Don’t forget about the older people!

Global Nutrition Cluster MeetingNairobi, October 2015

Addis, 2014Copyright Inzajeano Latif

Case Study: South Sudan 2014 (inspired by an MSF blog)

• Located in one of the world’s largest swamps, for much of August, people were living knee-deep in floodwater contaminated with raw sewage. Many slept standing up, their children in their arms.

26.09.2014 Tens of thousands of people have taken refuge in a camp near Bentiu, one of several “Protection of Civilian” camps managed by the UN's mission in South Sudan and set up spontaneously after violence swept across the country last December.

Concerns for women and children …

What about the older people???

• Humanitarian Principles− Humanity− Impartiality− Neutrality− Operational independence

• Is the humanitarian world prejudiced?− Ageism− Scarcity of resources (funds)

• Ignoring a few facts:− The world is ageing− Older people have an important role in the

society

The humanitarian agenda

• “Cross cutting issues”

− People-centred issues: gender, age

− Other crossing issues: environment

− AGE MARKERS

• Accountability to population

• Sphere standards

− Protection principles

− Core standards: assessment

− SADD

− Appendix on measuring acute malnutrition…

Older people have an important role

• Carers of children

• Supporting their household

• Traditional roles− Conflict resolution− Mediation

• Less traditional roles− Activists− Peer educators− Older people associations

Older people: the invisiblevulnerable group

• The number of older people affected by crisis will grow

• They are vulnerable in disasters, conflicts, displacement situations

Yet…

not widely targeted• In needs assessments

• In funding

• In specific interventions

Are older people vulnerable to undernutrition?

YESThey need a balanced diet:• Energy• Macronutrients• Micronutrients

They have specific problems with food, that can be exacerbated in humanitarian contextsWhen they get malnourished: what happens? No access to appropriate care

Vulnerability in Health and Nutrition

• Absence or limited access to health centres• Non - availability of appropriate drugs, especially

for chronic diseases, poor quality of care for OP• No appropriate outreach or referral services

available• Vision impairment is extremely common• Disability/mobility problems• No prioritisation in health centres or food

distribution• Food provided through “general distribution” • General food ration might not be appropriate or

accessible

Problems in nutrition in emergencies

• Older people’s nutritional status is not

assessed

• Older people are not recognised as a

vulnerable group

• Guidelines and policies do not include older

people

• Health staff and NGOs are lacking expertise to

treat older people malnutrition (severe)

• Donors are reluctant to fund nutrition

interventions targeting them

There is a huge data gap

But now, the method for assessing the need exists

RAM-OPRapid assessment method

for older people

A cheap, robust, multisectoral assessment method

Rapid Assessment Method for Older People: RAM-OP

• Comprehensive assessment of the needs of older people

• Prevalence of malnutrition in older people, but also a whole range of indicators, most of them age-specific

• Rapid: sample size 192

• Final product includes:– A users’ manual– A questionnaire (using OpenOffice)– A data entry file (using EpiData Entry)– A data analysis file, to be used on R (free software

elaborated by a team from Oxford)

Rapid Assessment Method for Older People: RAM-OP

• Nutrition/ Food security indicators:• GAM, MAM, SAM (MUAC-based criteria)

• Dietary diversity and meal frequency

• Age-specific micronutrients intake (eg Vit B)

• Hunger scale

• Coverage of food rations

• Health and mental health indicators

• Disability and impairment indicators

• Socio-economic indicators

•WASH

Rapid Assessment Method for Older People: RAM-OP

• Sample size: 192 older people, in 16 clusters (or PSUs) of 12

• Sampling method: double-stage sampling:• First stage: sampling the 16 clusters/PSUs:

systematic sampling, 2 possibilities:• List-based: Communities are selected systematically from a

complete list of communities in the survey area.

• Map-based: Communities are selected from the centres of the squares of a grid drawn over a map (Centric systematic area sample: CSAS sample)

• Second stage: sampling of households• random walk method if the houses are grouped in a cluster

• systematic sampling if the houses are forming a line (or ribbon)

Rapid Assessment Method for Older People: RAM-OP

• 3 or 4 teams of 2 enumerators, plus 1 data-entry clerk, plus supervisors

•The survey will take maximum 4 days with 4 teams, or 6 days with 3 teams

•Training: 1 week

•Data analysis: immediate, by linking the data entry file and the analysis software:• Tables

• Graphs

RAM-OP: extract of results’ table

AnthropometryALL MALES FEMALES

INDICATORTYPE EST LCL UCL EST LCL UCL EST LCL UCLMUAC (mm)Mean 269.9141 261.9576 277.7307 262.4544 253.9382 271.1736 275.2209 265.0165 285.9474Global acute malnutrition : GAMProportion 0.0301 0.0043 0.0648 0.0084 0 0.0292 0.0405 0.0006 0.0838Moderate acute malnutrition : MAMProportion 0.0296 0.0042 0.0647 0.0084 0 0.0292 0.0379 0 0.082Severe acute malnutrition : SAMProportion 0.0001 0 0.0036 0 0 0.0004 0.0016 0 0.0121

RAM-OP: example of graph

Rapid Assessment Method for Older People: RAM-OP

•Partners: Brixton HealthVALID Internationaldonor: HIF

•Launching RAM-OP: 25 November 2015

•RAM-OP dissemination workshop: London 7 December

•Webinar in December (date tbc)

There are other bottlenecks than the data gap

• Lack of awareness

• Lack of capacities

• Lack of consensus on how to manage the issue of older people’s malnutrition

• Inadequacy of some national policies and guidelines

• UNICEF, WFP and many INGOs’ mandate

Case Study: South Sudan 2014HelpAge assessment POC Juba

• No assessment of older people’s nutritional status: the vicious circle

• Difficulties to obtain an acknowledgement of their vulnerability: vs pregnant or lactating women

• Reluctance to include them in the SRP or cluster’s objectives: risk of not meeting the objectives

• No national policy

• UN agencies reluctant to provide the specialised foods to treat malnutrition in older people: the problem of their “mandate”

• No expertise within national and international humanitarian actors on the treatment of older people’s malnutrition

• No inclusion in the NIE training

HelpAge assessment POC JubaApril 2015, People aged 55+, MUAC-based criteria

Other contexts…

• Results of 2 nutrition surveys: people ≥60• Dadaab 2011: GAM 4.63 per cent (95% CI=3.3 ; 6.0)

• Chad 2012: GAM 6.1 per cent (95% CI = 4.0 ; 9.1)

• Risk factors in Dadaab linked with food intake: not included in general food distribution, low diet diversity, low meal frequency

• Risk factors in Chad linked with health status: being very old, being bedridden, having a low score of ADL, having disabilities (poor eyesight or hearing)

Nutrition interventions for older people

• Assess the food situation of older people

• General food ration

• Availability of food in the household, in the market

• Hunger scale, dietary diversity

• Assess the nutritional status of older people:

MUAC

• Prevent and treat acute malnutrition:

CMAM

• Prevent and treat micronutrient deficiencies • Vitamin B, Vitamin D and calcium

• iron

Nutrition interventions

Assess the nutritional status of older people:

MUAC I ndicator &ODVVLILFDWLRQ

MUAC ≥210mm Normal

185mm≤

MUAC <210mmModerate acute

undernutrition

MUAC <185mmSevere acute

undernutrition

Oedema

Medical complication

Possible severe acute undernutrition

Nutrition interventions

Plan nutrition interventions for older peopleIndicator Classification Course of action

MUAC ≥210mm NormalScreen again within 30 days

185mm≤

MUAC <210mmModerate acute undernutrition

Refer to supplementary feeding programme (SFP) and follow up

MUAC <185mmSevere acute undernutrition

Refer to therapeutic feeding programme (TFP) for clinical screening and follow up

OedemaMedical complication

Possible severe acute undernutrition

Need medical check up

Refer to medical consultation, potentially to TFP and follow up

Key messages: What do we need?

• Need for more evidence and more advocacy on older people’s vulnerability in humanitarian situations• Need for collecting and analysing SADD in all

humanitarian needs assessments (as recommended by Sphere, OCHA, IASC, and most guidance material)• Need to include older people in the

humanitarian response, from assessment to implementation…• Need to systematically include nutrition

interventions for older people in the NIE training

What can we do as GNC members?

• Assess nutritional status more systematically

• Include older people in the clusters’ objectives

• Build capacity within the GNC and its members

• ……

THANK YOU FOR YOUR ATTENTION!http://www.helpage.org

HelpAge guidelines available at http://www.helpage.org/resources/practical-guidelines/emergency-guidelines

Godana Guyo Duba, 80 Ethiopia 2011Erna Mentesnot-Hintz, HelpAge International