The role of qualitative methodologies in nutritional surveillance.
The objectives of nutritional surveillance were published in 1976 by the World Health Organization and subsequently elaborated upon by the Cornell Nutritional Surveillance Program (CNSP) in 1984. The uses of nutritional surveillance are: 1) problem identification and political sensitization; 2) policy formulation and planning; 3) program management and evaluation; and 4) timely warning and intervention. The vast majority of countries embarking on nutritional surveillance did so without having performed the prior steps of identifying decision-makers and the type of surveillance systems required. The most common type was nutritional monitoring, which could not facilitate decisions on immediate action. Ancillary data were adequate only for confirming that locations with a high prevalence of protein-energy malnutrition (PEM) also have a high prevalence of socioeconomic deprivation without pinpointing specific factors. Rapid assessment procedures (RAP) face similar problems, which could be improved by the development of guidelines. Another reason for linking qualitative methodologies to nutritional surveillance is that the infectious disease model of surveillance is not the most appropriate one for nutritional surveillance because of the complex etiology of chronic PEM. Timely warning and intervention systems (TWIS) are relevant in warding off possible food crises, as the case of Central Lombok District of Indonesia illustrated. Qualitative information methods were used in collecting agro-meteorological indicators by extension workers; assessing household food consumption patterns; alerting of district officials to an impending food crisis; and evaluating the extent to which this system triggered decisions. Nutritional surveillance for policy and planning is difficult to implement, as the examples of Costa Rica and Kenya showed. In the former, a national sample survey of low-weight-for-age children stratified according to father's occupation revealed the highest rate of malnutrition in sugar cane and banana plantations because of poor water and high food prices. This finding led to legislative action.