organizations (NGOs) in weight, height and mid upper arm circumference (MUAC) measurement for staff in emergency nutrition programmes.
• To analyse and evaluate the anthropometric measurement training guides and methods used by a sample of NGOs.
• To explore methods of standardising training for field staff in emergency nutrition programmes.

Methodology

A literature review was undertaken to look at anthropometric measurement error, training and standardisation methods that have been employed in emergency nutrition programmes. Staff and students at LSHTM who had previously worked for a NGO in a nutritional intervention capacity were solicited to be involved in the study and recruitment emails were targeted at international NGOs and to contacts supplied by the Emergency Nutrition Network (ENN). Both self-administered and interview-administered questionnaires were used.

Participants were split into three categories:

• National nursing or nutritional staff working within a nutrition programme.
• Nursing or nutritional supervisors (national or expatriate) working within a nutritional programme.
• Nutritional or medical coordinators or advisors to the nutrition programmes

One questionnaire was devised for each of the three categories of interviewee. The questionnaire was pilot tested by five individuals with experience in nutritional interventions.

Fourteen nutrition and anthropometric measurement manuals were tested for:

• Readability
• Clarity of instructions/explanation
• Clarity and depth of diagrams

The Flesch/Flesch-Kincaid Readability Tests were used to measure how difficult a pasage of text was to read and what level of education would be needed to comprehend the text (American grading converted to age in years) Clarity of instruction was assessed according to defined criteria and scored (1-3). Diagrams were also scored 1 (clear diagram present), 2 (diagram present) and 3 (no diagram).

Participants

Thirty-two individuals participated in the study (91% response rate). Countries represented included Somalia, Ethiopia, Niger, Malawi, Zimbabwe, and Uganda. The participants worked for a variety of NGOs including Samaritans' Purses, Medecins sans Frontieres (MSF) Holland, MSF UK, MSF France and MSF Spain, Concern Worldwide, Valid International, Action Contre la Faim (Spain, UK and USA offices), Save the Children UK and Medecins du Monde.

The limitations of the study included:

• Small sample size
• High proportion of the nursing and nutritional staff having a good level of English and computer skills
• Some of the participants required translation of the questionnaire. This process introduces an element of error.
• There were discrepancies between the two readability scores used to measure the manuals.

Results

Questionnaires

Of the 32 study participants, 94% had received anthropometric training. Five respondents (16%) had received only theoretical training from reading a book or listening to a lecture. One fifth (20%) of the supervisors have not received anthropometric measurement training in the last 5 years.

In general, national staff received longer anthropometric training - 87% reported training of 2 or more days, compared to 7% and 10% of coordinator/advisors and supervisors respectively. Over half (55%) of the national staff were trained by the nursing or nutritional supervisor.

Twenty two percent of the trainings received did not include infants less than 6 months and adult assessment.

Ten of the 13 medical / nutritional coordinator or advisors had been actively involved in training nursing or nutritional staff within a nutritional programme. One third (33%) of the coordinator/ advisor participants described the training at the project sites as "very good".

Of the nursing and nutritional supervisors, 64% were content with the anthropometric measurement training they received. Half of the 36% of participants who were unhappy with the training received attributed this to a lack of practical training and experience. Recurring issues regarding anthropometric measurements/training reported by nursing and nutritional supervisors included:

• Undertaking MUAC on infants under 6 months
• Staff becoming tired and bored causing sloppy measurements
• Inconsistent clothing removal and positioning of individual
• Calculation and number problems
• Problems distinguishing between calibration and zeroing of scales
• Concept of eye level for Salter scales
• Time of day the measurement is undertaken
• When to measure length or height
• Scales not accurate enough to measure infants
• Too many different MUAC tapes that can be confusing to read.

Calibration

Half (50%) of the supervisors said calibration of the weighing scales occurred every time the scales were used, 25% said calibration occurred monthly and 12.5% said calibration never occurred. A quarter of nursing / nutritional staff had never calibrated, whilst three-quarters reported calibration with each use³. However over half (63%) of the supervisors highlighted calibration as an area of concern with little consistency of calibration or zeroing in the project sites.

Perceived competency

While 88% of national nursing and nutritional staff said they felt very competent at undertaking weight measurement for children aged between 6 months and 5 years, this fell to 29% for infants less than 6 months. The majority (86%) of participants said they were 'very competent' at measuring height, while a lower proportion (71%) felt 'very competent' at measuring length.

The study identified some confusion amongst participants on when to measure height and length (75cm v 85cm cut off).

Policy on training

Two-thirds (67%) of participants said there was no agency recommendation for the frequency of training, while 17% of participants said that training depended on a number of variables, namely:

• Undertaken before every nutrition survey
• Depending on the motivation of the trainer
• Depending on the need of the project and context
• On induction for new staff members.

When asked about refresher training, 11% of the participants said it occurred prior to the surveys or randomly rather than routinely.

Evaluation of training manuals

Most of the manuals scored '1' in clarity, i.e. the anthropometric measurement instructions were clear and broken down into a step-by-step process. Overall, nearly half (46%) of the participants said the manuals were "very good", because the manuals were clear, comprehensive, user friendly and complete. One third (33%) of respondents considered the manuals were "OK", describing them as not stimulating or interactive and too focused on the 6 - 59 months age bracket. This report varied between the three groups - three quarters (75%) of the nursing and nutrition staff said the manuals provided by the NGOS were very good, compared with only one third (33%) of supervisors. One fifth (19%) of the supervisors and advisors/coordinators said the manuals were not good. For the manuals to be more engaging participants suggested the diagrams needed to be updated and a training CD should accompany the manual.

The average readability score of those manuals assessed was rated 60, which is considered consistent with average readability. With a score of 84, the Sudan Nutrition Manual had the highest readability score, which indicated it was 'easy' to read. The World Health Organisations' The Management of Nutrition in Major Emergencies8 and Valid International's Community Based Therapeutic Care (CTC); A Field Manual had the lowest readability score of 34, which indicated they were 'difficult' to read.

The average number of years of education required to read the manuals was 12. This indicates that most of these manuals would not be ideal for staff that have a limited education or are reading in a second language. The Sudan Nutrition Manual required the lowest level of education, as individuals only needed 5 years of education to be able to understand the manual. The most difficult manuals required over 13 years of education to understand them.

There appeared to be no recommended frequency of calibration or clarity between the use of calibration and zeroing in the anthropometric measurement manuals.

Some of the coordinators and supervisors said interactive training tools would help reduce their burden of work. Standardising training plans would ensure that all the important topics are covered in the training.

Recommendations

The following recommendations will hopefully reduce the irregularities in anthropometric measurement in emergency programming:

• Universal anthropometric measurement training policies which standardise training frequency, cali bration, cut off points for length and height measurements, standardisation strategy and population age groups which are focused on in the training.
• Availability of interactive training tools and session plans, with updated diagrams and instruction that can be adapted by the facilitator to the project context.
• Training that includes all population groups including infants under 6 months and adults.
• Standardised MUAC tape with colours.

The following issues are suggested areas to concentrate on in the anthropometric measurement training:

• Allow increased time for practical training.
• Measurement training includes all population groups.
• Guidance on clothes removal that is context specific.
• When to use lying and standing length/height measurements.
• Involving parents when measuring smaller children and infants.
• Calibration and zeroing and when they should be used.
• Standardisation sessions.
• Storage, maintenance and setting up of equipment.
• Importance of accuracy and precision.
• MUAC training.

This study has highlighted some of the problems that the participants faced with regards to anthropometric measurement and training and will hopefully provoke further thought and discussion on anthropometric measurement training.

For further information or to obtain the project report, contact: Naomi Tilley, email: naomitilley@hotmail.com

¹Field Exchange 29. Dec 2006. Angood C. Weighing scales for young infants. A survey of relief workers.

²Investigation into Anthropometric Measurement Training in Emergency Nutrition Programmes. LSHTM. Report of a project submitted in part fulfillment of the regulations for the degree of Master of Science in the Faculty of Medicine, University of London. August 2007.

³The study findings suggested that there was confusion amongst respondents on the difference between calibration and zeroing. The high reported calibration is likely a reflection of this.