The Metrics module provides solutions to questions on what indicators to measure and how they can be measured.

We offer services on 1) indicators development; 2) assessment design; and, 3) assessment implementation.

These services leverage Valid International's experience and expertise drawn from a long history of innovation that includes the development of indicators and methods for the assessment of coverage of community-based management of acute malnutrition (CMAM), highly-scalable spatial survey methods that can be used to measure and map multiple indicators and assessment methods that utilise small sample sizes and can be implemented rapidly and repeatedly over time across a wide range of indicators.

CMAM coverage

Valid International is a pioneer in the development of coverage assessment metrics and methods for CMAM. Increasing numbers of organisations have used these metrics and methods to assess the coverage of selective feeding programmes they implement or support.


Centric Systematic Area Sampling or CSAS was developed in 2002 and was initially used to test and reform the community-based therapeutic care or CTC model of service delivery, later referred to as community-based management of acute malnutrition (CMAM) or integrated management of acute malnutrition (IMAM). Since then it has been used as an evaluation tool but has proved too resource-intensive to be used for routine monitoring. Although largely superseded in this area by the less resource intense SQUEAC and SLEAC, CSAS is still an effective method for estimating and mapping coverage with useful precision and can be used by teams


Semi-quantitative evaluation of access and coverage (SQUEAC) is a method that provides an in-depth analysis of barriers and boosters to coverage. It is designed for use as a regular service monitoring tool through the intelligent use of routine monitoring data complemented by other relevant data that are collected on a “little and often” basis.   Design SQUEAC is more an investigation than a survey. SQUEAC is made up of three stages: Stage 1: Semi-quantitative investigation into factors affecting coverage. This is carried out using the SQUEAC toolkit, which is a set of simple and rapid tools and methods for collecting


Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage or SLEAC is a rapid low-resource survey method that classifies coverage at the service delivery unit (SDU) level. The SDU may be a health centre catchment area, commune, or district. A SLEAC survey identifies the category of coverage (e.g. “low”, “moderate” or “high”) achieved by the service delivery unit being assessed. The advantage of this approach is that relatively small sample sizes (e.g. n ≤ 40) are required in order to make an accurate and reliable classification. SLEAC can also estimate coverage over several service delivery units and is suited

CMAM coverage at scale

The adoption of the CMAM model at national levels has led to the need for methods that can provide information about coverage over wide areas. This need is being met by adaptations of the SLEAC method and also by the Simple Spatial Survey Method (S3M): an adaptation of the CSAS method but with improved spatial sampling and a more efficient use of data.


Beyond CMAM and coverage

Valid International's innovation on CMAM coverage continue with recent contributions to refining and optimising of CMAM coverage indicators, developing new approaches of coverage barriers and boosters investigation, and reviewing the SAM case-finding methods used in coverage surveys (soon to be published). But, the innovation work on indicators development, assessment design and implementation has grown and evolved beyond CMAM and beyond coverage.

Using the same set of methods described above, we have expanded their application to assess coverage of programmes other than CMAM such as targeted supplementary feeding, complementary food supplementation, and food-based prevention of moderate acute malnutrition to name a few.

We have also innovated and developed key health and nutrition and related indicators other than coverage such as the use of the infant and child feeding index (ICFI) and the adaptation of the multi-dimensional poverty index (MPI) as a corollary measure of health and nutrition risk and vulnerability. We have also developed a set of health and nutrition indicators specific for older people.

National Multi-indicator S3M in Sudan

“The S3M survey is a gold mine of credible data on child malnutrition and its underlying causes. Up to now, Sudan has only had general data on the nutritional status of its children – and we know that national and even state level averages often mask disparities at lower levels. Up-to-date, reliable data are indispensable to realize the right of every child in Sudan. With these new survey results, we know exactly where the pockets of high need are located, so investment can be tailored to make sure that every single child in need is reached.”

Geert Cappelaere UNICEF Representative in Sudan, January 2014
sudanS3M-front-smallS3M was conducted in all 18 states of Sudan by the Federal Ministry of Health and UNICEF with technical support from Valid International and funding from DFID in June 2013 up to November 2013. S3M was used to obtain data for basic health, WASH and nutrition indicators (a total of 59 indicators) for small areas (at sub-locality level) of about 187 sq km. Such data would allow for mapping of indicator results to show geographical areas of highest need and 'hot-spots' which in turn would enable better targeting of existing interventions and will inform programm expansion.

SQUEAC investigation into barriers to prevention of chronic malnutrition in Kambia District, Sierra Leone

blockagesSierraLeoneSmallMaking progress on malnutrition in Sierra Leone

Using SQUEAC as a framework of investigation, Valid International together with Focus1000 under the Secure Livelihoods Research Consortium (SLRC) led by the Overseas Development Institute (ODI) conducted a study into the barriers to preventing chronic malnutrition in Kambia District, Sierra Leone and to assess and evaluate access to and coverage (uptake) of initiatives established by MoHS and other partners to improve nutrition of women and children.

The study found that the issues causing malnutrition are both multifactorial and complex, suggesting a range of initiatives are needed in order to prevent it. Many of these initiatives already exist at community level, but they require strengthening and expansion. The evidence also suggests that, in order to achieve sustained behaviour change at the local level, there is a need to target key decision-makers within the household, such as fathers and elders, and to engage seriously with traditional practices.


Impact evaluation of Empowering New Generations to Improve Nutrition and Economic Opportunities (ENGINE) in Ethiopia

ENGINE supports the Government of Ethiopia’s efforts to improve the nutritional status of women and young children. The ENGINE program provides nutrition and health services to 3.1 million children under the age of five, half a million pregnant and lactating women and 3.2 million women of reproductive age in 100 woredas in the Amhara, Tigray, Oromia, and SNNP regions. The ENGINE program also provides nutrition services to 2.7 million households participating in agricultural and livelihood programs sponsored by USAID. In addition, ENGINE provides nutrition and health services for women and children in the rural areas who are infected and affected by HIV/AIDS through partial funding provided by the President’s Emergency Plan for AIDS Relief (PEPFAR). The ENGINE program is designed to break the cycle of malnutrition, an underlying factor for more than fifty percent of all child deaths in Ethiopia, resulting mainly from the poor nutritional status of women before and during pregnancy.

USAID’s lead partner, Save the Children, is implementing ENGINE in cooperation with the Feinstein International Center and the Friedman School of Nutrition Science and Policy at Tufts University, Jhpiego, Johns Hopkins University Center for Communications Programs, Land O’ Lakes Inc., and Valid International.

Rapid Assessment Method

The accurate, reliable and rapid measurement of health, nutrition and other related indicators in a humanitarian emergency setting is critical for appropriate health and nutrition programming. Programming that is designed based on robust and timely assessments is more likely to ensure emergency response targets the most vulnerable with appropriate life-saving activities that achieve maximum positive impact on health and nutrition outcomes in humanitarian crises. Currently, the Standardized Monitoring and Assessment of Relief and Transitions or SMART is the commonly-used method-of-choice for rapid assessment of health and nutrition in emergencies. It is used mainly to define areas of need and to guide the allocation of resources. SMART and other existing nutrition survey methods mostly commonly use cluster sampling methods and suffer from a number of limitations as documented in global nutrition cluster guidance: 1) accurate population data is needed to list the population in villages or population units. This may not be available in an emergency; 2) the data cannot be disaggregated to produce statistically reliable results for geographical sub-samples when cluster sampling is used; 3) surveys are time- and resource-consuming, but are often necessary to assess the anthropometric situation with accuracy; 4) mobile and pastoral populations are difficult to assess because they do not easily form an identifiable cluster with sufficient children to be measured; 5) sampling is especially challenging in big towns, particularly when clusters represent a large number of households and where households are aggregated, such as in buildings; and, 6) interpreting results of anthropometric nutrition surveys in relation to contextual factors and interventions is not straightforward and requires a wealth of information including food security and public health.

Valid International wanted to address these issues and limitations by developing a quick, simple, and low- cost method for estimating the prevalence of global acute malnutrition within acceptable precision plus a reasonable set of additional indicators relevant to emergencies that allow for the establishment of an evidence-base to support planning and decision-making in emergencies. This has brought about the development of rapid assessment method or RAM.

Rapid Assessment Method for Older People

When disasters strike, older people are frequently neglected, especially when it comes to nutrition. Humanitarian actors tend to focus their activities on children and women of childbearing age, not taking into account or addressing the nuances and specific needs of older people.

Older people’s needs are quite specific. When it comes to food and nutrition, they may find relief rations are inappropriate to their tastes, have problem digesting or chewing food or they may simply not be able to reach distributions or transport the goods home once there. The end result is that older people are at great risk of malnutrition in humanitarian contexts. However, their specific needs are rarely assessed.

The Rapid Assessment Method for Older People (RAM-OP) is a solution to fill this data gap. It is a thorough, quick, simple, low-cost tool that allows humanitarian and development workers to obtain valuable information on older people specific needs, including their nutritional status, through a house to house survey.