May 2021 Issue 65 ISSN 1743-5080 (print)

Special
section on
COVID-19
nutrition
programming
Nutrition SMART Large scale food Calculating Streamlining
villages INDIA & fortification people in need national SMART
BANGLADESH HAITI AFGHANISTAN surveys KENYA
 Contents ...............................................................
54 Adapting infant and young child feeding 72 Post-discharge interventions for children
3 Editorial interventions in the context of COVID-19 hospitalised with severe acute malnutrition
in Somalia 72 Conceptual framework of food systems for
News 57 Infant and young child feeding in
emergencies: Programming adaptation in
children and adolescents
73 Fortified blended flour supplements displace
5 Statement of Commitment on Climate by the context of COVID-19 in Lebanon plain cereals in feeding of young children
Humanitarian Organisations 60 Adaptations to SMART surveys in the context 73 Effectiveness of breastfeeding support
5 UNICEF Nutrition Strategy 2020-2030 of COVID-19 in Cox’s Bazar, Bangladesh packages in low- and middle-income
6 CMAM programmes: A handbook to analyse countries for infants under six months
cost-effectiveness
Research Snapshots
6 Frequently asked questions on COVID-19
vaccines and breastfeeding 64 The burden of malnutrition and fatal Research Summaries
COVID-19: A global burden of disease 74 Impact of maternal mental health on recovery
6 Food Systems Summit 2021 analysis from severe acute malnutrition in Malawi
7 Community-based management of acute 64 Improving complementary feeding
malnutrition (CMAM) Conference 2021 76 Response to malnutrition treatment in low
practices through smartphone-based weight-for-age children: secondary analyses
8 The launch of the Healthy Mothers Healthy maternal education in Iran
of ComPAS trial data
Babies Consortium 65 Misalignment of global COVID-19 77 Commentary on the implications of this
8 Within our grasp: Childhood malnutrition breastfeeding and newborn care
analysis from the perspective of the ENN
worldwide and the revolution taking place guidelines with World Health Organization
wasting and stunting (WaSt) project
to end it recommendations
78 Transforming food systems to improve diet
8 Launch of the Nutrition Year of Action 65 The Lancet Series on Maternal and Child
affordability: Fill the Nutrient Gap analysis
9 Infant and young child feeding in Undernutrition Progress
in Burkina Faso
emergencies programming in the context 66 Sustainability evaluation of a national
80 The No Wasted Lives Research Agenda -
of COVID-19: learnings from a webinar series infant and young child feeding programme
Revisited
in Bangladesh and Vietnam
10 Launch of the MAMI Care Pathway 81 Seasonality of acute malnutrition and its
66 Nutrition data use and needs: Findings
drivers: a case study from eastern Chad
from an online survey of global nutrition
Views stakeholders 84 Scale-up of severe wasting management
within the health system: A stakeholder
11 Kwashiorkor – reflections on the ‘revisiting 67 An exploration of district-based health
perspective on current progress
the evidence’ series decision-making in West Bengal, India
14 Improving the way we address acute 67 Greater precision of interactions between
malnutrition in Africa’s drylands community health workers and household Research
members to improve maternal and
86 Link NCA offers a new opportunity to study
newborn health outcomes in India
Field Articles 68 Effect of nutrition-sensitive agriculture
drivers of concurrent wasting and stunting
(WaSt)
18 Multi-sector nutrition programming: ‘Nutrition interventions on maternal and child
89 Estimating the burden of wasting during
Smart Villages’ in Bangladesh and India nutritional outcomes in rural Odisha, India
COVID-19 based on empirical experiences in
22 In Chad, the Mother-MUAC approach (UPAVAN trial)
the Sahel
improves treatment access for 68 Biannual azithromycin distribution and
92 Use of educational videos to improve
malnourished children child mortality among malnourished
maternal breastfeeding knowledge and
children in Niger
26 Calculating wasting caseloads and geographic practices in Ethiopia
prioritisation of nutrition services in the 69 Analysis of gestational weight gain using
96 A systematic review of nutrition interventions
context of limited data in Afghanistan nationally representative data
for mobile pastoralists
30 Large-scale food fortification efforts in Haiti 69 Rates and risk factors for preterm birth
and low birthweight
33 Nutrition-sensitive WASH programming to
improve the nutritional status of women 69 Relapse and post-discharge body Report Summaries
and children in Nepal composition of children treated for acute 100 Asia and the Pacific Regional Overview of
malnutrition using a simplified, combined Food Security and Nutrition
38 Streamlining SMART survey processes in
protocol
support of a high quality, nationally owned 100 The effects of food systems interventions on
nutrition information system in Kenya 70 The importance of food systems and the food security and nutrition outcomes in low-
environment for nutrition and middle-income countries
70 Monitoring systems for the management
Covid-19 of severe acute malnutrition programmes
101 Simplified approaches for the treatment of
child wasting: A rapid evidence review
42 Remote Integrated Phase Classification in northern Nigeria
102 Children eating well in cities: A roadmap for
during the COVID-19 pandemic: 70 Triple trouble: The triple burden of child action to support nutritious diets and
experiences from Madagascar undernutrition, micronutrient healthy environments for all children in
46 A risk communication and community deficiencies and overweight in East Asia urban settings
engagement (RCCE) response to support and the Pacific
maternal, infant and young child nutrition 71 COVID-19 pandemic and mitigation
in the context of COVID-19 in Rwanda strategies: implications for maternal and Evaluation
50 Localising food supply chains during the child health and nutrition 103 Early lessons from Swabhimaan, a multi-
COVID-19 pandemic: An example from the 71 Assessing nutrient gaps and affordability of sector integrated health and nutrition
Philippines, Move Food Initiative complementary foods programme for women and girls in India
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Field Exchange issue 65, May 2021, www.ennonline.net/fex
Editorial

© Sudharak Olwe, 2020

Women’s meetings being conducted by Poshan Sakhi
using participatory learning and action methods

Dear readers,

A
warm welcome to the 65th edition of nutrition Phase Classification (IPC) exercise for promising nutrition impact. A mid-term evaluation
Field Exchange. This edition features government – the first remote IPC to be under- of the UNICEF-supported Swabhimaan initiative
a range of programming issues that taken worldwide, while a research article from shows promising change in adolescent and ma-
unfortunately reflect that we are still Cox’s Bazar in Bangladesh describes the experi- ternal undernutrition indicators as well as improved
in the midst of the COVID-19 global pandemic. ences of adapting standard SMART methodology household food security. This programme, inte-
But, on the positive side, the experiences reflect to enable SMART surveys to be possible in the grated within the Government of India’s flagship
how the nutrition sector continues to innovate COVID-19 context. Remote innovation is also re- poverty alleviation programme, Deendayal An-
to accommodate this new reality, coming up flected in an article by GOAL where breastfeeding tyodaya Yojana-National Rural Livelihoods Mission
with new ways to ensure continuity of services videos were used to support one-to-one IYCF (DAY-NRLM), mobilises village level collectives of
whilst also ensuring pre-COVID projects and re- counselling in Ethiopia, applicable to the COVID- women and strengthens the access of women
search have continued and, in doing so, are build- 19 context but, in this instance, implemented to and adolescents to services. A field article authored
ing critical evidence. save the time of busy health workers. Rising to by Welthungerhilfe shares the implementation
the challenge of disrupted food supply chains of the ‘SMART nutrition villages’ model in 200 vil-
Given that, our edition features a special due to the COVID-19 pandemic, a team from the lages in India and Bangladesh. Again, village in-
section on COVID-19 nutrition programming Philippines describe the ‘move food’ initiative, stitutions are used as a platform to support com-
adaptations across Asia and Africa. An article where a novel non-governmental organisation- munities to plan and implement multi-sector nu-
from Rwanda describes the characteristics of an led system supported the movement of food trition activities and access government entitle-
effective risk communication and community en- from farmers to consumers during a time of re- ments. Half of the project villages showed marked
gagement strategy to address myths and mis- stricted movement, also serving to reduce food improvement in women’s and children’s dietary
conceptions around nutrition and COVID-19. Re- waste. This has proved so successful that it is set diversity and in water, sanitation and hygiene
lated to this theme of communication, two field to continue. ‘Innovations’ around COVID-19 pro- (WASH) practices but not in wasting prevalence.
articles describe adaptations made to infant and gramming are a mixed bag. Some of the COVID- A field article from Nepal describes how WASH
young child feeding (IYCF) programmes in Somalia 19 programme adaptations may be a compromise actions that were integrated across Suaahara II
and Lebanon. In both contexts, more women too far in the long term and are a temporary so- districts through local government coordination
were reached than in the year prior to COVID-19; lution until full service can be resumed. Others and capacity building demand the creation of
in Lebanon due to the use of remote communi- may be developments that were long overdue improved facilities and behaviours and engage-
cations and in Somalia due to an increased fre- but, fast-tracked by the urgency of the crisis, are ment with the private sector on supply chains.
quency of counselling meetings. The reallocation here to stay. Commitment to documenting learn- Monitoring data showed successful uptake of
of funds through flexible donor funding greatly ing on processes and outcomes remains critical some promoted WASH behaviours in both non-
enabled innovation. in order to distinguish the difference. intensive and intensive areas, with a greater
change over time in intensive areas.
Remote ways of working emerged as a feature Field Exchange features some nice examples
in several articles in this special section. A field of multi-sector programming from South Asia These three examples of multi-sector pro-
article from Madagascar highlights the experiences embedded in or supporting local government gramming show some positive directions but, in
of carrying out a remote Integrated Acute Mal- systems and services and with some signs of some instances, a lack of anticipated nutrition

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Editorial
impact, yet again reflecting the complexity of Accurate nutrition data is critical to inform originally projected). As we go to press, long
undernutrition. This is further echoed in several caseload projections, programme planning and overdue incidence correction factors for wasting
articles in this edition, including two from Tufts budgets. A field article on Nutrition Information are for imminent release by UNICEF; watch ENN’s
University that examine the multiple drives of Systems (NIS) in Kenya describes how SMART home page for updates.
undernutrition in Africa’s drylands. Young et al surveys were streamlined, harmonised and insti-
argue that there is a need for innovative inter- tutionalised under the coordination and leadership Finally, how to treat wasting at scale is a theme
disciplinary research and learning to better un- of the national Nutrition Information Technical across several articles. This was the focus of the
derstand the basic drivers in each context and Working Group. The NIS in Kenya is now ‘owned’ recent global CMAM conference hosted by Concern
for researchers, programmers and policymakers and largely funded by government, with greater Worldwide that aimed to facilitate an exchange
to engage more closely to build consensus on use of high-quality nutrition data to inform timely of evidence and experiences on CMAM scale-up
solutions. The need for ‘joined up’ thinking and nutrition and multi-sector actions. Strong gov- in fragile contexts. A background paper by ENN
action – this time across wasting and stunting – ernment leadership and coordination and a shift identified drivers and barriers to CMAM scale-up
is reflected in an article by Action Contre la Faim over time in the focus of international agencies from global and national key informants. Siloed
on the drivers of concurrent child wasting and and donors from emergency programming to a nutrition and health workforce teams, inadequate
stunting (WaSt) in Liberia. While they found the health systems strengthening approach were key investment in community health workers, the
principle driver of stunting in this context was success factors. need to streamline ready-to-use therapeutic food
limited access to markets, the drivers of WaSt (RUTF) requirements and the costs of RUTF, as
were younger child age, recent episodes of diar- The ongoing challenge of estimating people well as shorter supply chains, were also identified
rhoea, a child being taken care of by a non-im- in need in the absence of current data is reflected as crucial. Related to this, several articles are on
mediate family member and reduced coping and in an article by UNICEF Afghanistan. In this the continued ‘hot’ topic of simplified approaches
support of caregivers. The authors reflect that an instance, the team combines historical data, Sea- to wasting treatment. This includes a UNICEF
analysis of the drivers of stunting alone would sonal Food Security Assessment data and mid- review of the use of simplified approaches across
not have prompted interventions to address the upper arm circumference (MUAC) screening data 21 different countries and an article by Première
risks associated with WaSt which is associated from Health Management Information Surveys. Urgence Internationale that describes how Mother
with higher mortality. By no means coming up with a perfect or simple MUAC in a CMAM programme in Chad increased
solution, the authors describe what they are screening coverage and the proportion of severely
The global burden of micronutrient deficiencies trying in highly constrained contexts. Another wasted children admitted for treatment. The Sim-
also continues to demand collective action and longstanding information challenge is our de- plified Approaches Working Group, co-led by
innovation for scale. Working with government pendence on prevalence data for wasting which UNICEF and IRC, has also just launched a new
and the private sector, an article on the USAID- underestimates caseloads and limits trend analysis. website (https://www.simplifiedapproaches.org/)
funded RANFOSE describes how this collaboration An article by the World Food Programme describes with resources and emerging guidance on sim-
supported the government of Haiti to legislate a new mathematical model to generate an inci- plified approaches.
for food fortification and worked with private dence correction factor in six Sahelian countries
sector companies to influence manufacturing which accounted for frequent food insecurity, It takes courage but also requires care to act
practice. As a result, fortified products are now seasonal variation and COVID-19 in the region. ‘outside the box’. It is heartening to see the com-
increasingly replacing unfortified products on As suspected, this led to a higher estimated mitment and drive on simplified approaches to
the Haitian market. burden of wasted children (5.35 vs. 4.54 million treat wasting to improve service coverage, but
we must make sure we do not unnecessarily
sprint (and trip up) as we run. Evidence on
different types of ‘simplification’ is varied; for ex-
Nyiraminani Beatrice breastfeeds
baby Gael, who is just 1 month old ample, the state of evidence for rolling out Family
MUAC is at a very different stage to reduced
dosage of RUTF. We are not yet there on the
pathway to scale, but our collective narrative
does not seem to reflect that. There are still many
important unanswered questions, such as what
the implications of different types of ‘simple’
adaptations for child growth are for very young
and older children. As with the COVID-19 adap-
tations, we should not shy away from innovation
and change but be willing to take steps back as
well as forward when it is right to do so. We
should also make sure that by convening around
the latest ‘buzz areas’ we do not neglect issues to
which our attention is overdue, a reminder prompt-
ed by a views piece by Fitzpatrick et al that calls
for greater investment in research to understand
the aetiology, pathophysiology and burden of
kwashiorkor.

As always, your experiences spark great dis-

cussions amongst the ENN team. Share your
©UNICEF/UNI354877/Kanobana

thoughts with us – letters to the editor always

welcome.

Nicki, Chloe, Marie

Field Exchange editorial team

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 News ...........................................................................
C
Statement of limate change and the resulting envi- on the anticipated focus of the COP 26 (taking
ronmental effects are having a place in 2021) and conscious of each agency’s
Commitment profound impact on the world’s
people, affecting in particular the
humanitarian responsibilities, the solidarity
organisations have committed to:
on Climate by most vulnerable and poorest. Without drastic
changes to reduce greenhouse gas emissions,
1. Measure the environmental and carbon
impacts of agencies.
Humanitarian limit rises in global temperatures and restore
biodiversity, climate change emergencies will
2. Reduce the carbon footprint of agencies,
aiming to halve emissions by 2030.
Organisations likely have a major impact on future humanitar-
ian needs. The actions of humanitarian
3. Incorporate climatic and environmental risk
analysis in all areas of work and promote
organisations, as vital as they may be, can add to prevention, mitigation and adaption actions
Bangladesh this crisis as the agencies themselves generate
during floods where relevant.
environmental and climate impacts. 4. Make a positive impact on the environment
It is therefore essential that agencies adapt by reducing the negative impacts of human-
their ways of working to ensure coherence of itarian and development actions.
action, exemplarity and respect the principle of ‘do 5. Develop and identify local expertise in con-
no harm’. Agencies must also adapt to respond to nection with the Grand Bargain’s commit-
these crises, support resilience building in vulner- ments on localisation.
able populations and work to preserve and 6. Make information on progress towards these
conserve the environment. The solidarity organi- commitments public on an annual basis.
sations, made up of ACTED, The Alliance for 7. Raise awareness across all agency collaborators.
International Medical Action, CARE France, Elec- 8. Contribute to the project to develop an envi-
triciens Sans Frontieres, Groupe URD, Medecins du ronmental and climate charter for the entire
Monde, Premiere Urgence Internationale, Secours sector (currently being launched by the ICRC
© UNICEF/G.M.B. Akash/2016

Islamique France and Solidarites International, and the Red Cross).

have committed to make such changes.
More information can be found at
In line with the commitments made by coun- https://alima.ngo/en/blog/2020/12/15/state-
tries at the Conference of the Parties (COP) 21 ment-of-commitment-on-climate-by-humanit
(also known as the Paris Agreement), reflecting arian-organisations/

The Strategy reflects a number of strategic

UNICEF Nutrition shifts from previous strategies. Firstly, there is a
focus on all forms of malnutrition, including over-
Strategy 2020-2030 weight and obesity and a focus on bringing
together the prevention of both forms of under-
Report Summary1 nutrition (stunting and wasting). The UNICEF
Conceptual Framework has also been adapted to

I
reflect the broader malnutrition focus. Secondly,
n December 2020, UNICEF published its new encompasses programming for the early while maternal and child nutrition in the first
Nutrition Strategy, to guide the next ten detection and treatment of children with 1,000 days of life remains core to UNICEF pro-
years of its nutrition related activities. The wasting through facility- and community- gramming, a broader focus on nutrition in middle
strategy outlines UNICEF’s vision of ‘a world based approaches, in all contexts. childhood and adolescence is taken to break the
where all children, adolescents and women real- 5. Maternal and child nutrition in humanitarian intergenerational cycle of malnutrition. There is
ize their right to nutrition’ and highlights strategic action: which includes UNICEF’s nutrition also a deliberate emphasis on the centrality of
objectives to support governments and partners programming in emergencies, guided by nutritious, safe, affordable and sustainable diets
in ending child malnutrition in all its forms. Cen- UNICEF’s Core Commitments for Children in and the importance of the food system. More
tered around six results areas, the strategy Humanitarian Action and its commitments broadly, the strategy focusses on a multisectoral
emphasises a universal premise, that prevention as Cluster Lead Agency for Nutrition. approach to nutrition improvements as well as a
comes first, in all contexts, and if prevention fails, 6. Partnerships and governance for nutrition: greater focus on the role of the private sector to
treatment is a necessity. The result areas are: which includes programming to strengthen advocate for optimal nutrition practices. Criti-
1. Early childhood nutrition: focuses on pro- the enabling environment for nutrition cally, while the strategy has a universal vision and
gramming to prevent of all forms of malnu- through improved partnerships, data, agenda, it calls for approaches to be contextual-
trition in the first five years of life. knowledge, advocacy and financing. ized- the strategy stresses that UNICEF country
2. Nutrition in middle childhood and adolescence:
Programme priorities are outlined for each result programmes are not expected to implement all
encompasses programming to prevent of
area. Furthermore, the Strategy recognizes that in components but develop context-specific pro-
malnutrition in middle childhood (5-9 years
order to improve nutrition outcomes, a systems grammes, informed by analysis of the unique
of age) and adolescence (10-19 years of age).
approach is needed and there is a central role to determinants, drivers, potential impact pathways
3. Maternal nutrition: concentrates on preven-
tion of malnutrition programming in women be played by five systems: food social protection, and available resources in each context.
during pregnancy and breastfeeding as well as education, water & sanitation and health to deliver
the prevention of low birthweight in newborns. diets, services and practices to support adequate 1 https://www.unicef.org/media/92031/file/UNICEF%20Nutri
4. Nutrition and care for children with wasting: nutrition. Priorities for each system are outlined. tion%20Strategy%202020-2030.pdf
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News
CMAM programmes:
A handbook to analyse Food
cost-effectiveness Systems
Summit

M
ark Myatt and colleagues have pub-
lished a short handbook1 to help
This handbook provides a useful guide to CEA in the
context of CMAM programming. The handbook
2021 News Item1

guide nutrition programmers and covers the types of outcomes used in cost-effective-
monitoring and evaluation staff to ness analyses (cases treated, cases cured, deaths
perform simple cost-effectiveness analysis (CEA) for averted or disability adjusted life years averted), the
community-based management of acute malnutri- creation of counterfactuals to model the absence of

T
tion (CMAM) interventions. CEA is a way of an intervention and the building of models of pro- his year,2 the United Nations Sec-
examining the costs and health outcomes of one gramme outcomes, accounting for uncertainty. It retary-General will convene a
or more interventions. It enables comparisons also details the types of costs that need to be con- Food Systems Summit as part of
between one intervention and another (or to no sidered in CEAs, the methods and tools needed to the Decade of Action to achieve
collect and work with costs data from a variety of the Sustainable Development Goals. This
intervention) by estimating how much it costs to
sources and how to interpret cost-effectiveness esti- Summit aims to launch bold new actions to
gain a unit of a desired health outcome. Results are
mates. Examples of CEA for CMAM programmes in advocate for and accelerate a transforma-
presented as a cost-effectiveness ratio, for example
Bangladesh, Ethiopia, Kenya and Nigeria are pro- tion in the way the world produces,
cost per year of life gained, cost per case cured or
vided that give concrete illustrations of the steps to consumes and thinks about food. Five
cost per life saved, allowing comparisons between
follow and the results that may be obtained. This action tracks have been developed to facil-
interventions. Without CEA, CMAM may seem an book is now available from international booksellers.
expensive intervention. However, when the cost- itate work to meet the Food Systems
effectiveness is tested, it is usually found to be
1
Myatt, M et al (2021) A simple approach to cost-effectiveness Summit’s aims and to identify ‘game chang-
analysis of community-based management of acute malnutrition ing and systemic solutions’ for the global
cheap and effective. (CMAM) Programs. Eliva Press.
food system:
1. Ensuring access to safe and nutritious
food for all – aims to work to end all
forms of malnutrition through increas-
Frequently asked ing food availability and affordability
and reducing food access inequities.
questions on 2. Shift to sustainable consumption patterns
– aims to build consumer demand for
COVID-19 vaccines sustainably produced food, strength-
ening local value chains and promoting

and breastfeeding recycling of food resources.

3. Boost nature-positive production – aims
to realign incentives to reduce food
loss and environmental impacts and to

A
midst the COVID-19 pandemic and the optimally supported, a set of Frequently Asked support small-holder farmers across
initiation of COVID-19 vaccinations in Questions (FAQs) has been jointly developed by the the food value chain.
different countries from December IFE Core Group (www.ennonline.net/ife), UNICEF 4. Advance equitable livelihoods – aims to
2020, varied advice regarding the safety and the COVID-19 Infant Feeding Working Group contribute to the elimination of poverty
of vaccines for breastfeeding mothers has been based on the most recent WHO SAGE guidance. The by promoting employment and decent
emerging. Initially, different scientific and advisory FAQs are intended to provide answers to healthcare work across the food value chain.
groups recommended that breastfeeding mothers providers and the public, including mothers who 5. Build resilience to vulnerabilities, shocks
should not receive the vaccine or were cautious are breastfeeding or expressing milk, regarding and stress – aims to ensure the continued
about recommending it. However, from January breastfeeding and the Pfizer–BioNTech, BNT162b2, functionality of sustainable food systems
2021 onwards those recommendations changed, Moderna and AstraZeneca AZD1222 COVID-19 vac- in areas prone to conflict or natural
particularly after the issuing of the World Health cines. The FAQs are regularly updated and confirm disasters. These actions include a focus
Organisation (WHO) Strategic Advisory Group of that breastfeeding mothers should be supported on broader global challenges.
Experts on Immunization (SAGE) interim recom- to breastfeed and that they can be vaccinated Much work has already been done across
mendations for the use of the Pfizer–BioNTech when part of a high-risk group. However, the lack the action tracks, including ‘idea genera-
COVID-19 vaccine1 which clarified that breastfeed- of data available for recommending the vaccine to tion’ surveys, two public dialogues on each
ing mothers can be safely vaccinated with minimal breastfeeding women is acknowledged by WHO track and the development of discussion
risk. These WHO interim recommendations were SAGE which has called for this topic to be priori- starter papers to further drive the work for-
later followed by the interim recommendations for tised by researchers. ward. A number of food system dialogues
the use of the Moderna mRNA-1273 vaccine have also been conducted, with more
Download the FAQs from https://www.ennon-
against COVID-192 and the interim recommenda- planned in the lead up to the Food Systems
line.net/breastfeedingandcovid19vaccines
tions for use of the AZD1222 (ChAdOx1-S Summit in order to support the transforma-
[recombinant]) vaccine against COVID-19 devel- 1 https://www.who.int/publications/i/item/WHO-2019-nCoV- tion of the global food system.
oped by Oxford University and AstraZeneca.3 vaccines-SAGE_recommendation-BNT162b2-2021.1
2 https://www.who.int/publications/i/item/interim-recom
In response to the need to ensure that these rec- mendations-for-use-of-the-moderna-mrna-1273-vaccine- 1 https://www.un.org/en/food-systems-summit/about
against-covid-19 2 The tentative date for this Summit is from the 13th
ommendations are disseminated and adopted at a 3 https://www.who.int/publications/i/item/WHO-2019-nCoV- September but this is still to be finalised. A pre-Summit
country level and that breastfeeding mothers are vaccines-SAGE_recommendation-AZD1222-2021.1 gathering is planned for July 2021.
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News
Wasting affects 1 in 10
children in Mali
Community-based
management of
acute malnutrition

© UNICEF / Bourama Coulibaly

(CMAM) Conference
2021

C
oncern Worldwide and Irish Aid hosted We must continue to simplify protocols and tools currently underway, is expected to review evi-
a virtual conference on the commu- to improve access, increase coverage and reduce dence related to CHW-led treatment of wasting,
nity-based management of acute cost. We need to ensure quality and continuity of simplified nutrition protocols and the manage-
malnutrition (CMAM) in March 2021. services but we must also ensure that the ‘perfect’ ment of small and nutritionally at-risk infants
The conference aimed to provide a forum for does not become the enemy of the ‘good’. under six months of age.
health and nutrition practitioners to exchange
Wasting is a continuum from severe to moderate. Integration of services for severe wasting into
evidence and experiences in scaling up treat-
There is an arbitrary, unhelpful divide between health systems in all fragile contexts is essential
ment services for wasting and nutritional
severe and moderate wasting. We need to and governments of these countries must play
oedema in fragile contexts and translate these
improve the continuum of care for wasted chil- a central role. The Country Operational Road
into practical actions and advocacy. The confer-
dren across this spectrum of severity and across Maps being developed as part of the United
ence was a mix of presentations on the ‘main
age groups – starting from maternal malnutrition Nations-led Global Action Plan on Child Wasting2
stage’ and in smaller parallel sessions as well as
through to the management of small and nutri- will inform the development of a Road Map for
daily panel discussions. Smaller working groups
tionally at-risk infants under six months through Action and offer an opportunity to plan strategies
also met on the last day to identify practical con-
to children under five years of age. and funding to support this more fully.
siderations and priority actions to further refine
and scale up several of the core CMAM adapta- Family MUAC and CMAM Surge are essentially
Innovative approaches and funding to prevent
tions and approaches (Box 1). These working ready to scale while other adaptations – partic-
and treat the large caseload of moderately
groups have continued to shape short summary ularly CHW-led treatment of wasting and
wasted are critical. Of the at least 30 million
papers on each of the themes that will soon be simplified nutrition protocols – will require more
wasted children currently not covered by treat-
available along with the main conference report. testing, endorsement from the World Health
ment services, the majority suffer from
Organization (WHO) and major increases in fund-
All presentations and conference materials moderate wasting. These children will swiftly
ing before governments can bring them to scale.
are available on the Concern website become more severely wasted and face even
The MAMI Care Pathway Package, an integrated,
www.concern.net/CMAM2021. These include higher mortality risk.
contextualised approach for managing small and
case studies summarising the experience of
nutritionally at risk infants under six months, is in A full conference report will be available by the
seven governments in scaling up wasting serv-
the early phases of scale up with evidence grow- end of May 2021. For more information, please
ices as well as broader learning from South Asia.
ing and a formal trial planned in Ethiopia.1 contact Kate Golden at
A report prepared by ENN in advance of the con-
[email protected]
ference entitled ‘Scale-up of severe wasting The update of WHO guidelines on the preven-
Visit: www.concern.net/CMAM2021
management within the health system: a stake- tion and treatment of wasting, expected at the
holder perspective on current progress’ is also end of 2021, is critical to enable scale-up by gov- 1 https://www.ennonline.net/ourwork/research/mamiriseethiopia
available at the same link. ernment. The guideline development process, 2 https://www.childwasting.org/

Important themes highlighted during the confer-

ence were as follows:
Coverage still remains far too low. Twenty years Box 1 Main adaptations and approaches to CMAM explored in the conference
ago, CMAM promised access, scale and coverage.
Coverage has increased tenfold since CMAM was Simplified approaches
first introduced but much more still needs to be 1. Family mid-upper-arm circumference (MUAC)
done to realise this promise. This must include 2. Community health worker (CHW)-led treatment of wasting
revitalising the community aspect – putting the 3. Simplified nutrition protocols (usually a combination of expanded admission criteria based
‘C’ back in CMAM. on MUAC >125mm and oedema, the use of a single treatment product (ready-to-use
The cost of producing and delivering RUTF must therapeutic food (RUTF)) for severe and moderate wasting, using modified RUTF dosages
be reduced. To do this, we need to invest in devel- based on MUAC not weight)
oping alternative formulas that achieve the same Other adaptations to improve delivery of wasting services
or similar outcomes with non-dairy formulations, 4. Management of small and nutritionally at-risk infants under six months and their mothers
support more localised production and unlock (MAMI)
global competition.
5. CMAM Surge
More funding is needed for wasting treatment.
Cross-cutting themes
We must explore innovative financing mecha-
6. Integration of severe wasting services into health systems
nisms, such as the Global Financing Facility,
7. Management of moderate wasting services
particularly to ensure the long-term financing of
RUTF supply.
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News

The launch of the Healthy Mothers Launch of the

Healthy Babies Consortium Nutrition Year
of Action

T
he Micronutrient Forum and its part- reviews have highlighted that, compared to IFA,

I
ners, supported by Kirk Humanitarian using MMS can decrease the risk of low birth-
and the Children’s Investment Fund weight, 6-month mortality, preterm birth, n December 2020, the Governments of Canada
Foundation, launched the Healthy small-for-gestational age and stillbirth. Despite and Bangladesh, in partnership with the Govern-
Mothers Healthy Babies Consortium (HMHB) this, many women in low- and middle-income ment of Japan, hosted a virtual launch of the
https://hmhbconsortium.org/ at a global countries do not have access to MMS, placing their Nutrition Year of Action. This began a year-long
webinar on 10th March 2021. The consortium own health and that of their babies at unaccept- initiative to address the global hunger and nutrition
aims to generate momentum for coordinated able risk. crisis which will culminate in the Nutrition for Growth
action on maternal nutrition, initially focusing (N4G) Summit in Tokyo, Japan, during December
One of the reasons there is limited access to 2021. The Year of Action falls midway through the
on scaling up access and use of affordable mul-
MMS is because it is not yet on the World Health United Nations (UN) Decade of Action on Nutrition,
tiple micronutrient supplements (MMS).
Organization’s Essential Medicines List (EML) with only five years left to achieve the World Health
Through the combined effort of the consor-
which includes the medications considered to be Assembly (WHA) targets on maternal, infant and
tium members, it is envisaged that more
most effective and safe to meet the most impor- young child nutrition, and 10 years to reach the SDGs.
pregnant women will benefit from improved
tant needs in a health system. The list is Given that the COVID-19 pandemic has exacerbated
nutrition through MMS, have healthier preg-
frequently used by countries to help to develop an already perilous nutrition situation for the most
nancies and thereby give their babies a better
their own local lists of essential medicines. If vulnerable, the need for commitment to, and invest-
chance to survive and thrive.
MMS were on the EML, this would help open the ment in, achieving a world in which all people have
HMHB members represent a diverse com- door for countries to improve access. An applica- access to safe, affordable and nutritious food by 2030
munity, united in their vision to increase the tion has been made to include MMS on the EML is all the more critical.
global demand, supply and delivery of MMS to this end. HMHB is asking its members and
through effective advocacy, networking and stakeholders to write letters of support for this At the time of the launch, new data released by
knowledge management. Dr Saskia Osendarp, application and has more information on its the Standing Together for Nutrition consortium
Executive Director of the Micronutrient Forum, website on how to take action. highlighted the devastating impacts of COVID-19 on
explains, “At the core of this initiative is the belief maternal and child nutrition, with an additional
On 31st March 2021, HMHB facilitated an 168,000 child deaths predicted over the next two
that women and babies deserve our best, and
online workshop where participants helped to years. Additionally, in the absence of immediate and
our best requires us to work together through
shape an advocacy agenda for MMS, outlining significant global action, a further 9.3 million chil-
an inclusive platform that brings advocates and
strategies to improve engagement with the dren are estimated to be at risk of wasting. Thus, an
experts across sectors and across the world
maternal health sector and how the upcoming emphasis on the need for new and revived commit-
together around one common agenda and a
Nutrition For Growth (N4G) Summit (taking place ments to achieving the nutrition agenda was made.
unified voice”.
in Tokyo in December 2021) could be leveraged
MMS contain 15 micronutrients that are for global policy and financial commitments to To this end, more than US$3 billion in financing
essential to the health of mothers and their maternal nutrition. A living draft of the advocacy was pledged by various stakeholders with the Gov-
babies. The consortium builds on the strong evi- strategy for the N4G Summit (“Maternal Nutrition ernment of Canada committing US$407 million and
dence base that MMS are safe, cost-effective and and Multiple Micronutrient Supplementation: A the Government of Pakistan committing US$2.18 bil-
consistently associated with better birth out- Commitment Guide for Tokyo’s 2021 Nutrition for lion to nutrition programming through to 2025. This
comes compared to iron folic acid (IFA) Growth Summit”) can be found at https://hmh- was bolstered by various multilateral organisations
supplementation alone. Recent systematic bconsortium.org/nn4g-commitment-guide and non-government organisations with World
Vision International pledging an extended US$500
million to be spent on nutrition by 2025. An annual
investment of at least $700 million per year towards
Within our grasp: Childhood nutrition programming for children, adolescents and

malnutrition worldwide women was committed by UNICEF over the next five
years and the World Bank committed $500 million in
and the revolution taking Early Response Financing from the IDA-19 Crisis
Response Window to target countries facing food
place to end it insecurity crises.
While serving as a basis for renewed action
Sharman Apt Russell has recently published a book1 that examines towards eradicating malnutrition, these pledges will
the urgent problem of childhood malnutrition worldwide and meet only a fraction of the global need. As such, the
explains why this is an environmental concern as well as a humanitarian one. Intertwined Year of Action provides a platform for further invest-
with stories of scientists and nutrition experts, Russell writes of her travels to Malawi, one of ment via a roadmap of key pledging, momentum
the poorest and least-developed countries in the world and also the site of cutting-edge building and global moments. With the key pledging
research into childhood malnutrition. She visits Malawian farmers coping with erratic weather moments outlined, namely the UN Food Systems
patterns due to global warming and highlights an agroecology that relies on more drought- Pre-Summit, the UN Food Systems Summit and the
tolerant and nutrient-rich crops. Tokyo N4G Summit 2021, to begin in July, the need
As she explores new friendships and insights in a country known as ‘the warm heart of Africa,’ to further mobilise resources for nutrition through
Russell describes the programmes that are working best to reduce childhood malnutrition. the coming months is critical to ensuring that the
She explains why the empowerment of women may be the single most effective factor in vision for the Year of Action is met.
eliminating childhood malnutrition, which vitamins and minerals are the most essential to a More information on the launch and a full list of
child’s development and how much ending malnutrition and stunting will cost. The book is the commitments made can be found here:
now available from booksellers worldwide. https://nutritionforgrowth.org/nutrition-year-of-
1
Russell, S A (2021) Within our grasp: Childhood malnutrition worldwide and the revolution taking place to end it. New York: action-launch-event-recap/
Pantheon Books.
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News

© UNICEF / Frank Dejongh / Cameroon / 2021

Background and a session evaluation. The details of each
In late 2019, the Infant Feeding in Emergencies webinar and the key learning points are sum-
(IFE) Core Group1 webinar committee organised marised in Table 1.
a series of webinars to celebrate the 10 year
anniversary of the endorsement of the Infant
Summary of main
and Young Child Feeding in Emergencies (IYCF- programmatic adaptations
E) Operational Guidance (OG-IFE, 2017) by the Key adaptations and challenges around IYCF-E
World Health Assembly. This committee is programming in the context of COVID-19 were
chaired by Save the Children and has represen- shared in the webinars from a wide range of
tatives from UNICEF, the World Food actors in varied contexts. Across these learn-
Programme, Johns Hopkins University, the ings many common adaptations were made.
Improving access to nutrition services by strengthening Center for Disease Control, Emergency Nutrition These are summarised as follows:
community interventions in the COVID-19 context
Network, Technical Rapid Response Team Practising COVID-19 preventative
(TechRRT)2 and USAID Advancing Nutrition. The
measures
Infant and aim of the webinar series was to highlight the
OG-IFE and showcase best practices from the
• Providing personal protective equipment
(PPE) for staff and beneficiaries participating
young child field on how the guidance has been successfully
implemented. However, in early 2020 when
in activities
• Installing or increasing access to hand-
COVID-19 was declared a global pandemic and
feeding in the relevant guidance was issued (GTAM,
UNICEF (2020); UNICEF & USAID (2020); Word
washing facilties for community-based
activities

emergencies Health Organization (WHO) (2020)), the aim of

the webinars was redirected to focus on IYCF-E
• Increasing awareness activities on hygiene
promotion
• Adapting group counselling to include
programming programmatic adaptations in the context of
COVID-19.
infection prevention control procedures,
including social distancing, hosting less
in the context Implementation of the than five individuals per group, ensuring
counselling spaces are well ventilated with
webinar series
of COVID-19: The webinar series aimed to raise awareness of
sufficient space, checking temperature of
beneficiaries on entry and monitoring early
the updated recommendations for IYCF-E best
learnings from a practices in the context of COVID-19, share best
practices and lessons learnt on implementing
signs of COVID-19
• Redesigning patient flow and waiting areas
to minimise congestion and risk of
webinar series the OG-IFE in the context of COVID-19, provide
examples of programmatic adaptations at the
COVID-19 transmission

By Alessandro Iellamo, country level and galvanise actors for scaling Adapting individual and group
Linda Shaker Berbari, Ben Allen, up evidence-based and collective actions for support activities
the effective implementation of the OG-IFE in • Switching from group counselling to
Brooke Bauer, Aashima Garg,
the context of the COVID-19 pandemic. The individual one-on-one counselling
Andi Kendle, Peggy Koniz-Booher, webinars were referred to as ‘Learning and • Having a greater reliance on remote coun-
Mija Ververs and Deborah Joy Wilson Sharing Cafés’ to reflect the intended informal- selling and education
Alessandro Iellamo is Global Infant and Young ity of the events and to encourage the sharing • Using a hotline, online platforms and
Child Feeding in Emergencies (IYCF-E) Adviser of programme experiences in a safe space and WhatsApp messages for providing coun-
for Save the Children. active engagement and interaction by the selling and education
audience. The webinars attracted a wide range • Deploying community nutrition volunteers
Linda Shaker Berbari is the Infant Feeding in
of practitioners and decision-makers including and using mobile units to reach mothers
Emergencies (IFE) Core Group facilitator and
consultant for ENN.
frontline field workers, staff from government during lockdown
entities, national and international organisa-
Ben Allen is Deputy Program Director of the tions, programme managers, technical advisors Capacity-building and developing
Tech RRT (now part of the Global Nutrition in both nutrition and non-nutrition fields, information, education and
Cluster Technical Alliance’s Technical Support communication (IEC) materials
donors and policy- and decision-makers. A
Team)
process for soliciting interest was initiated by • Launching necessary trainings and capacity
Brooke Bauer is the IYCF-E Advisor for the the webinar committee to encourage countries building through on-the-job and remote
Global Nutrition Cluster Technical Alliance. and organisations to prepare presentations on training
Aashima Garg is Nutrition Specialist at UNICEF their programme experiences. A total of 15 pro- • Developing and disseminating necessary
Headquarters, New York. posals were received, reviewed and scored by IEC materials on IYCF and COVID-19
the webinar committee resulting in 12 being • Tailoring messages to the COVID-19 con
Andi Kendle is Coordinator of the Global
included in the final line-up. text and incorporating COVID-19 related
Nutrition Cluster Technical Support Team.
messages into IYCF messages
Peggy Koniz-Booher is JSI/USAID Advancing The Learning and Sharing Cafés were organ- • Increasing coordination with the Ministry
Nutrition Senior Advisor. ised and facilitated under the guidance of the of Health and local authorities
IFE Core Group and TechRRT. Members of the
Mija Ververs is Senior Associate at Johns The challenges to programming identified in
webinar committee led the facilitation of the
Hopkins Center for Humanitarian Health,
cafés on a rotational basis. The cafés followed a the experiences shared include a lack of suit-
Johns Hopkins University.
standard format including a welcome and 1 https://www.ennonline.net/ife
Deborah Joy Wilson is Maternal, Infant and introductions, an overview of the objectives of 2 Since December 2021, the Technical Rapid Response Team
Young Child Nutrition (MIYCN) Specialist and the session, the presentation of two or three (Tech RRT) has been expanded to form the Technical Support
Inclusive Nutrition Operations Team Lead, at Team (TST) of the Global Nutrition Cluster (GNC) Technical
case studies, an interactive quiz, a facilitated Alliance. More information can be found here:
World Food Programme Headquarters, Rome.
questions and answers session, closing remarks ta.nutritioncluster.net
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News

Table 1 Summary of learning and sharing café sessions

Webinar Date Topics and presenters
Launch 6 April 2020 - Infant feeding and COVID-19: Current evidence and recommendations (John Hopkins University)
- IYCF-E in the context of COVID-19 (UNICEF)
- Communication on protecting, promoting and supporting breastfeeding during COVID-19 (Safely Fed Canada)
- How we can continue to protect, promote and support infant and young child feeding (IYCF) in the context of COVID-19 (Save the
Children)
Café # 1 30 July 2020 - IYCF programmatic adaptations in the context of COVID-19: resources and tools (IFE Core Group),
- Remote IYCF-E support in Colombia (Save the Children Colombia)
- IYCF-E in Somalia (Save the Children Somalia)
Café #2 10 August 2020 - How to communicate: infant and young child feeding recommendations in the context of COVID-19 – IYCF-E (USAID/UNICEF)
- Adaptations experience in the context of COVID-19 in Somalia (Concern Worldwide Somalia)
- IYCF-E adaptations in the mother baby areas of Uganda (Save the Children Uganda)
Café #3 22 October 2020 - IYCF-E to strengthen IYCF practices during COVID-19 in Nepal (Helen Keller International)
- Adaptations to routine IYCF activities in response to the COVID-19 pandemic in Jordan (International Medical Corps Jordan)
- Kyrgyz Republic adaptation of nutrition programming for COVID-19 (JSI/USAID Advancing Nutrition, Kyrgyz Republic)
Café #4 27th October 2020 - IYCF-E response in Syria during COVID-19 (UNICEF Syria)
- IYCF programming during COVID-19 in Sierra Leone (Action Against Hunger and Community Action for the Welfare of Children)
- IYCF-E interventions in Lebanon ( International Orthodox Christian Charities Lebanon)
Café #5 30 November 2020 - IYCF-E response in South Sudan during COVID-19 (Action Against Hunger South Sudan)
- Infant feeding with refugees in Greece (CHEERing)
- IYCF-E and COVID-19 in Yemen (International Medial Corps Yemen

able infrastructure needed to allow social dis- ways that this can be translated into context-spe- themes to support the continuation of quality
tancing and other hygiene practices, insufficient cific programme adaptations/guidance. IYCF programming in the light of COVID-19.
quantities of PPE including face masks, funding The webinars can be found at the following link:
Several recommendations for webinars in
gaps and gaps in human resources to support https://www.nutritioncluster.net/IYCF-E_
additional activities. Two detailed case studies are 2021 were made including technical themes
learningandsharingcafeseries_presentations
presented in articles within this edition of Field such as complementary feeding in emergencies,
Exchange from Somalia3 and Lebanon.4 community-based management of acute malnu- For more information, please contact the IFE Core
trition (CMAM) and IYCF-E, maternal mental Group at [email protected]
Feedback from the cafés health, conducting IYCF-E assessments, develop- 3 See article in this edition of Field Exchange entitled “Adapting
A total of 1,555 individuals registered for the ing IYCF-E indicators and adolescent and infant and young child feeding interventions in the context of
webinars representing countries from all over the maternal nutrition linkages with IYCF-E. The COVID-19 in Somalia”
4 See article in this edition of Field Exchange entitled, "Infant and
world and 665 (43%) attended the events. The webinar committee of the IFE Core Group is young child feeding in emergencies: Programming adaptation
majority of the participants were female (73%). A planning new webinars in response to these rec- in the context of COVID-19 in Lebanon"
5 WHO Breastfeeding and COVID-19 FAQ
post-webinar evaluation revealed a high level of ommendations to share new country case 6 USAID/UNICEF IYCF in the context of COVID-19 counselling
participant satisfaction. Results of a rapid survey studies and newly emerging guidance and package
revealed that 88% were aware of the WHO Breast-
feeding and COVID-19 FAQ5 and 49% made some UNICEF & USAID Advancing Nutrition (2020) Counselling
References
adaptations to this document for their own use. Cards on Infant and Young Child Feeding Recommendations
A total of 71% of respondents knew the GTAM, UNICEF (2020) Infant and Young Child Feeding in when COVID 19 is suspected or confirmed. Available from:
the Context of Covid 19, Brief no. 2. Available from: https://www.advancingnutrition.org/what-we-do/social-
USAID/UNICEF IYCF in the context of COVID-196 https://www.unicef.org/media/68281/file/IYCF- and-behavior-change/iycf-recommendations-covid-19
counselling package and 48% made some adap- Programming-COVID19-Brief.pdf
WHO (2020) Frequently asked questions: Breastfeeding and
tations to this package for their use. This IFE Core Group (2017) Infant and Young Child Feeding in COVID 19. Available from:
demonstrates a need to continue updating pro- Emergencies, Operational Guidance. Available from: https://www.who.int/publications/m/item/frequently-asked-
grammers around existing guidance and the https://www.ennonline.net/operationalguidance-v3-2017 questions-breastfeeding-and-covid-19

Launch of the MAMI

Care Pathway

T
he MAMI Global Network, co-chaired and practitioners, this integrated pathway of
by the Emergency Nutrition Network care leverages existing systems and services
(ENN) and London School of Hygiene across health and nutrition, and supports
and Tropical Medicine (LSHTM), has implementation of World Health Organization
Access the package at
released the MAMI Care Pathway Package, v3.0 (WHO) guidelines on wasting management
https://www.ennonline.net/mamicarepathway
(formerly the C-MAMI Tool) - an implementation and Integrated Management of Childhood
including a short orientation video.
guidance with resources to support the Illness (IMCI). The MAMI Care Pathway
management of small and nutritionally at risk requires adaptation for different contexts; To join the MAMI Global Network, contact:
infants under six months and their mothers implementation experiences will inform [email protected] and for more information,
(MAMI). Developed in consultation with experts future updates. visit: www.ennonline.net/ourwork/research/mami
.......................................................................................................................................
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 Views .......................................................................
Sofine Heilskov, with thanks to Mwanamugimu and the caretakers of the children

Background public day-long seminar. This will include

In 1968, a collection of kwashiorkor re- presentations of the most recent research
searchers and practitioners gathered in followed by a discussion with invited re-
Cambridge, Massachusetts for a collo- searchers to identify research priorities
quium to discuss the evidence relating to and consider the gaps in current treatment
kwashiorkor. Attendees shared their ex- protocols. The group will together deter-
periences, understanding and research mine if sufficient evidence now exists to
findings. The merits of the evidence were support diagnostic criteria for moderate
discussed and debated and a diagnostic kwashiorkor, allowing practitioners to
criteria for kwashiorkor was determined catch cases of kwashiorkor before they
Clinical characteristics in children aged 6 to 59 months – bipedal pitting oedema – that remains progress to severe acute malnutrition with
hospitalized with oedematous severe acute malnutrition the primary diagnostic criteria for classi- a high risk of mortality. The aim of this
(Kwashiorkor), Mwanamugimu Nutrition Unit, Uganda, 2012
fying kwashiorkor today, 50 years later. article is to reflect on the purpose of these
discussions, the webinars covered so far
Following in the footsteps of these re- and the next steps to garner interest
Kwashiorkor – searchers, an informal working group
comprised of a new generation of kwa-
shiorkor researchers and practitioners
among Field Exchange readers to engage
with this important topic.

reflections on the has formed to support each other in the

continuing quest to improve the under-
What is kwashiorkor and
why is it important to
standing and treatment of kwashiorkor. understand it better?
‘revisiting the Members share journal articles, discuss
findings and share opinions on points
Kwashiorkor is one of two major classifi-
cations of severe acute malnutrition. While
within the evidence. The researchers also
evidence’ series discuss their research struggles and help
each other with study designs, occasionally
marasmus is characterised by low weight-
for-height, kwashiorkor is diagnosed by
bipedal pitting oedema. Other associated
By Merry Fitzpatrick, collaborating on studies and proposals. signs include pale and brittle hair, skin
Gerard Bryan Gonzales, Encouraged and supported by the en- lesions, lethargy and a fatty liver as well
Alexandra Rutishauser-Perera gagement of this working group, several as numerous metabolic anomalies.
and André Briend members worked together to initiate a
series of webinars to review the current More than 4000 articles have been
evidence on kwashiorkor and to identify published on kwashiorkor since Cicely
Merry Fitzpatrick is a Researcher
gaps in the evidence. Williams introduced the name for this
Assistant Professor at the Feinstein
unique syndrome in the 1930s but only a
International Center, Tufts University. Three webinars were held towards the small portion of these articles have been
end of 2020 covering the following topics: published in the past 40 years (Figure 1).
1) the basic characterisation and treatment Older publications are primarily descriptive
of kwashiorkor, 2) observable signs of and most recent studies are observational
Gerard Bryan Gonzales is an Assistant
kwashiorkor and 3) metabolic and bio- comparisons. Although data on kwashi-
Professor in the Division of Human
Nutrition and Health, Wageningen
chemical characterisation of kwashiorkor.1
University and Research. Three more webinars are planned for the 1 Recordings of the webinars can be found on:
spring of 2021 and, later in the year (pan- https://fic.tufts.edu/research-item/revisiting-the-evi
demic permitting), we hope to host a dence-on-kwashiorkor-malnutrition/.
Alexandra Rutishauser-Perera is Head
of Nutrition at Action Against Hunger Peer reviewed articles referring to ‘kwashiorkor’ or ‘oedematous
UK. Figure 1 malnutrition’ published per year from 1930 to 2020
140

120
André Briend is an Adjunct Professor at
University of Tampere.
Number of publications

100

80

60
The authors would also like to acknowledge James A
Berkley (FRCPCH FMedSci), Robert Bandsma (MD, PhD) 40
and Asha Badaloo (BSc, MSc, PhD) who presented at the
webinars thereby contributing to this article. 20
The full recordings of the webinar series can be found at
0
https://fic.tufts.edu/research-item/revisiting-the-
1930 1950 1970 1990 2010
evidence-on-kwashiorkor-malnutrition/
Year
Source: Data search from the PubMed website using the terms ‘kwashiorkor’ and ‘edematous malnutrition’ (National Library
of Medicine 2021)
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Views
orkor is slowly accumulating, only 10 clinical hide areas where kwashiorkor prevalence is The 2019 World Health Organization (WHO)
trials specific to kwashiorkor have been con- alarmingly high (Fitzpatrick et al., 2018; Fonaroff, International Classification of Disease defines
ducted, making it impossible to determine 1969; Annegers, 1973; Kamalu, 1993). Most kwashiorkor as a “form of severe malnutrition
causality among all the observed phenomena concerning is that areas where we know kwa- with nutritional oedema with dyspigmentation
associated with cases of kwashiorkor. The aeti- shiorkor is the most common type of acute of skin and hair”.3 Skin changes in kwashiorkor
ology of kwashiorkor therefore remains elusive. malnutrition, but where prevalence data is poor, have been described for as long as oedema has.
are areas where nutritional treatment programmes However, skin dyspigmentation and hair changes
Despite its long history, the prevention and are also all but non-existent. are often missed because the changes can be
treatment of kwashiorkor still relies on very little subtle, requiring skill to detect, and/or require
solid evidence. Not only has research on kwa- The lack of prevalence and incidence data is
a longer time to manifest. The aetiology of the
shiorkor languished, no treatment specific to important because it allows the problem to be
skin changes is unknown and its relation to
kwashiorkor has been developed and cases of ignored. In a self-reinforcing negative cycle,
other clinical outcomes, especially mortality, is
kwashiorkor receive treatment designed to treat with less visibility and understanding about
poorly documented. Hence, standardised global
marasmus. Although these treatments do support the aetiology of kwashiorkor and its global
assessment of skin characteristics in severe acute
the recovery of children with kwashiorkor, the prevalence, the condition receives less policy
malnutrition is required to obtain credible data
very different metabolic anomalies and low cir- attention and guidance. For example, kwashi-
that may be used to optimise treatment protocols.
culating levels of key amino acids seen in kwa- orkor was not included in the recent Global
A tool for grading skin changes, SCORDoK
shiorkor, even after resolution of oedema, indicate Nutrition Report and is not even mentioned
(Scoring of skin changes in severe acute malnu-
that adjustments to treatment would likely on its website2 and the 2008 and 2013 Lancet
trition) developed by the Department of Der-
improve both short and long-term outcomes. Maternal Child Nutrition Series, which has
matology at the Aarhus University Hospital in
dominated the formation of nutrition policy
Global prevalence of kwashiorkor is difficult Denmark, was presented at this webinar. Tools
over the past 13 years, also did not include any
to establish. Regardless of the very different such as SCORDoK may be used to standardise
reference to kwashiorkor (Lancet, 2008; Lancet,
metabolic and clinical differences in marasmus the registration of skin changes in severe acute
2013). When this was pointed out to the authors,
and kwashiorkor, studies of acute malnutrition malnutrition, a necessary first step in building
their response was there was insufficient evidence
and national nutrition surveys continue to either the evidence on relationships between skin
of the scale of the problem to include it in the
aggregate kwashiorkor with marasmus or exclude changes and kwashiorkor. However, the utility
policy priorities.
it altogether. Furthermore, normal nutritional and translatability of SCORDoK in other settings
surveys to estimate prevalence are poorly designed With the availability of new technologies, remains to be demonstrated.
for the capturing of acute conditions such as we now have the opportunity to review a growing
The severity of oedema is the main criteria
kwashiorkor because children with kwashiorkor body of evidence, identify the gaps in evidence
for admission and discharge while other signs
either die or spontaneously recover in a much and design better studies to fully unravel the such as the treatment of dehydration and skin
shorter time than children with marasmus who aetiology and pathophysiology of kwashiorkor lesions in kwashiorkor remain largely unopti-
may linger in a chronic state of wasting. This and promote surveillance that captures the global mised. Dehydration is a topic of contention and
exaggerates the differences in the numbers of scale of the problem. In doing so, we will enable conflicting opinions exist on rehydration protocols
children with marasmus in comparison to chil- the development of better treatment protocols for children with kwashiorkor. Skin lesions may
dren with kwashiorkor. and prevention strategies which will help to lead to infections and hypothermia, further en-
reduce the burden of kwashiorkor and improve dangering the health of already compromised
Survey teams are also often poorly trained the clinical outcomes of hundreds of thousands individuals. Hence, management of skin changes
to detect or characterise kwashiorkor. More re- of affected children each year. in kwashiorkor is important but seldom included
cently, evaluation of family mid-upper arm cir-
in treatment protocols. The integration of a ho-
cumference (MUAC) programmes reveal that What has been covered in the
listic approach, including wound care and pain
most parents forget to check the presence of webinars so far? management, is essential. However, evidence
oedema when checking the nutrition status of The diagnosis of kwashiorkor remains largely so far of effective treatment strategies has been
their children (Lort-Phillips & Macias, 2016). based on the observation of oedema. However, very heterogenous or scarce and largely built
Hence, reports on the incidence or prevalence many other clinical signs accompany, or may upon expert opinion rather than strong evi-
of kwashiorkor are believed to underestimate even precede, the development of oedema such dence-based research.
the scale of the problem. The figures that are as lethargy, loss of appetite, behavioural changes,
available indicate that hundreds of thousands skin lesions and fatty liver. This therefore indi- The difficulty in the diagnosis and treatment
of children are affected and at least tens of thou- cates that oedema may be a late sign of kwashi- of kwashiorkor stems from our lack of under-
sands die annually (Alvarez et al., 2016). Kwa- orkor and its pathophysiology may be better 2
https://globalnutritionreport.org/reports/2020-global-nutri
shiorkor tends to cluster in specific regions and understood by also considering the other signs tion-report
communities meaning that aggregate figures of the disease. 3
https://icd.who.int/browse10/2019/en#/E40

Clinical characteristics in children aged 6 to 59 months hospitalized

with oedematous severe acute malnutrition (Kwashiorkor),
Mwanamugimu Nutrition Unit, Uganda, 2012

Sofine Heilskov, with thanks to Mwanamugimu and the caretakers of the children
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12
....................................................................................................................................... Views
standing of its aetiology. The role of diet, specifi- sensus that the metabolism of kwashiorkor is lymphatic system drains fluid from the interstitial
cally protein deficiency, has been the most pop- different from that of marasmus and charac- sector back to the plasma using an active mech-
ularly described mechanism for the development terising these as similar diseases is not appropriate anism of pumping fluid by lymphatic vessels.
of kwashiorkor but the results of studies on diets and will not be helpful in improving current This has a major role in regulating the volume
estimating total dietary protein have not been rehabilitation guidelines. However, despite in- of the interestitial sector independently from
consistent. However, many kwashiorkor study teresting findings, these studies are observational fluid movement across the capillary membrane.
designs start with the assumption that decisive and did not test causation using randomised As a result, it is not clear how important albumin
evidence has shown there is no quantitative controlled trials (RCTs). is as a determinant of oedema.
difference in the diets of children developing
One aspect that will benefit from well- Although a causal association remains to be
kwashiorkor and those developing marasmus.
designed RCTs is modified therapeutic foods fully demonstrated, there is general agreement
This is based on a misinterpretation of a much- that there is an association between kwashiorkor
(F75 and ready-to-use therapeutic food) that
disputed study conducted by Gopalan in 1967 and low serum albumin; nevertheless, many
specifically address the metabolic requirements
for which the data was never published (Gopalan, in kwashiorkor. For instance, apart from reduced children with low serum albumin concentration
1968). While some more recent studies using protein and lipid oxidation, liver fat accumulation do not develop oedema and some adults with
food frequency measures have also failed to find has been observed to be more prevalent among ascites and oedema have normal albumin con-
a difference (Kismul, Van den Broeck & Lunde, kwashiorkor than marasmus. There is therefore centrations. More basic research needs to be un-
2014; Lin et al., 2007; Sullivan et al., 2006), two a basis to question whether children with kwa- dertaken on albumin-dependent and -indepen-
studies that conducted more rigorous quantitative shiorkor will benefit more from a rehabilitation dent mechanisms that drive oedema formation.
dietary recalls reported that children with kwa- food designed to meet their specific metabolic
shiorkor had consumed diets with less protein Lastly, most of the reports on kwashiorkor
needs. For example, a very small trial showed
than children developing marasmus in the same rely on cross-sectional observations that attempt
the faster disappearance of oedema with the
environment (Gupte, 1975; Gupte & Mehta, to explain a snapshot of a highly dynamic
addition of cysteine to treatment (Badaloo et
1971). A fresh look at the evidence indicates we process. Therefore, capturing this dynamic
al., 2002). On the other hand, promoting a spe-
should not dismiss diet as a major contributing process, either by observing determinants of
cialised treatment package for kwashiorkor may
cause of kwashiorkor and any new quantitative kwashiorkor before it occurs or by subjecting
increase the logistical hurdles and cost, thereby
dietary research should examine the intake of children with kwashiorkor to a metabolic nudge
reducing the coverage of rehabilitation pro-
individual amino acids instead of total protein. and monitoring their response, may provide
grammes. More research is therefore needed to
deeper insights into the pathophysiology, or
Unravelling the aetiology of kwashiorkor find cost-effective strategies to address kwashi-
perhaps aetiology, of kwashiorkor. In conclusion,
also requires a deep understanding of the bio- orkor-specific metabolic perturbations.
there is still much more we do not know about
chemical and metabolic perturbations that these There is also an ongoing debate as to the role kwashiorkor and more research, especially tar-
children experience, especially in comparison of serum albumin concentration in the oedema geting mechanistic pathways, is necessary to
to marasmus. Metabolism of kwashiorkor has associated with kwashiorkor. Oedema is the elucidate the aetiology of this disease.
been reported to differ from marasmus on result of the expansion of the interstitial sector
several fronts. Protein and lipid oxidation are Details of the upcoming webinars will be
and could be explained by an excessive net
reduced in kwashiorkor compared to marasmus announced on the ENN website and the Kwa-
transfer of fluid from the vascular system to the
although these results were observed in the shiorkor: Revisiting the Evidence Webinar website
interstitial sector. The Starling principle4 describes
at https://fic.tufts.edu/event/kwash-series/ We
postabsorptive state, where circulating insulin how fluid movement across the capillary mem-
hope you will join us.
levels are low, thereby affecting both lipid and brane depends on the balance between hydrostatic
carbohydrate metabolism. Studies in fed states, and oncotic pressures on both sides of this For more information, please contact Merry
which may provide deeper insights into the membrane. This principle is based on standard Fitzpatrick at [email protected]
differences in lipid and carbohydrate metabolism physical laws. When the albumin level is reduced,
between kwashiorkor and marasmus, are how- this has an effect on plasma oncotic pressure 4
Starling’s hypothesis, not to be confused with Starling’s
principle, states that fluid flows from the capillary into the
ever lacking. Tracing studies performed earlier and leads to an increase of fluid transfer from interestitial sector at the arterial end of the capillary and
in Jamaica also indicated an increased demand the vascular to the interstitial sector (Starling, flows from the interstitial sector into the capillary at its
for sulphur-containing amino acids, cysteine 1896). There are, however, several factors unre- venous end (Starling 1896). While Starling’s principle remains
unquestioned, recent evidence shows Starling’s hypothesis
and methionine, in the early rehabilitation lated to Starling’s principle that influence the is no longer tenable (though it still remains in many text
phase of kwashiorkor. There is therefore a con- volume of the interstitial sector. For one, the books) (Michel 2004).

References Gopalan, C (1968) Kwashiorkor and Marasmus: Evolution Lort-Phillips, H and Macias, D (2016) Enquête SLEAC du
and Distinguishing Features. In Calorie Deficiencies and programme PECMAS et étude sur l’impact du projet pilote
Alvarez, J L, Dent, N, Brown, Mark Myatt, M and Briend, A Protein Deficiencies: Proceedings of a Colloquium held in « PB Mamans ». In Renforcement de la lutte contre la
(2016) Putting Child Kwashiorkor on the Map. In CMAM Cambridge April 1967, edited by R.A. McCance and Elsie M. malnutrition aigüe sévère et de sa prise en charge au
Forum Technical Brief. Widdowson, 49-58. Boston: Little, Brown and Company. Sénégal par une approche multisectorielle et intégrée dans
Annegers, J F (1973) The protein-calorie ratio of West Gupte, S (1975) Marasmus and Kwashiorkor. Pediatrics 56 la région de Matam, Sénégal. Matam, Senegal: Action
African diets and their relationship to protein calorie (1):152-152. Against Hunger UK.
malnutrition. Ecology of Food and Nutrition 2 (3):225-235. Michel, C C (2004) Fluid exchange in the microcirculation.
doi: 10.1080/03670244.1973.9990340. Gupte, S and Mehta, S (1971) Advanced Protein-Calorie
Malnutrition; Clinical observations on North Indian J Physiol 557 (Pt 3):701-2. doi: 10.1113/jphysiol.2004.063511.
Badaloo, A, Reid, M, Forrester, T, Heird, W C and Jahoor F children. Pediatric Clinics of India 5:91-100. National Library of Medicine (2021) "PubMed." accessed 2
(2002) Cysteine supplementation improves the
Kamalu, B P (1993) Cassava (Manihot Esculenta Crantz) in April 2021. https://pubmed-ncbi-nlm-nih-gov.ezproxy.
erythrocyte glutathione synthesis rate in children with
the Aetiology of Kwashiorkor. Nutrition Research Reviews 6 library.tufts.edu/advanced/.
severe edematous malnutrition. The American Journal of
Clinical Nutrition 76 (3):646-652. (01):121-135. doi: doi:10.1079/NRR19930009. Starling, E H (1896) On the Absorption of Fluids from the
Fitzpatrick, M, Ghosh, S, Kurpad, A, Duggan, C and Hallgeir, K, Van den Broeck, J and Markussen Lunde, T Connective Tissue Spaces. J Physiol 19 (4):312-26. doi:
Maxwell, D (2018) Lost in Aggregation: The Geographic (2014) Diet and kwashiorkor: a prospective study from 10.1113/jphysiol.1896.sp000596.
Distribution of Kwashiorkor in Eastern Democratic rural DR Congo. PeerJ 2:e350. doi: 10.7717/peerj.350. Sullivan, J, MacDonald, N, Maker, D, Hotz, C and Manary, M
Republic of the Congo. Food and Nutrition Bulletin. doi: Lin, C A, Boslaugh, S, Ciliberto, H M, Maleta, K, Ashorn, P, J (2006) The quality of the diet in Malawian children with
10.1177/0379572118794072. Briend, A and Manary, M J (2007) A Prospective kwashiorkor and marasmus. Maternal & Child Nutrition 2
Fonaroff, L S (1969) Settlement typology and infant Assessment of Food and Nutrient Intake in a Population (2):114-122. doi: 10.1111/j.1740-8709.2006.00053.x.
malnutrition in Jamaica. Tropical and Geographical of Malawian Children at Risk for Kwashiorkor. Journal of
Medicine 21:177-185. Pediatric Gastroenterology and Nutrition 44 (4):487-493.
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13
 © FAO/IFAD/WFP/Michael Tewelde
Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
By Helen Young, Abdalmonim Osman,
Improving
Anne Radday, Anastasia Marshak,
Emmanuella Olesambu, Nola Jenkins, the way we
Darana Souza and Dr Patrizia Fracassi

Helen Young is a Professor at the

address acute
Friedman School of Nutrition Science
and Policy, Tufts University where she
directs Feinstein’s Research Program
malnutrition
on Nutrition, Livelihoods and Conflict.
Over the past 35 years, her research
in Africa’s
has contributed to practical guidelines, policy changes,
institutional learning and capacity development.

Abdalmonim Osman, Ph.D., is currently a

drylands Woman and baby, eastern Chad
senior emergency and rehabilitation
officer at the Food and Agriculture
Organization (FAO) of the United Nations.
From 2014 to 2017 he worked as FAO
Head of Programme in South Sudan.

Dr. Marshak is a Senior Researcher at

the Feinstein International Center at
AFRICA’S DRYLANDS
Tufts University. She has over 10 years What we know: High levels of persistent global acute malnutrition (P-GAM) are a
of experience working in humanitarian problem across the Sahel and Horn of Africa which are typically dryland regions.
contexts with a focus on study design
and methods, evaluating impact on What this article adds: An adapted conceptual framework for analysing and
nutrition and food security outcomes.
addressing acute malnutrition in Africa’s drylands has been developed by Tufts
Anne Radday is the focal point for University based on research by Tufts and the Food and Agriculture Organisation
research communications and (FAO), discussed by a wide group of stakeholders during a series of technical
knowledge management at the webinars and a roundtable meeting in 2020. The framework acknowledges that the
Feinstein International Center, Tufts
immediate and underlying causes of acute malnutrition depicted in the UNICEF
University. She has more than 15 years
of experience in marketing and
conceptual framework remain relevant but proposes three new interlinked basic
communications, knowledge management, knowledge drivers: environment and seasonality (acknowledging recent research that reveals
product development, organisational strategy and seasonal peaks in acute malnutrition), systems and formal and informal
external relations. institutions and livelihoods systems. The vulnerability and resilience of
Emmanuella Olesambu is a Programme
communities and their livelihoods to climate, conflict and other shocks are also
Officer working on Disaster Risk explicit. The authors argue that three critical shifts are necessary to address P-
Management in Ethiopia with the FAO, GAM in Africa’s drylands: a shift in conceptual thinking that emphasises the basic
previously serving as an Emergency drivers of malnutrition in Africa’s drylands, a shift in policy at national level
and Rehabilitation Officer in FAO’s following the lead of the UN Global Action Plan on Child Wasting and a shift in
headquarters in Rome. She has approach that operationalises the adapted framework. This must be underpinned
engaged in the field of resilience, natural resource
management, livestock and pastoral and drylands
by research and learning on the basic drivers of acute malnutrition using
development for well over two decades, mainly in Africa. innovative mixed methods and inter-disciplinary approaches with researchers
actively engaging with stakeholders to share evidence, learn and build consensus
Nola Jenkins is a Programme Assistant at on solutions.
the Feinstein International Center at
Tufts University. She is pursuing a career
in global health and health policy and
has experience researching food
security and specialty drug coverage. Introduction have been investigating the problem of
Child acute malnutrition is an increasing acute malnutrition and livelihoods in pro-
Darana Souza is a Nutrition and Food tracted crises in Sudan, Chad and South
global public health problem. For some
Systems Officer in FAO, working in Sudan (Young and Marshak, 2019). Building
emergency and resilience building
years, nutrition professionals have acknowl-
edged that emergency rates of global acute on this earlier research, in 2020 Tufts pro-
contexts. She has worked in different
organizations, such as UNDP, WFP and malnutrition (GAM), a measure of child posed an adapted framework for analysing
Action contre la Faim in Africa, Asia and wasting, are persistently re-occurring, even and addressing acute malnutrition specific
South America. She is interested in the humanitarian- in the absence of an obvious emergency to Africa’s drylands. This was presented
development nexus for nutrition and food systems. and despite ongoing interventions (Young and further refined through a series of
Dr Patrizia Fracassi is Senior Nutrition and Marshak 2018). Persistent global acute technical webinars in 2020 and a roundtable
and Food Systems Officer at FAO malnutrition (P-GAM) is particularly evident meeting with the UN GAP agencies and
leading the country support work on across the Sahel and Horn of Africa, much their resource partners.1
governance, policies, programmes and of which is typically dryland region (Figure
investments. She has 20 years of
This article reflects on the discussions
1). More broadly, the 2020 United Nations held during the technical series and round-
experience working with INGOs,
(UN) Global Action Plan (GAP) on Child table meeting, covering the unique context
UNICEF, the World Bank and the SUN Movement
Secretariat. She is interested in the political economy of
Wasting (WHO, FAO et al. 2020) acknowl- of Africa’s drylands, the three interlinked
food and nutrition. edges this problem and the need to increase basic causes of acute malnutrition in this
efforts to prevent child wasting as part of context, the adapted conceptual framework
This article draws on findings from projects funded by the Sustainable Development Goals (SDGs).
the Food and Agriculture Organization of the United and recommendations for how we can change
Nations, the Dignitas Foundation and the USAID Center Since 2017, the Food and Agriculture the way the international community ad-
for Resilience. Organisation (FAO) and Tufts University 1
https://sites.tufts.edu/malnutritionframework/
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dresses acute malnutrition to better address the crises in the drylands and unprecedented donor the causal framework, and specifically the im-
problem of P-GAM in this region. expenditure. mediate and underlying causes, is a set of
technical interventions that have become widely
Understanding Africa’s An adapted conceptual advocated and adopted over the past 20 years
drylands framework to understand the (Bhutta, Das et al., 2013).
Africa’s drylands are characterised by low-lying drivers of acute malnutrition in
arid and semi-arid areas inhabited mainly by Inadequate food intake and disease are the
pastoralist and agro-pastoralist communities
Africa’s drylands direct causes of child acute malnutrition which,
Since the 1990s, there has been broad agreement in turn, are driven by factors related to food,
whose production systems have evolved to adapt
on a conceptual framework to describe the health and care at household and community
to these harsh environments. Climate variability
causes of malnutrition (Figure 2 - left). This levels. Implicit in this downstream focus on the
is extreme, rainfall erratic and seasonal tem-
peratures reach as high as 40 or 50oC. framework has three levels: immediate causes, immediate and underlying causes of malnutrition
underlying causes and basic causes. Linked with is the assumption that part of the solution to
Africa’s drylands are facing multiple chal-
lenges. Insecure access to farmland, pastures, Comparison between Africa dryland areas and countries in East Africa and the
water and forest resources is threatening liveli- Figure 1 Sahel where P-GAM is reported
hoods that are predominantly based on these
a. Africa Dryland Areas. b. Countries in East Africa and the Sahel where
same natural resources. Increasing competition
P-GAM is reported.
and the appropriation of natural resources have
led to growing conflicts between resource users
which are often overlaid by or interconnected
with wider conflicts (inter-tribal, rebel insur-
gencies, cross border etc.). Population growth,
migration and displacement are contributing
to rapid demographic and social change, ac-
companied by increasing livelihood diversifi-
cation and transformation that often renders
women and youth in particular dependent on
marginal low return activities. Climate change
has been associated with the increasing frequency
of drought and floods and increasing tempera-
tures in the Sahel. The institutions that should
be able to mitigate these challenges and support
livelihoods and good nutrition are often weak
and under-resourced. These factors have con-
tributed to the increasing scale of humanitarian Source: Sorensen, 2007 Source: Young and Marshak, 2018

Figure 2 Original UNICEF framework (left) compared with the proposed updated framework (right) in which only the basic causes are changed

Malnutrition Manifestation
and Death

Inadequate Immediate
Disease
Dietry Intake Causes

Insufficient Inadequate Insufficient Underlying

Household Food Maternal & Child Health Services & Causes
Security Care Unhealthy Environment

Formal
and Non-Formal
Institutions

Political and Ideological Superstructure

Basic
Causes
Economic Structure

Potential
Resources

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15
.......................................................................................................................................
Views
child acute malnutrition lies within the agency better understanding of the major causal factors hoods (including human, social, natural, eco-
of communities and households. However, it is of wasting, including seasonal patterns” nomic and physical resources).
critical that we also look upstream to the basic (WHO/UNICEF/WFP, 2014). They emphasised
drivers to better understand the social and eco- the importance of prevention strategies leading Livelihood systems
nomic systems and institutions that have such up to the lean/hungry periods and the scaling The predominant livelihoods in drylands are
powerful influences on acute malnutrition and up of treatment services in response to seasonal pastoralism, agro-pastoralism and farming which
its proximal causes. A failure to give attention “surges” of acute malnutrition. Yet, as the have long since adapted to the environmental
to these more structural, basic drivers of acute FAO/Tufts research on seasonality shows, the variability affecting the distribution of water,
malnutrition accounts for the persistence of timing of seasonal peaks may differ markedly pasture, forest and crops. Dryland producers
acute malnutrition (Gillespie, Haddad et al., from that which is widely assumed, underlining are expert in managing this variability, knowing
2013; Brown, Backer et al., 2020). If we are to the urgent need for evidence to support sus- where the best conditions can be found for herds
develop more effective approaches to effectively tainable and appropriately timed solutions for or for farming at different times of the year
prevent acute malnutrition, it is critical that we the prevention of acute malnutrition. (Krätli, 2015). This specialised livelihood adap-
co-develop our understanding of these basic tation accounts for the inherent resilience of
drivers and how they work.
Systems and institutions pastoralism. However, the ways in which dryland
Systems and institutions determine how things producers manage risk are not always well un-
The adapted conceptual framework (Figure work and influence people’s access to resources. derstood and can be inadvertently undermined
2 - right) acknowledges that the immediate and Systems include governance, political and eco- by inappropriate policies or programmes.
underlying causes remain relevant but proposes nomic systems, food systems, public health sys-
a new framework for understanding the basic tems and livelihood systems. Formal and informal Worsening conditions linked to shocks, com-
drivers of acute malnutrition, drawn from the institutions are embedded within systems and bined with poor governance, have undermined
evolving body of knowledge and experience in reflect agreed ways of working or living together. livelihood resilience and prompted coping strategies
relation to disaster vulnerability, dryland envi- Formal institutions include policies and formal that have led to the transformation of livelihoods,
ronments, livelihood systems and resilience. rules and regulations, such as the regulations often to the disadvantage of women who bear
Building on the original framework, the revised governing the quality of the food supply. most responsibility for the nutrition of children.
version conceptualises the following three in-
Informal institutions reflect widespread and Attention to livelihoods sharpens the focus
terlinked basic drivers: environment and sea-
persistent patterns of behaviour and practices on household priorities and local agency – two
sonality, systems and formal and informal in-
that are structured by the norms and values of factors which are often missed by remote pro-
stitutions and livelihood systems. The vulnera-
society. For example, deeply held gendered gramming or ignored by top-down aid delivery
bility and resilience of communities and their
social norms shape the roles and responsibilities approaches. By incorporating livelihood systems
livelihoods to climate, conflict and other shocks
of women, men, girls and boys at household and institutions as part of the malnutrition
are also explicit.
and community level, including access to and causality framework, recognition is given to in-
Understanding the three basic control over resources and participation in de- equalities in access to all forms of resources
drivers of acute malnutrition cision-making in community affairs and politics. (not only wealth), as well as the importance of
Environment and seasonality The voices and concerns of women, youth and wider forms of institutional agency and power
Environment and seasonality are underpinned other marginalised groups are often excluded that maintain inequalities or marginalise certain
by our understanding of dryland systems as from local decision-making fora. These social groups (as in structural racism).
ecosystems with particular characteristics. Dryland determinants of power and control have a pow-
regions are characterised by extreme variability erful influence on the nutrition of children Developing a new approach to
in rainfall and vegetation in space and time. So, and women. addressing acute malnutrition
although there are predictable seasons, there is The climate and conflict shocks that drive in drylands
wide variability from year to year and between acute malnutrition, as well as the social and The 2020 UN GAP framework calls for radically
nearby areas. For example, when the rains start, economic inequities that drive the underlying improved solutions and “a crucial policy shift”
where the rain falls and the duration and intensity causes of acute malnutrition, can be potentially towards prevention and a more sustainable
of the showers varies widely which means the mitigated (or exacerbated) by deeper structural systems-wide approach. The framework is in-
availability of water and pastures is to some and institutional processes. For this reason, a tended to facilitate countries that are most af-
extent unpredictable as is the crop growth cycle. lasting and sustainable impact on acute malnu- fected by acute malnutrition to develop their
trition can only be sustained through systemic own operational roadmaps with “context- specific
The FAO and Tufts research reveals the im-
and institutional change that reduces inequities commitments, targets and actions to accelerate
portance of seasonality in relation to dryland
livelihoods. A re-analysis of 350 surveys from and positively influences access to the wide- progress and contribute to reaching the global
Chad, Sudan and South Sudan found two seasonal ranging resources necessary for sustaining liveli- SDG targets” (WHO et al, 2020). The Tufts/FAO
peaks in acute malnutrition: the first and larger
peak at the end of the hot dry season, as the Prevalence of acute malnutrition (wasting) across months (Chad, Sudan
rains start, and the second peak coinciding with
Figure 3 and South Sudan)

the end of the rains and the beginning of the

harvest season (Figure 3). Chad Sudan South Sudan
30%
Additional Tufts’ work has confirmed the
% of children wasted

25%
relationship between these climatic variables
20%
and multiple yearly seasonal peaks in acute mal-
15%
nutrition using both primary data collection in
Chad as well as 15 years of secondary data 10%

across all unimodal dryland contexts in Africa 5%

Jan Mar May Jul Sept Nov Jan Mar May Jul Sept Nov Jan Mar May Jul Sept Nov
(Marshak, Venkat et al., 2021). month month month
In 2014, the World Health Organization 95% confidence interval mean children wasted
(WHO), UNICEF and the World Food Pro-
gramme (WFP) recommended developing “a Source: (Young and Marshak, 2019)
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16
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......................................................................................................................................

© WFP/Evelyn Fey
technical series concluded that three critical capturing long term trends in acute malnutrition
shifts are necessary to address P-GAM to make and confirming seasonal patterns of malnutrition
this happen: and its drivers. Without solid evidence, countries
will face challenges building a stakeholder con-
1. A shift in conceptual thinking that sensus regarding the specific seasonal drivers
emphasises the basic drivers of and the most cost-effective and sustainable ap-
malnutrition that are specific to proaches to addressing these.
Africa’s drylands
Addressing P-GAM in Africa’s drylands is a very Attention to systemic and institutional ap-
specific and pressing problem that can no longer proaches requires commitments and buy-in
be seen as an aberration linked to humanitarian from a diverse cast of players. Such commitments
emergencies. It is now well proven that unac- cannot be assumed and neither can the identities
ceptably high levels of acute malnutrition have of the key players or stakeholders. Studies must
persisted over years, if not decades, in many identify key stakeholders at all operational levels,
countries. The scale and severity of this problem starting at the local level in order to comprehend
justifies further analysis of its long-term trends local perspectives, knowledge and understanding
and drivers, in particular the basic drivers. This as well as their capacities and ongoing commit- Women working
must start with an appreciation of environmental ments. Key stakeholders will include a range of in a communinty
variability and seasonality and the way this is governance and non-state institutions with local garden in Chad
managed on the one hand by the prevailing institutions that influence people’s lives and
formal and informal institutions and on the livelihoods being particularly important.
other by dryland producers whose livelihoods tatives and resource partners. Particularly striking
are fundamentally adapted to these harsh dryland Research and learning should underpin new was the acknowledgement at the highest level
conditions. In addition, the resilience of dryland approaches. While impact studies will always that business as usual is not working. As one
livelihood systems has been undermined by mul- have a role to play, researching the basic drivers senior commentator remarked, “the historical
tiple processes and institutions such as centralised of acute malnutrition requires innovative mixed emergency/humanitarian entry point into wasting
decision-making that ignores local priorities, methods and inter-disciplinary approaches. has resulted in an overemphasis on services and
regulations that restrict herd mobility and process- programmes, rather than on systems, national net-
A proper stakeholder analysis combined
es of land privatisation that limit women’s access works and institutions”. At the same time, panellists
with an analysis of P-GAM trends, potential
to cultivable land or access to water. A new con- spoke authoritatively about the basic systemic
hotspots and drivers and seasonal patterns in
ceptual framework, as presented in Figure 2 - drivers, how they play out and how they might
those drivers and nutrition outcomes can provide
right, will support the generation of new evidence be addressed in a more sustainable way. Through
an excellent starting point for developing such these discussions, it became clear that there is no
to inform more effective strategies.
an operational roadmap and designing evi- blueprint for multi-systemic strategies and re-
2. A shift in policy at national level dence-based strategies to prevent malnutrition. sponse. This means that researchers cannot simply
following the lead of the 2020 UN GAP Given the potential complexity of this task, it write research papers and interact mostly with
The UN GAP on Child Wasting recognises the should be approached as a capacity-building other researchers. We must continue the positive
limitations of technical fixes or interventions exercise ensuring the active participation of shift towards ‘engaged scholarship’ in which schol-
and emphasises instead the need for systemic key stakeholders in the analysis and in developing ars and researchers actively seek out stakeholders,
and institutional change, for example strength- the roadmaps. Fortunately, research and learning share evidence, listen and learn and together
ening systems that can contribute to improved provide an excellent basis for collaboration, ca- promote collaborative learning and consensus
food, health and social systems. This recognition pacity-building and developing local leadership building regarding systemic solutions to acute
of the limitations of current approaches is a and ownership of evidence. malnutrition. While there is much more work to
transformation in public policy and requires be done, this marks a significant shift in approach
systemic change at every level of public office Conclusion that we aim to continue as we work toward oper-
for real change to happen. Concurrent policy Much was learned during the technical webinar ationalising the adapted framework.
changes are needed across multiple sectors at series and roundtable discussion from the wide
all relevant levels to ensure a conducive policy audience participation, inputs from panellists For more information, please contact Helen
environment to effect change. and moderators and also from the UN represen- Young at [email protected]

3. A shift in approach that

operationalises the adapted References
framework Bhutta, Z A, Das, J K, Rizvi, A, Gaffey, M F, Walker, N, Horton, S, Plan on Child Wasting. A framework for action to
While there has been considerable progress on Webb, P, Lartey, A and Black, R E (2013) "Evidence-based accelerate progress in preventing and managing child
interventions for improvement of maternal and child wasting and the achievement of the Sustainable
the shift in conceptual thinking and international nutrition: what can be done and at what cost?" The Lancet
policy shifts, the greatest challenge lies in de- Development Goals.
382: 452-477.
veloping and operationalising a new approach Brown, M E, Backer, D, Billing, T, White, P, Grace, K, Doocy, S WHO/UNICEF/WFP (2014) Global nutrition targets
in a specific context. The UN GAP on Child and Huth, P (2020) "Empirical studies of factors associated 2025: wasting policy brief (WHO/NMH/NHD/14.8).
Wasting advocates promoting government lead- with child malnutrition: highlighting the evidence about Geneva, World Health Organization.
climate and conflict shocks." Food Security 12: 1241–1252.
ership committed to building their own multi- Young, H and Marshak, A (2018) Persistent Global
stakeholder consensus to achieve the necessary Gillespie, S, Haddad, L, Mannar, V, Menon, P and Nisbet, N Acute Malnutrition. A discussion paper on the scope of
(2013) "The policies of reducing malnutrition: building
systemic changes and impacts at the local level. commitment and accelerating progress." The Lancet
the problem, its drivers and recommendations for
Government commitments and ownership of policy, practice and research. A Feinstein International
382(9891): 552-569.
prevention strategies should be evident in their Center Publication. USA, Feinstein International Center,
Krätli, S (2015) Valuing variability. New perspectives on Tufts University.
operational roadmaps. climate resilient drylands development, IIED. Edited by de
Jode, H. Young, H and Marshak, A (2019) Twin peaks: The
Developing these roadmaps must include seasonality of acute malnutrition, conflict and
Marshak, A, Venkat, A, Young, H and Naumova, E N (2021)
demand-led, applied research to understand the "How seasonality of malnutrition is measured and analyzed." environmental factors in Chad, the Sudan and South
drivers of acute malnutrition, including the International Journal of Environmental Research and Public Health. Sudan. Rome, Food and Agriculture Organization of
basic drivers, as well as monitoring systems for WHO, FAO, UNHCR, UNICEF and WFP (2020) Global Action the United Nations.
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© Welthungerhilfe
INDIA & BANGLADESH
What we know: High rates of undernutrition exist among infants, young children
and women of reproductive age in India and Bangladesh.
What this article adds: Nutrition Smart Villages – a multi-sector nutrition-sensitive
approach to address the multiple causes of undernutrition by supporting communities
to plan and implement activities and access government entitlements to improve
agricultural, water, sanitation and hygiene (WASH), nutrition and care practices – was
implemented in 200 target villages in India and Bangladesh over 24 months. The
results of the baseline and endline surveys in 50% of the project villages showed
marked improvement in women’s and children’s dietary diversity and improvement in
WASH practices. However, few gains were made in the reduction of child wasting,
particularly in India. This may be due to the heavy workload of women in India
compared to Bangladesh, low dietary protein and also a long dry season during which
A nutrition camp, Mahatma dietary diversity could not be maintained. Key lessons learned are the need for a multi-
Gandhi Seva Ashram, 2019 sector approach to create an enabling environment for behaviour change, the need to
integrate programming into existing institutions and government services and the need
to strengthen government systems and find ways to overcome capacity gaps. The next
Multi-sector phase of the project will focus on context-specific actions to sustain and improve the
gains made for scale-up through the government.
nutrition
programming: Background
Undernutrition among women of reproductive
for increased cash income. The impact of climate
change has led to an increase in extreme weather
age is a major public health problem in India events including floods, cyclones, drought and

‘Nutrition and Bangladesh. In both countries, the prevalence

of anaemia is high among pregnant women, at
heat spells which compound the challenges ex-
perienced by smallholder farmers and lead to
increased food and nutrition insecurity. It is
40% and 41% in India and Bangladesh respec-
Smart Villages’ tively (Development Initiatives, 2020). Under-
nutrition before and during pregnancy puts
predicted that the collective economy of South
Asian countries could lose 1.8% of its annual
women and their offspring at risk of adverse Gross Domestic Product by 2050, rising to 8.8%
in Bangladesh health outcomes and transfers the risk of un-
dernutrition to the next generation. Levels of
by 2100 as a result of the impacts of climate
change (Ahmed & Suphachalasai, 2014).

and India childhood undernutrition are also extremely

high; in India and Bangladesh respectively, only
an estimated 16.4% and 26.6% of children aged
This article describes a multi-sector approach
used in rural villages in Bangladesh and India
by Welthungerhilfe (WHH) and partners that
By Sweta Banerjee 6-23 months achieve minimum dietary diversity, aims to address the multiple causes of under-
38% and 30.8% of children are stunted and 21% nutrition by improving agricultural, WASH, nu-
Sweta Banerjee is the and 8.4% of children are wasted (Development trition and care practices using a holistic, com-
Nutrition Specialist for Initiatives, 2020).
Welthungerhilfe’s India
munity-led approach. The Nutrition Smart Vil-
country programme. She Poor water, sanitation and hygiene (WASH) lages project was carried out for 24 months in
provides support to the food practices are a major risk factor for undernutrition target villages in India and Bangladesh from
and nutrition security and negative health outcomes in both countries. September 2018 to August 2020. The results of
projects in India, Bangladesh and Nepal. Sweta According to the latest National Family Health the baseline and endline surveys are presented
holds a Master’s degree in Dietetics and Public Survey, 51% of households in India have no im- along with lessons learned.
Health Nutrition and has worked in the public proved sanitation facilities (94% among the
health nutrition sector for the last 25 years. poorest households) and less than 50% of the
Programme description
WHH first started applying a multi-sector ap-
This project was conducted with funding from population have access to safely managed drinking
proach in 2011 in the context of a long-term,
the German Federal Ministry for Economic water (IIPS & ICF, 2017). In Bangladesh, open
rights-based programme, the ‘Fight Hunger
Cooperation and Development. The author defecation reduced from 17.68% in 2000 to
would like to thank the project staff and First Initiative’. This initiative was designed
0.27% in 2016, however, by 2016 only 47% of
management of Welthungerhilfe India, through a consultative process with 10 Indian
households had access to basic sanitation facilities
Bangladesh and Nepal. The involvement of the partners with a vision to develop a long term,
(WHO/UNICEF, 2017).
following partners was also critical in low-cost project that would engage multiple
achieving results: in India, Mahatma Gandhi The loss of crop diversity in South Asia is stakeholders and that could be scaled up through
Seva Ashram, Darshana Mahila Kalyan Samity, considered a major environmental and health government systems. The project aimed to
Vikash Sambad Sanstha, in Nepal, FORWARD concern. Traditional seeds are being replaced attract long term financing from donors in
Nepal and Aasaman Nepal and in Bangladesh, by high yielding/hybrid varieties and farmers order to implement the concept and generate
Anando and Friends in Village Development are increasingly using monocropping (growing evidence of its impact. To date, 15 partners
Bangladesh (FIVDB). a single crop year after year on the same land) across three countries (Bangladesh, India and
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© Welthungerhilfe
other sustainable agriculture techniques. Reduced
dependence on markets for staples and pulses
during lean periods enhances the capacity of
families to buy fruits, vegetables and animal
products to increase household dietary diversity.
Food preservation and storage is included in
farm planning as well. This farming system also
supports the use and protection of natural re-
sources in the local environment and the use of
uncultivated foods.

Nutrition-sensitive micro planning

Elected village members are trained in nutri-
tion-sensitive micro planning skills after which
they work with villages to develop plans that
focus on the needs of families with undernour-
ished women and children. These members sup-
Self-help group members
preparing nutri-mix, Mahatma
port households to develop their own resource
Gandhi Seva Ashram, 2020 plans to maximise food production, income
and sanitation facilities using existing resources.
They also work at village-level to develop village
Nepal) have tested this multi-sector approach WHH’s India and Bangladesh offices imple- plans, mandated by government and linked to
which has now evolved into the ‘Nutrition ment the programme of work through local village development budgets, which are a com-
Smart Villages’ concept. non-governmental organisations (NGOs) with pilation of the household plans submitted to
support from WHH in the form of capacity the village assembly for approval.
The Nutrition Smart Villages approach helps
building on project and financial management, Nutrition behaviour change campaigns
communities to understand nutrition in prac-
skills development around implementation ac- Campaigns are designed to support families,
tical terms and plan their agriculture practices,
tivities and project monitoring and evaluation. especially mothers with undernourished children,
natural resource management, entitlements
The programme requires minimal infrastructure to adopt care practices that support good nu-
and livelihoods according to the nutrition
support and focuses on skills and capacity build- trition. The government service providers, along
needs of the family, particularly focusing on
ing. Interventions carried out by the NGOs are with volunteers and SHG members, are trained
the nutrition needs of children and women of
described as follows. to measure height, weight and mid-upper arm
reproductive age (15-49 years). The project
circumference. Children aged 6-36 months are
also aims to demonstrate to local government Village-level interventions
how existing government schemes in India weighed and height/length is measured in each
In each Nutrition Smart Village, five evidence-
and Bangladesh can be converged at household village to identify undernourished children.
based interventions are implemented in part-
level to target support to its members that are Caregivers of children identified as undernour-
nership with community and grassroots service
most vulnerable to undernutrition. The hy- ished receive counselling on infant and young
providers.
pothesis is that if families understand their child feeding, hygiene and care practices. This
nutrition situation and needs, have control Linking agriculture and natural resource initiative is further strengthened through pro-
over their own resources and are empowered management towards nutrition security motional activities and low-cost interventions
enough to create a demand for their entitle- Linking agriculture and natural resource man- such as nutrition gardens, hand washing stations,
ments, then their members will be able to agement towards nutrition security (LANN+) water filters and waste management. Under
achieve optimal nutrition. The increased de- meetings are held within the villages, through this activity, 15-day positive deviance camps
mand for services is in turn expected to stimulate which community members learn about agri- are facilitated for the mothers/caregivers of
adequate service supply thereby creating an cultural practices and natural resource man- children identified as undernourished through
enabling environment for good nutrition. agement to support nutrition as well as diet, which they receive demonstrations of care prac-
childcare and WASH practices. Local service tices, the making of low-cost nutritious food
In India and Bangladesh, the Nutrition Smart providers along with volunteers from local com- recipes, nutrition gardening (including com-
Villages project is currently implemented in mittee/self-help groups (SHGs)1 use Participatory position, preparation of bio-pesticide and seed
100 villages in two districts of Madhya Pradesh Learning for Action2 techniques to deliver the preservation) and preservation of foods for
in central India (Chhatarpur and Sheopur) and sessions over a period of 12 to 15 months. lean periods.
100 villages in three districts of Bangladesh
(Netrokona, Sirajganj and the Chittagong Hill Sustainable integrated farming systems Strengthening institutions
Tracts). Districts and villages were targeted Sustainable integrated farming systems, including Existing village institutions, SHGs and local
based on social and geographical exclusion, nutrition gardens, are important agroecology- committees within the village are strengthened
landlessness and other social vulnerabilities. based interventions that enable households to by project facilitators to understand government
The government schemes of primary interest use all the available resources including uplands, entitlements and how to access them. By in-
to the project are the Poshan Abhiyan in India degraded land and fallow land to produce food forming, up-skilling and motivating these vil-
and the National Plan of Action for Nutrition for their own consumption. Every family is en- lage-level institutions, government service
under the Bangladesh National Nutrition Com- couraged to develop their own nutrition garden providers are held accountable and villagers gain
mission in Bangladesh. Links are also made in to produce seasonal vegetables, legumes, roots/tu- access to all the services that they are entitled to.
both countries with government departments bers, spices and fruits. Gardens are integrated
of livelihoods and rural development, food and with crops, trees, fisheries, aquatic birds and 1
SHG – Self-help groups (SHGs) are informal associations of
people who choose to come together to find ways to
supplies, agriculture, horticulture, fisheries, an- livestock so that all the resources are optimally improve their living conditions.
imal husbandry and WASH, all accessed through used to increase diet diversity. Hunger periods 2
Participatory Learning for Action is a family of approaches,
the local administration. Strong links are also are reduced through the promotion of millets methods, attitudes, behaviours and relationships that
enable and empower people to share, analyse and enhance
made with village assemblies for village planning and the use of root intensification, farm bunds, their knowledge of their life and conditions and to plan, act,
and budgeting. multi-layer farming and mixed cropping among monitor, evaluate and reflect.
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Field Articles
and households with children aged 6-36 months
Table 1 Sample households survey were selected randomly. A total of 1,186 house-
holds were surveyed across both countries (Table
Number of Total population Number of Number of Number of
Country project from project
Number of
children 6-36 villages in households 1). The survey was repeated at endline to measure
households change in key indicators.
villages villages months the sample surveyed
Bangladesh 100 (3 districts) 110,000 21,529 5,622 60 559 Findings
India 100 (2 districts) 112,084 22,091 6,284 50 627 Figure 1 presents the baseline and endline
findings for each of the indicators outlined as
Total 200 222,084 43,620 11,906 110 1,186
project targets.

Baseline (2019) versus endline (2020) findings of the Nutrition Child nutrition status
Figure 1 Smart Villages project in India and Bangladesh Results show that in Bangladesh the levels of
child wasting in Nutrition Smart Villages were
reduced during the project period, particularly
100
severe wasting which reduced to zero. However,
the number of cases in India did not improve
80 and in fact rose slightly (Table 2). Underweight
% respondents surveyed

data was also collected but has not been shared

here given the short time frame between baseline
60 and endline surveys; these results will be reported
at the end of the next phase of the project.
40
Women’s diet diversity
The overall minimum diet diversity of women
20 in the project villages improved dramatically in
both countries. More than half of the target
women were found to be consuming five or
0 more food groups at endline compared to only
Wasting 6-36 MDDW % MDDC % Safe drinking Sanitation % Hand washing
months in % water % (at least (at least 5/7 good with soap 3% in India and 5% in Bangladesh at baseline.
5/7 good practices) practices)
Although Bangladesh villages had a higher per-
Bangladesh baseline India baseline centage of women consuming five or more food
MDDW: minimum diet diversity for women
Bangladesh endline India endline MDDC: minimum diet diversity for children
groups compared to India, both countries
achieved over the target of 30% improvement
in spite of the nutrition gardens being less suc-
Numbers and percentages of wasted children in target villages at baseline cessful in the Indian villages. Findings also show
Table 2 (2019) and endline (2020) that own production as a source for cereals in-
Baseline Endline Baseline Endline creased substantially; only 16% of respondents
reported purchasing cereals from the market
Severe wasting (≤-3 WHZ) 23 (3%) 31 (4%) 68 (12%) 0 (0%)
across all locations compared to almost 70% at
Moderate wasting (≤-2 and ≥-3 WHZ) 99 (15%) 150 (18%) 82 (15%) 80 (14%) the time of baseline. Respondents also reported
Total 122 (18%) 181 (22%) 150 (27%) 80 (14%)
increased consumption of animal products
among those women farming animals including
hens, goats and fish.
Members of the village institutions are also en- Results of baseline and endline Children’s diet diversity
gaged as volunteers for the LANN+ sessions,
surveys The proportion of children consuming four or
nutrition awareness, village micro planning and
After 24 months of implementation, the project more food groups increased from 4% at baseline
integrated farming to ensure project sustainability.
aimed to achieve a 15% reduction in wasting to 41% at endline in India and 2% to 100% in
Meso- and macro-level interventions (measured by weight-for-height z-score) for Bangladesh. Children aged 9-23 months of age
Activities also take place at the meso- and children aged 6-36 months, a 30% improvement also showed 100% achievement in minimum
macro-level through local NGOs supported by in the number of women of reproductive age meal frequency in Bangladesh but only a 9% in-
WHH. Partner NGOs develop knowledge man- attaining minimum diet diversity for women, a crease from baseline in India in the same age
agement platforms to facilitate exchange between 40% improvement in children aged 6-23 months group, and meal frequency in children aged 6-8
communities and policymakers. They also work in target households attaining a minimum ade- months actually decreased in India (15% at base-
to build the capacity of elected representatives quate diet and a 60% improvement in target line compared to 7% at endline). The lack of in-
at gram panchayat/ward/municipality levels on households improving WASH practices. crease in meal frequency in India may be as a
nutrition-sensitive village micro planning and result of strong social taboos and myths around
understanding government schemes and budgets. To measure success, a baseline survey was complementary feeding. In addition, twice as
Platforms are also created at state and national carried out prior to implementation, from April many women from agrarian families are engaged
level to facilitate networking between partner to May 2019, followed by an endline survey in the agriculture sector in India than in
organisations and to lobby government on policy after 12 months, carried out in May to June Bangladesh, so the feeding of young children is
development and citizen rights at national level 2020. For the baseline survey, a sample of 10% often taken care of by older siblings or grand-
for local-level support. To support these activities, of households with children aged 6-36 months parents. Efforts are being made to popularise
WHH has developed manuals, training videos was selected. Due to budget limitations, the homemade instant mixes which are high in pro-
and information, education and communication survey was restricted to 50% of the project tein, carbohydrates and micronutrients to help
materials to support the training of community villages and random sampling was used to to boost the nutrient intake of young children.
and service providers in scaling up services to identify the 110 villages. Clusters from each of
new villages.3 these villages were selected using ENA software 3 https://welthungerhilfeindia.org/publications/
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WASH behaviours main protein sources are pulses and milk, com- These are still early days in the project.
Access to safe drinking water has improved. In pared to fish, eggs and chicken in Bangladesh. Funding from the German Federal Ministry
India, larger numbers of families now access Project areas in Central India also have a very for Economic Cooperation and Development
private and public taps for drinking water (from long dry spell during which water is scarce has enabled the project to be extended for an
16% at baseline to 57% at endline). In Bangladesh, which affected the ability of many households additional three years. Activities at village-level
where the primary source of drinking water is to support dietary diversity throughout the year are ongoing with a focus now on sustaining
handpumps, access to safe drinking water has (in between the baseline and endline studies). new behaviours and achieving the ‘last mile’ in
increased from 42% to 89%. Hand washing knowl- A major limitation of these findings is that there project villages before partners gradually phase
edge and practices improved at household level was no control group; changes therefore cannot out. This will take time and will require a con-
from baseline to endline in both countries. Every be definitely attributed to the project. That said, tinued multi-sector approach that is refined
household in Bangladesh has now installed an the impact on the quality of life of the project for the specific context of each country. In
improvised tippy tap.4 In India, tippy taps have participants was readily observed by partners India, the focus will be on reducing women’s
been installed at service delivery points but they and has resulted in attention from governments engagement in work outside the household and
are yet to take off at household level. Some house- and development agencies. on home-based income-generating activities,
holds have been provided with hand washing as well as building skills to ensure sustainable
An important lesson learned from this pro- dietary diversity and increased meal frequency
stations but, due to scarcity of water knowledge,
gramme is that increased knowledge can only for children. In Bangladesh, the focus will be
this has not translated into practice in terms of
translate into new behaviours in the context of on scaling up the programme through govern-
hand washing to the expected degree (nearly all
an enabling environment including access to ment systems. The creation of knowledge man-
respondents reported washing their hands after
water, livelihood opportunities within the village, agement platforms for experience sharing and
using the toilet but not at other key times such as
access to markets, improved infrastructure and the exchange of tools to minimise duplication
after handling animals or before eating and
the improved delivery of government services and save time during scale-up of the Nutrition
preparing food). Positive change was seen in the
and good governance. To be successful, multi- Smart Villages model is another focus area of
use of toilets among households who already
had toilets but were not previously using them. sector programmes must be designed to integrate the second phase, as well as the piloting of a
into existing community-level institutions and mobile-based data collection and management
Discussion link to existing government schemes. This is system in Bangladesh that will share information
Over the course of one year, substantial gains what makes the programme scalable. The limita- with government institutions.
were seen in project areas in both India and tions of local government institutions in countries
Bangladesh in terms of improved dietary diversity such as India and Bangladesh are a major im- Further afield, evidence from this programme
of women and children as well as in the adoption pediment to sustainable change, in particular the is being used to inform the implementation of
of improved WASH practices. There was some lack of staff at grassroots level provides a major the same model in other countries with high
decline in levels of child wasting in project constraint to realising full government services. burdens of undernutrition. During this next
villages in Bangladesh but no improvement (and Strengthening local institutions and financially phase, WHH is supporting implementation
in fact a slight increase) in levels in India. The supporting volunteers were found in this context and scale up in Tajikistan, Afghanistan, Pakistan
lack of expected change in child nutrition status to be a suitable stopgap. Financial models are and Myanmar. Virtual workshops and ‘South
may be as a result of the short implementation being explored to sustain this in the long term, to South’ exchange programmes are planned
period (11 months). Poorer outcomes in India such as service charges for volunteers paid by the to support this effort as well as joint conferences
compared to Bangladesh may be driven by the community. The collection of data is also important with the SAARC agriculture centre5 in Dhaka
fact that women in Central India are heavily to enable proper monitoring of progress. Data involving representatives from all seven coun-
engaged in agriculture, wage labour, migration collection should focus not only on inputs and tries. Learnings will continue to be captured
and fetching water (more so than in Bangladesh) outputs but also results, for example, not just on and shared.
and therefore have less time for childcare which whether toilets are constructed but the levels of For more information, please contact Sweta
may compromise infant feeding practices. Vari- open defecation, or not just on the development Banerjee at
ations in dietary practices between the two of nutrition gardens but on the consumption of [email protected]
countries may be another cause; in India, the vegetables year-round.
© Welthungerhilfe

4 Tippy Tap is a hands-free device for hand washing that is

specially designed for rural areas where there is no running
water. It is operated by a foot lever and thus reduces the
chance for the transmission of pathogens, as the user only
touches a bar of soap suspended by a string.
5 SAARC Agriculture Centre is a South Asian Association for
Regional Cooperation agency responsible for promoting
Research and Development in agriculture in South Asian
countries.

References
Ahmed, M and Suphachalasai, S (2014) Assessing the
costs of climate change and adaptation in South Asia.
Mandaluyong City, Philippines: Asian Development Bank.
Access at: http://hdl.handle.net/11540/46
Development Initiatives (2020) 2020 Global Nutrition
Report: Action on equity to end malnutrition. Bristol, UK:
Development Initiatives. Accessed at:
https://globalnutritionreport.org/0fb38d
International Institute for Population Sciences (IIPS) and
ICF (2017) National Family Health Survey (NFHS-4), 2015-
16: India. Mumbai: IIPS. Accessed at:
https://dhsprogram.com/pubs/pdf/FR339/FR339.pdf
Matka filter distribution, Darshana
Mahila Kalyan Samity, 2019 WHO/UNICEF (2017) Joint monitoring programme (JMP)
for water supply and sanitation. https://washdata.org/
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© Equipe Projet, PUI, Mission Tchad.

Field Articles
.........................................

In Chad, the
Mother-MUAC
approach
improves
treatment
access for
malnourished Practice session for MUAC

children measurement by MUAC mothers

in the Mahamata area of Chad

By Hyppolite Gnamien,
Chantal Autotte Bouchard,
Jean-Robert Bwanaissa Shabani,
Emily Helary and Marion Blanloeuil CHAD
What we know: Screening for malnutrition is increasingly conducted by family
Hyppolite Gnamien is a
medical doctor specialising members as a means of enabling broader and earlier detection of child malnutrition.
in public health. Hyppolite is What this article adds: In 2018, the non-governmental organisation, Première Urgence
the Medical Coordinator of
Internationale, introduced the ‘Mother-MUAC approach’ into its nutrition programme
the Première Urgence
in the Ouaddaï province of Chad. Screening coverage increased from 79.6% when
Internationale mission in Chad.
using the previous approach (screening conducted by community health workers
Chantal Autotte Bouchard is (CHWs)) to 85.5% (screening conducted by family members). An increased percentage
a nurse specialising in of children diagnosed with severe wasting were also admitted for treatment at a health
malnutrition, public health facility (63.2% in the Mother-MUAC approach versus 50.2% in the CHW approach).
and tropical medicine.
Therapeutic treatment performance indicators were comparable between both
Chantal is the health and
strategies. Results also demonstrated strong acceptance by mothers of the Mother-
nutrition referent for
Première Urgence Internationale MUAC approach, both by mothers doing the screening and by mothers whose children
Headquarters. were screened by mother-peers. Health staff are also highly supportive of the approach
due to the improved programme coverage and the cooperation of caregivers. In
Jean Robert Bwanaissa
addition, the programme support costs were reduced by 27% according to average
Shabani is a medical doctor
specialising in public health. support cost per health centre. In this programme, the Mother-MUAC approach has
He is the Health/Nutrition proven effective in facilitating diagnosis and accelerating the management of children
Technical Manager in in situations of concern.
Ouaddaï for the Première
Urgence Internationale mission in Chad.
Emily Helary is a Program
Officer at Première Urgence Background rhoea (13.5%)3 with malnutrition being a major
Internationale Ouaddaï province is located in Eastern Chad contributing factor. In Ouaddaï province in
Headquarters. on the border with Sudan. It is subject to 2018, the prevalence of global acute malnutri-
strong climate fluctuations, rapid desertification, tion (GAM) was 17.8% and 5.1% for severe
soil erosion and reduced land productivity1 as acute malnutrition (SAM) (Republic of Chad
Marion Blanloeuil is Desk well as inter-community conflicts leading to Ministry of Public Health, 2019). Nutrition
Assistant at Première internal population displacements. Chad also interventions in the province therefore have a
Urgence Internationale hosts over 300,000 refugees from Sudan in crucial role to play in ensuring child survival
Headquarters. and growth. In its National Nutrition and
camps in the Eastern provinces.2 Climatic con-
ditions and migratory flows put great pressure Food Policy (Republic of Chad, 2013), the
on already weak natural food and financial Chadian government put in place strategies
The activities described in this article are to improve the nutritional situation including
implemented by Première Urgence resources in the Ouaddaï province, as well as
on response capacities for the provision of prevention activities and the adequate man-
Internationale in partnership with the
basic social services. agement of acute malnutrition. The treatment
Provincial Health Delegation of Ouaddaï,
Chad, thanks to the support of UNICEF and of SAM cases with medical complications is
the European Union through the Directorate- The infant and child mortality rate in Chad carried out in therapeutic feeding centres
General for European Civil Protection and is 113 deaths per 1,000 live births which means (TFC) in district hospitals while cases without
Humanitarian Aid Operations (DG ECHO). that one child in ten dies before reaching the 1
Climate vulnerability index https://www.maplecroft.com/
age of five years. Leading causes of death are 2 www.unhcr.org
malaria (20.4%), pneumonia (15.7%) or diar- 3 https://data.unicef.org/country/tcd/
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22
 Mother-MUAC practice measurements on
their children in the Mahamata area, Chad Field Articles
...................................................

Informing and mobilising the commu-

nity around the approach
PUI, together with the District Executive Teams,
discussed the approach with HC managers (re-
sponsables des centres de santé, RCS), health
centre management committees (comités de
gestion des centres de santé, COGES) and
health committees (comités de santé, COSAN)
in each zone to obtain their approval so that
they could then sensitise the community on
the value of the early detection of acute mal-
© Equipe Projet, PUI, Mission Tchad.

nutrition and the role of mothers in the pre-

vention of malnutrition.

Identification of beneficiary villages

In collaboration with community leaders, the
RCS, COSAN/COGES and functional women
groups in the villages, 759 villages were identified
to be part of the programme's coverage area. A
complications are treated at the community total of 201 out of 960 (21%) were excluded as
months were carried out by Community Relays
they were small or very small villages. Those
level in outpatient therapeutic programmes (in French, ReCo) – community health agents
comprised a large number of ferricks, villages
(OTP) attached to Health Centres (HCs). supervised by the team of around four community
with only a few households, and nomadic non-
health workers (CHWs) from each HC. By this
In 2016, the non-governmental organisation permanent settlements.
time, PUI had recruited and trained 370 ReCos
(NGO), Première Urgence Internationale (PUI),
began implementing a project to prevent and
and 152 CHWs across the three health districts. Identification of the mothers
The ReCos were assigned to a group of villages In order to reach as many mothers as possible,
treat SAM in children under five years of age
to carry out malnutrition screening. These several criteria guided the identification of Moth-
and pregnant and lactating mothers in Ouaddaï
screenings were expensive because ReCos and er-MUACs. To become a Mother-MUAC, vol-
province. In recent years, PUI has identified the
CHWs were paid, with additional bonuses paid unteers were asked to be available and active in
need to improve the quality of nutritional care
on condition of results (number of children their community, be of childbearing age, be ac-
by, among other things, improving the quality
screened for malnutrition, proper reporting cepted by the community, have resided in the
and coverage of screening for malnutrition in
done, community sensitisation carried out). village for at least one year and accept doing the
the community and the referral of children iden-
screening activity on a voluntary basis.
tified for treatment. The ‘Mother-MUAC’ approach From May 2018, several adaptations were
involves mothers screening their own children made to the programme in response to reduced Training and awareness
for signs of acute malnutrition using mid-upper funding. Firstly, the number of targeted HCs was In July 2018, mothers were trained on the use
arm circumference (MUAC) tapes. The effec- reduced by three – from 24 to 21. The three HCs of the MUAC tape to screen for malnutrition
tiveness of this approach has been demonstrated with the best performance criteria (programme (MUAC measurement), identification of oedema,
in Niger (Blackwell et al, 2015) and has been coverage, quality of care, etc.) were selected for effective infant and young child feeding practices
successfully tested in Chad by several NGOs4 as reduction in support services to minimise any and how to refer children identified as having
a means of enabling broader and earlier detection negative impacts. In addition, Mother-MUAC SAM to nutritional management units. All
of child malnutrition. PUI began incorporating screening was introduced as a more financially women identified to be Mother-MUAC were
Mother-MUAC within its wasting treatment and sustainable form of community screening as well grouped in central locations for a one-day
prevention programme in Ouaddaï province in as to support the more rapid identification and training session. Training was conducted by a
2018, adapting it to the programme realities of referral of children with acute malnutrition for team comprised of two nurses – one from the
the context. This article describes that process, treatment, thereby reducing the complications RCS and the other a PUI staff member.
the results and the lessons learnt. and mortality associated with late treatment.
Implementation of community-based
Implementation of the Mother- In this approach, mothers were trained to screening and referral
MUAC approach in Ouaddaï identify acute malnutrition, either by using a Following the training, each mother received
coloured tape to measure MUAC or by detecting MUAC tapes and began to screen all children
province aged 6-59 months in their village/neighbourhood
oedema. Mothers were trained to screen their
PUI has been implementing a SAM prevention
own children as well as other children from on a monthly basis. Mothers were also given
and treatment programme in an area covered
within their neighbourhood or village. This is yellow and red coupons to pass on to the care-
by 24 HCs in the health districts of Adré (11
different to the common application of the givers of children identified with acute malnu-
out of 22 HCs), Abougoudam (four out of 11
Mother-MUAC approach whereby each mother trition in place of referral forms (yellow if the
HCs) and Abéché (nine out of 30 HCs) in Ouad-
only screens her own child. PUI chose to adapt child was referred for MAM and red if the child
daï province since 2016. The decision to provide
this and train mothers to screen around 12 chil- was referred for SAM). When a child was iden-
support to these three health districts was based
dren aged 6-59 months each, including their tified as having either MAM or SAM, the care-
on a request from the national authorities who
own children and others in their village, all in a giver was sensitised by the trained mother to
had noted that the management of malnutrition
voluntary, unpaid capacity. transfer the child to the HC for treatment. If
was insufficient due to the lack of support from
the caregiver refused, further sensitisation
a technical and financial partner. The services Process for introducing the sessions were held to overcome the barriers pre-
of PUI were recruited to improve the quality of
existing SAM management services and set up
Mother-MUAC approach venting the mother taking her child to the HC.
The process of moving from the ReCo screening When the caregiver of the identified child went
new services where they did not already exist.
to Mother-MUAC was implemented over a two- 4 The Mother-MUAC approach is being used in Chad by the
Until May 2018, community screenings and month period in June and July 2018. The main NGOs: Action contre la Faim, International Rescue Committee
referrals of malnourished children aged 6-59 steps in this process are described below. and ALIMA.
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to the nutrition unit, she gave the coupon to the • Screening performance: based on the responsibility (Figure 1).
health worker who then performed a further number of children identified as having
assessment to validate (or not) the diagnosis SAM by the mothers, PUI analysed the Screening performance
based on admission criteria of the national pro- number of children who were referred, the The Mother-MUAC approach identified 22,791
tocol, i.e., either MUAC or weight-for-height z- number of children referred who arrived at malnourished children including 15,812 cases of
score. Transportation costs for the referral were the HC and the number of referred children MAM6 (23.7% of the children screened) and 6,979
borne by the families. who were confirmed as having SAM at the cases of SAM (10.5% of the children screened).
HC and treated according to the protocol. Of the SAM cases detected, 6,271 (89.8%) were
Follow-up and reporting • Treatment performance indicators: based SAM cases where mothers accepted referral to a
Monitoring of the activity was carried out by the on the number of children who exited the nutritional care unit, 4,971 (71.2% of the SAM
CHWs who were already trained and experienced programme, those that exited as cured, cases detected) arrived at a HC supported by PUI
in MUAC screening. Each month, the CHWs dropped-out, died or non-recovered were and 4,413 (63.2% of the SAM cases detected)
summarised the number of children referred via recorded from both inpatient care and OTCs. were actually admitted for treatment (Figure 2).
Mother-MUAC at each HC. Each CHW also • Mothers' ownership of the activity: the Therefore, 63.2% (two out of three) of all children
conducted random MUAC measurements in perceptions of mothers around the approach identified as having SAM by the mothers were
households covered by the Mother-MUAC pro- were collected informally by the project confirmed as having SAM at an HC and treated
gramme to ensure the effectiveness of the screening managers during the monitoring of the following the protocol. In comparison, screening
and the reliability of measurements. A monthly implementation. by CHWs and ReCos during the previous phase
review was conducted with the PUI teams. When of the project7 identified 37,448 malnourished
an area showed low performance, on-site individual Feedback from HC staff was also sought which children including 13,471 cases of SAM, among
training was conducted in order to improve the provided informal yet key feedback on pro- whom 6,767 (or 50.2%, or half) were admitted to
quality of measurement. gramme implementation. a nutritional care unit for treatment.
At the health district level, the PUI project Programme achievements Therapeutic treatment performance
team and the CHWs documented the consistency From May 2018 to December 2019, 15,004 indicators
and reliability of the reported MUAC colour mothers were identified and trained in the areas The cure rate in OTCs was higher in 2019 (95%)
and the presence of oedema reported by mothers of responsibility of 21 HC in the three health after transitioning to the Mother-MUAC approach
compared to the result of CHW screening on districts of Adré, Abougoudam and Abéché. than before (91.5%). The cure rate in inpatient
arrival at the HC. care was not significantly different, a little over
Screening coverage 94% for both approaches. Other performance
Performance analysis Of the 77,920 children aged 6-59 months ex-
indicators (exited from the programme as
In order to analyse the performance of screening pected for the period, a total of 66,613 were
dropped-out, died or non-recovered) improved
and compare the two approaches, PUI analysed screened using the Mother-MUAC approach,
with the implementation of the Mother-MUAC
the following indicators pertaining to the treat- representing a coverage rate of 85.5% in 21
approach (Figure 3).
ment of children with SAM: areas of responsibility.5 Over the same period
• Screening coverage: number of children during the previous year (using the CHW- Ownership of the activity by the
screened for MUAC and/or oedema ReCos screening approach), 76,710 children mothers
compared to the total number of children were screened of the 96,417 children expected, Analysis of mothers’ perceptions of the effec-
in the coverage area. with a coverage rate of 79.5% across 24 areas of tiveness of screening through the Mother-MUAC
approach were carried out through 60 sessions
supervised by the PUI Health Supervisors and
Figure 1 Screening coverage according to approach (Mother-MUAC vs. ReCo/CHW)
the ReCos. These sessions revealed strong par-
Mother-MUAC ReCo/CHW ticipation of mothers in the management of
# Children expected in coverage area 77, 920 96, 417
their child's health and a strong sense of own-
ership of the activity that they carried out on a
# Children screened 66, 613 76,710 voluntary basis. The involvement of mothers in
Screening coverage 85.5% 79.6% malnutrition screening allows them to better
understand the signs of malnutrition, to partic-
ipate in monitoring the nutritional status of
Figure 2 Screening performance (Mother-MUAC vs. ReCo/CHW) their children and increases the frequency of
screening of children at the community level.
40% Nevertheless, 29% of children identified as
having SAM by the mothers never arrived at a
35%
HC unit. Discussions revealed that the common
30% causes for caregivers not taking referred children
to a HC were the long distances to be covered,
25% the natural barriers in the form of ouadis in the
20% rainy season (temporary watercourses making
access impracticable), mothers' refusal to be re-
15% ferred or a lack of authorisation from their hus-
bands and the heavy workload of mothers
10%
making them unavailable (other household
5% chores or work in the fields). The implementation
and monitoring of this approach helped to
0%
ReCo/CHW Approach Mother-MUAC Approach 5 Children are screened on a weekly basis but counted only once.
6 PUI only supported SAM treatment programmes. Children
Identified as SAM cases SAM cases reached health centre with MAM were therefore not tracked under this programme.
7 The first phase of the project covered a larger geographic
SAM cases where mothers accepted referral SAM admitted for treatment
area, thus the greater number of children expected.
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by mothers of the Mother-MUAC approach,

Figure 3 Treatment performance indicators (Mother-MUAC vs. ReCo/CHW) both by mothers doing the screening and by
mothers whose children are being screened by
Outpatient SAM treatment Inpatient SAM treatment
mother-peers. HC staff are also highly supportive
6% 6%
of the approach, due to the improved programme
coverage and the cooperation of caregivers. In
5% 5%
addition, compared to the CHWs-ReCos ap-
4% 4%
proach, the Mother-MUAC approach has reduced
the programme support costs by 27%, according
3% 3% to average support cost per HC. Given the lack
of funding and the need to ensure regular com-
2% 2% munity screening, the Mother-MUAC approach
is proving to be a sustainable approach in this
1% 1% context. The motivation of the mothers is not
financial which allows for its sustainability,
0% 0% replicability and scaling up at the national level.
Drop out Died Non ercovered Drop out Died Non ercovered
Community-based screening has shown that
ReCo/CHW Mother-MUAC more regular and earlier detection could reduce
the risk of mortality and morbidity in children
6-59 months of age. In our experience, the
strengthen community support and facilitate Screening for acute malnutrition at the com- Mother-MUAC approach has proven effective
acceptance of the programme in the area. Moving munity level is often the responsibility of CHWs. in facilitating diagnosis and accelerating the
forward, additional efforts will be made to im- However, there is growing evidence that families, management of children in situations of concern.
prove compliance with referrals, such as inten- especially mothers, can play an important role The implementation process is relatively straight-
sifying sensitisation (including targeted at men) in screening for acute malnutrition through the forward and empowers mothers to be actors in
and the strengthening of a community solidarity measurement of their child’s MUAC and for the health of their children. Regular monitoring
fund, managed by COGES, to provide financial signs of oedema in their own communities. In of the mothers' activity and good supervision
aid to families that are not able to afford the the context of this programme, the Mother- promote control over MUAC measurements.
transportation costs. MUAC approach provided better coverage of Although the impacts of COVID-19 were
screening than the CHW-ReCo approach and a not a major issue in PUI’s programme area and
Health Centre staff feedback higher screening performance, demonstrated
Interviews with HC staff indicated their per- did not modify the attendance rate at HCs, ap-
by the higher percentage of SAM children iden- propriate steps were taken to enforce proper
ception that, as a result of the training of mothers tified by mothers being admitted for treatment
on the Mother-MUAC approach, there is better prevention measures and to support newly
at an HC (63.2% in the Mother-MUAC approach formed epidemic surveillance committees.
programme coverage and mothers/children's versus 50.2% in the CHW-ReCo approach).
carers are more cooperative with treatment pro- There is some indication that this has led to Looking ahead, PUI aims to continue sup-
tocols and less likely to default. There is evidence shorter treatment duration which suggests that porting the management of acute malnutrition
that the radius of coverage was extended beyond children are being referred more quickly for in this area while working towards handing over
15km from most HCs, a radius that CHWs and treatment, thereby potentially reducing malnu- activities to the government structures and ex-
ReCos never exceeded due to a lack of transport trition-related morbidity and mortality. panding its activities to better address the un-
available to access remoter villages. derlying causes of malnutrition. With the support
Results also demonstrate strong acceptance of the 11th European Development Fund, and
Discussion and conclusions in partnership with a local NGO, this new phase
will focus on increasing agricultural production
while also working towards more preventive nu-
trition activities, including improving infant and
young child feeding practices.
For more information, please contact Chantal
Autotte Bouchard at
[email protected]

References
Blackwell, N, Myatt, M, Allafort-Duverger, T, Balogoun, A,
Ibrahim, A and Briend, A (2015) M others U nderstand A nd
C an do it (MUAC): a comparison of mothers and
community health workers determining mid-upper arm
circumference in 103 children aged from 6 months to 5
years. Archives of Public Health, 73(1), 26.
Institut national de la statistique des études économiques
et démographiques (INSEED) (2016) Enquête
démographique et de santé et à indicateurs multiples au
© Equipe Projet, PUI, Mission Tchad.

Tchad (EDS-MICS), 2014-2015. Rockville, Maryland, USA :

ICF International.
République du Tchad (2013) Tchad: Politique nationale de
nutrition et d’alimentation 2014 - 2025.

Mother-MUAC practice République du Tchad - Ministère de la santé publique

measurements on their children (2019) Enquête nationale de nutrition, TCHAD 2019.
in the Mahamata area, Chad Available at: https://reliefweb.int/sites/reliefweb.int/files/
resources/rapport_final_enquete_smart_27112019.pdf
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AFGHANISTAN
What we know: In emergencies, reliable and up-to-date data is
critical to inform the response but is often limited.
What this article adds: Nutrition Cluster partners in Afghanistan
undertook a process to calculate wasting caseloads and prioritise
geographic areas for services to inform the Humanitarian Needs
Overview (HNO) and funding decisions. People in need were
calculated using combined global acute malnutrition (cGAM), based
on SMART surveys. As recent SMART survey data was unavailable
in many provinces, data from 2015 was used and, where this was
unavailable, extrapolations were made using data from adjacent
provinces. In total, 2.9 million children under five years and 650,438
pregnant and lactating mothers were identified being in need of life
saving nutrition services. Due to lack of funds, provinces were
prioritised on the basis of recent SMART survey data and, where this

Calculating wasting was unavailable, either Seasonal Food Security Assessment data or
mid-upper arm circumference (MUAC) screening data from Health
Management Information Surveys. Data on five known aggravating
caseloads and factors (diarrhoea prevalence, household food insecurity,
immunisation coverage, conflict and risk of COVID-19) were also
considered. As a result, 26 priority provinces were identified (of 34).
geographic Based on an analysis of emerging needs, gaps and humanitarian
partner presence, 88 districts within 21 provinces were finally

prioritisation of targeted using funds available. For situations where SMART survey
data is unavailable, a globally validated standard methodology and
guideline for geographic prioritisation is required to support the
nutrition services in better identification and targeting of locations for nutrition services.

the context of limited Context The director of the Public Nutrition

data in Afghanistan The current humanitarian crisis in

Afghanistan is widespread and severe;
in 2020 it was estimated that 14 million
Directorate (PND) is the co-chair
from the government counterpart.
The Nutrition Cluster strategic advi-
By Beka Teshome Bongassie, Said M Yaqoob sory group (SAG) provides strategic
people were in need of humanitarian
Azimi and Maureen L. Gallagher direction, guidance and advice to the
protection and assistance (OCHA,
2020a). The crisis is characterised by Nutrition Cluster. There are five nu-
Beka Teshome is Nutrition Cluster co-lead for open internal conflict between the gov- trition technical working groups
Afghanistan with Action Against Hunger (AAH). ernment and opposition groups, major (TWGs) in Afghanistan housed under
He holds a Master’s degree in applied nutrition internal displacement, increasing food the PND, namely integrated man-
and has 20 years’ experience working in nutrition insecurity, high levels of malnutrition, agement of acute malnutrition, as-
and health in Ethiopia, Nigeria, Yemen, South limited access to basic services and sessment and information manage-
Sudan and Pakistan. access challenges to crisis affected areas. ment (AIM), mother, infant and young
child nutrition, capacity development
Said M Yaqoob Azimi is the Information
Malnutrition in all its forms is per- and micronutrients. The primary re-
Management Specialist (Nutrition) for UNICEF in
sistent and widespread across sponsibility of the TWGs is to provide
Afghanistan. He is a medical doctor with over 16
years’ experience in the reporting, monitoring Afghanistan, especially among children technical support to partners to im-
and management of information systems in under five years of age and pregnant prove the quality and coverage of
development and humanitarian contexts in and lactating women (PLW). Acute services, develop standard operating
health and nutrition programmes. and chronic malnutrition are highly procedures, review programmes, iden-
prevalent with 41% of children under tify gaps and problems, complete sur-
Maureen L. Gallagher was the Chief of Nutrition
five years of age stunted and 10% wast- vey validation (AIM), knowledge
for UNICEF Afghanistan from August 2018 to
ed (Government of Afghanistan, 2013). management and disseminate infor-
August 2020. She is a public health specialist with
over 15 years’ experience in nutrition-related mation to partners.
The Afghanistan Nutrition Cluster
programming in Africa and Asia in both has been active since 2008. It has The nutrition response in
humanitarian and development settings.
over 50 active partners including gov- Afghanistan is guided by the terms of
The Afghanistan Nutrition Cluster geographic prioritisation and ernment, national non-governmental reference of the Nutrition Cluster and
caseload calculation for Humanitarian Needs Overview 2020 was organisations (NGOs), international guidelines and protocols endorsed by
enabled by the active participation and contribution of individual NGOs, United Nations (UN) agencies, the Afghanistan Government. Services
members of the Strategy Advisory Group and Assessment and civil society, donors and observers. for the treatment and prevention of
Information Management Working Group. The authors would like The national Nutrition Cluster coor- child wasting are implemented through
to thank Aye Aye Khaine for her input into this article. dination team is currently comprised multiple delivery modalities including
The analysis, interpretation and conclusion reflected in this article of a Nutrition Cluster coordinator, fixed health facilities (basic health
are those of the authors. They do not necessarily represent the an NGO co-lead and a nutrition in- centres, comprehensive health centres,
views of UNICEF or Action Against Hunger. formation management specialist. sub-health centres, district and provin-
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Field Articles

People in need (PiN) Comparison of GAM prevalence using 2019 HMIS data vs 2019 SMART
Box 1 calculation formula Figure 1 surveys in selected provinces where all data was available

Total nutrition caseload (PiN) 18.0%

=
Number of SAM children under five years 16.0%
(using cSAM) (A) 14.0%

GAM prevalence
+
Number of MAM children under five years 12.0%
(using cMAM) (B)
10.0%
+
Number of undernourished PLW (MUAC 8.0%
<23cm) (C)
+ 6.0%
Number of children and women at risk of 4.0%
malnutrition among IDPs, refugees, returnees,
vulnerable populations residing in informal 0.0%
Khost Kabul Badghis Daikundi Helmand Nuristan Kunduz
settlements and populations affected by
rapid onset crisis and COVID-19 (D) SMART 2019 - WHZ SMART 2019 - MUAC HMIS 2019 - MUAC

cial hospitals) and through the deployment of available for 31 provinces. For the three remaining The number of PiN (D) among these populations
mobile teams to hard-to-reach areas. provinces with no SMART surveys (Wardak, Sar- was estimated to be 25.3% (17.3% of children
e-Pul and Faryab), extrapolations were made plus 8% of PLW).
Insufficient and delayed funding for lifesaving
using the results of adjacent provinces (based on
nutrition activities are major challenges for nu-
the assumption that the nutrition situation would Caseload results
trition partners in the delivery of timely assistance Using this methodology, it was estimated that,
be similar given that they share similar geographic,
in Afghanistan. As part of the overall joint hu- in 2020, 2.9 million children under five years of
population and livelihood characteristics). The
manitarian analysis and planning process, the age and 650,438 PLW were part of the PiN esti-
most recent population projections issued by the
Nutrition Cluster and its partners undertook a mate. Of the 2.9 million acutely malnourished
United Nations Population Division3 from Sep-
process to calculate caseloads (people in need children under five years of age, it was estimated
tember 2019 were used for estimating the total
(PiN))1 and prioritise geographic areas for that 783,583 children (27%) would suffer from
caseload for 2020. The under-five population was
services to inform the Humanitarian Needs SAM. A further 435,445 children under five
estimated to represent 17.3% of the total population
Overview (HNO) to help mobilise and prioritise years of age, 232,877 PLW and 414,534 mothers
and the number of PLW was estimated to represent
funds for nutrition programming. Given that and caretakers were also estimated to be nutri-
8% of the total population (NSIA, 2019).
few recent Standardised Monitoring and As- tionally ‘at risk’ among IDPs, refugees, returnees,
sessment of Relief and Transitions (SMART) Caseload calculation methodology vulnerable populations residing in informal set-
surveys exist in Afghanistan and the demographic The calculation formula is described in Box 1. tlements and populations affected by rapid onset
and health survey (DHS) does not currently in- Caseloads for SAM (A) and MAM (B) were cal- crisis, including COVID-19. Adding those up,
clude anthropometric data, alternative methods culated by multiplying the prevalence of cSAM the Nutrition Cluster identified 4.63 million
had to be found using available data. This article and cMAM by the under-five population and children and women who would need emergency
describes the process undertaken, results and multiplying this again by a correction factor of nutrition assistance in 2020.
lesson learnt. 2.6 to cater for incidence of acute malnutrition. The highest proportion of malnourished chil-
The caseload for undernourished PLW (C) was
Caseload calculation estimated using the proportion of acutely mal-
dren was located in Kabul (11% of the total
Sources of data for caseload PiN), followed by Nangarhar (8.2% of the total
nourished PLW (MUAC <23cm) in a province PiN), Helmand (6.3% of the total PiN) and
calculation multiplied by the estimated number of PLW in
Following discussions with the SAG and Nutrition Herat (6.3% of the total PiN). Of the total PiN,
that population. the COVID-19 pandemic was predicted to have
Cluster partners, it was agreed that the PiN
would be calculated using the combined preva- To estimate the likely impact of the COVID- pushed an extra 106,214 children under five
lence of global acute malnutrition (GAM), re- 19 pandemic on SAM and MAM prevalence, years of age into SAM, some 284,688 children
ferred to as cGAM. This is an aggregate indicator drawing from the experience of previous mal- under five years of age into MAM and some
that includes all cases of GAM as defined by nutrition crises4, it was estimated that SAM and 87,298 undernourished PLW to require lifesaving
weight-for-height z-score (WHZ) <-2, mid-up- MAM prevalence would increase by 20% in in- treatment and nutritional support.
per-arm circumference (MUAC) <125mm, and/or tegrated food security phase classification (IPC) 1 Defined as people who are acutely malnourished and in need
bilateral pitting oedema.2 This is further aggre- 4 provinces, by 15% in IPC 3 provinces and by of lifesaving treatment or nutritional support within the year.
2
gated into combined severe acute malnutrition 10% in IPC 2 provinces.5 This percentage increase A fuller description of cGAM can be found in an earlier article
in Field Exchange:
(cSAM) and combined moderate acute malnu- was applied to SAM, MAM and PLW caseloads. https://www.ennonline.net/fex/61/gamafghanistan
trition (cMAM) calculated by subtracting cSAM 3
https://data.worldbank.org/indicator/SP.POP.GROW?loca-
We estimated that all children under five tions=AF
from cGAM).
years of age and PLWs among internally dis- 4 In the absence of COVID-19 estimates at the time, and the
lack of country-specific or regional data, estimations drawn
SMART surveys are the only available source placed persons (IDPs), returnees, refugees, vul- from Ethiopia were used. Those were estimates for an emer-
of data for cGAM and cSAM in Afghanistan. nerable populations residing in informal set- gency nutrition response in Somali region refugee camps
However, lack of funding and lack of access to tlements and populations affected by rapid during the 2012 drought to account for an increased burden
of malnutrition.
conflict-affected areas meant that recent SMART onset emergencies, including COVID-19, were 5 The average increase for the 34 provinces was 15%. This is
surveys (2018-2020) were only available for 17 nutritionally at risk (requiring infant and young slightly higher than the Lancet paper global estimate of
of Afghanistan’s 34 provinces. The decision was child feeding in emergencies (IYCF-E) support, 14.3% increase in the prevalence of moderate or severe
wasting among children younger than five years due to
collectively made to use the results of available micronutrient supplementation or blanket sup- COVID-19 (https://www.thelancet.com/journals/lancet/arti-
SMART surveys from 2015 onwards which were plementary feeding programme (BSFP) services). cle/PIIS0140-6736(20)31647-0/fulltext)
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of 26 provinces were categorised as top priority

Figure 2 Afghanistan 26 provinces prioritised for nutrition response in 2020 provinces: nine provinces had a GAM prevalence
above 15% and 17 provinces had a GAM preva-
lence above 10% with two or more aggravating
factors (Figure 2).
Eighty five percentage of the wasting caseload
among children under-five in Afghanistan is
present in these 26 priority provinces. This is a
total of 2.47 million people. The total cost for
reaching PiN in these priority provinces was
estimated to be USD139 million.

Further targeting of resources

In the face of overwhelming needs and severe
funding constraints, in 2020 the Nutrition
Cluster had to further prioritise districts for
support for Afghanistan Humanitarian Funding
(AHF) through which USD8 million was allo-
cated for nutrition services. A further exercise
was therefore undertaken to prioritise districts
within the 26 priority provinces for the targeting
of these limited resources for lifesaving wasting
Prioritisation of provinces for results are not directly comparable to the survey treatment and prevention services. This exercise
data due to differences in methodology, data was carried out using gap analysis methodology.
lifesaving nutrition services analysis found them to be fairly consistent with Information was drawn from the online nutrition
The overall estimated cost to provide lifesaving
SMART survey data (Figure 1). Table 1 summarises database, HMIS, recent nutrition assessment
nutrition services to the 4.63 million children
the final GAM data and reliability scores. The reports, supportive supervision reports and up-
and women in need was USD234 million. In-
identification of high priority provinces was dated information on hard-to-reach districts
sufficient resources and limited programme ca-
guided by the IPC emergency thresholds for and functional health facilities. This provided
pacity meant that provinces needed to be pri- acute malnutrition guidance (IPC, 2019), i.e., a picture of overall nutrition service coverage
oritised to receive nutrition services. ≥15% GAM (critical) and/or ≥10% GAM (serious). and emerging needs and gaps.
Estimation of GAM prevalence Identification of aggravating factors Using these results, districts were prioritised
Geographic prioritisation is usually carried out To complement the GAM classification, provinces if they had emergency levels of GAM (≥15%),
on the basis of the prevalence of GAM among with aggravating factors that are known drivers poor coverage of SAM treatment (<30%), low
children under five years (based on WHZ) using of acute malnutrition (or hypothesised in the coverage of functional health facilities or high
data from recent SMART surveys, validated by case of COVID-19 risk) were identified. Aggra- levels of disruption to health services (due to
the AIM-TWG. However, as already discussed, vating factors were selected as follows: prevalence conflict) with high GAM rates (≥10%), or high
recent SMART survey data (2018-2020) was of diarrhoea, household food insecurity, coverage numbers of recent IDPs with high GAM rates
only available for 17 provinces. For 10 of the re- of childhood immunisation, level of conflict (≥10%). Districts were also prioritised where
maining provinces, MUAC data collected through (population displacement) and risk of COVID- humanitarian partners had operational presence
the Seasonal Food Security Assessment (SFSA) 19 transmission. Multiple available sources of and capacity to implement global and adapted
was used, validated by the AIM-WG. MUAC data were used to assess the presence of these guidelines and standards with COVID-19 pre-
data for children aged 6 to 59 months has been factors in each province. These selected thresholds ventative measures. As a result of this exercise,
collected via the SFSA since 2019 with support and findings are described in Table 2. 88 districts were targeted in 21 provinces.
from the Nutrition Cluster to Food Security
and Agriculture Cluster partners who provided Prioritisation of provinces Discussion
MUAC training, technical guidance and support The six indicators described above (prevalence The estimated wasting caseload of 2.9 million
during data collection. of GAM and five drivers) were used to prioritise for 2020 is much higher than that estimated in
provinces for nutrition services. High priority the previous round of calculations in 2019 of
In seven provinces where neither SMART provinces were determined as those with critical 1.58 million. This is partly because all 34 provinces
survey nor SFSA data was available, the routine levels of acute malnutrition (≥15% GAM) or were included in this exercise, compared to 22
2019 MUAC screening data from health facilities serious levels of acute malnutrition (≥10% GAM) in 2019. It is also likely due to the increase in
collected within the Health Management Infor- with two or more aggravating factors (according acute malnutrition as a result of the impacts of
mation System (HMIS) was used. Although the to the thresholds described in Table 2). A total movement restrictions related to the COVID-

Table 1 Data reliability scores for GAM levels used in Afghanistan

Source of data Recentness of Robustness of Data quality Indicator used for Reliability score (R4 # of
assessment methodology validation population estimate is most reliable and provinces
of acute malnutrition R1 is least reliable) concerned
Ideal: Ideal: Mandatory: Ideal: Ideal:
<12 month Standard/representative AIM-WG validation WHZ R4
SMART survey (Sept 2018 – Aug 2019) 1 – 12 months Standard/representative Validated WHZ R4 10
SMART survey (Sept 2018 – Aug 2019) 13 – 24 months Standard/representative Validated WHZ R3 7
SFSA assessment 1 – 12 months Sub-standard Validated MUAC R2 10
HMIS screening data 1 – 12 months N/A N/A MUAC R1 7
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28
 Field Articles
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Table 2 Aggravating factors identified in Afghanistan, 2020

Aggravating factors Data source Thresholds Findings
1. Diarrhoea prevalence 2018 Afghanistan Health Survey ≥18.1% (greater than the national 16 provinces had high prevalence of diarrhoea
among children prevalence of diarrhoea according to the (above 18.1%) – 13 out of these 16 also had high
under five years MoPH, 2018) GAM prevalence (≥10%)
2. Household food International Phase Classification (IPC) ≥36% of people in IPC levels 3 and 4 (above 15 provinces food insecure (IPC levels 3 and 4
insecurity the percentage of the general population in where ≥36% households food insecure) – 14 out
IPC levels 3 or 4 according to FSAC, 2020) of these 15 also had high GAM prevalence (≥10%)
3. Immunisation 2018 Afghanistan Health Survey Immunisation coverage <50% (less than the 25 provinces had low immunisation coverage
coverage national level of immunisation coverage (less than 50%) – 21 out of these 25 also had high
according to the MoHP, 2018) GAM prevalence (≥10%)
4. Conflict Office for the Coordination of Number of conflict-induced displaced 12 provinces had high levels of conflict induced
Humanitarian Affairs (OCHA) conflict- people ≥1,228 (median number of conflict- displacement – with strong correlation with high
induced displacement tracker (OCHA, induced displaced people) GAM rates (Figure 2)
2020b)
5. Risk of COVID-19 IOM Displacement Tracking Matrix Provinces with ≥50% COVID-19 ‘at risk’ 2 provinces had a high number of COVID-19 at
(DTM) Afghanistan (10 March 2020) districts, through human mobility risk districts (above 50%). Both of these provinces
also had high GAM prevalence (≥10%)

19 pandemic resulting in lack of access to services sources, a wider gap analysis was also undertaken dertake prioritisation to target limited resources
and increased food insecurity in Afghanistan. to prioritise provinces for immediate action. to people most in need. This exercise has demon-
strated the increasing severity of the crisis in
Geographic prioritisation and reliable esti- The process has obvious limitations. Com-
Afghanistan and the need for a higher coverage
mates of caseloads for nutrition treatment and bined prevalence of acute malnutrition was used
of wasting prevention and treatment services.
prevention services are critical for strategic and as a basis for the caseload calculation. However,
On this basis, the Nutrition Cluster partners in
operational decision-making and the planning the availability of SMART survey data covering
Afghanistan call for local civil society and the
of quality services in the context of competing all provinces within a 12 to 18 month period
international community to commit to the Nu-
priorities and limited resources. The SMART was limited. Thus, SMART surveys from previous
trition Cluster priorities outlined in the multi-
survey is the main globally validated methodology years were used which may have resulted in the
sector humanitarian response plan to ensure
for achieving timely and accurate nutrition data under or overestimation of caseloads in those
that the nutritional needs of PiN can be met.
at provincial level. However, where SMART sur- provinces. The use of HMIS nutrition data to
vey data is unavailable due to funding shortfalls prioritise provinces also has limitations as fa- In situations like Afghanistan where recent
and operational challenges, the experiences cility-based routine screening may be subjected and timely gold standard data sources are not
shared here demonstrate that it is possible to to an unknown level of sampling bias. A further available, a globally validated standard method-
bring together a wider set of data for analysis to limitation is that the impact of COVID-19 on ology and guideline for geographic prioritisation
inform the HNO. the nutrition situation is not yet well understood. is required to support the better identification
Data shows an initial drop in the uptake of nu- and targeting of locations with critical nutrition
In the context of Afghanistan in 2020, a PiN trition services due to fear of transmission with needs. This has relevance to the next iteration
calculation was made in order to create an un- a subsequent rise in the adaptation of program- of the Nutrition Humanitarian Needs Analysis
derstanding of the magnitude of the problem ming based on international guidelines. However, Guidance to come in 2021 (GNC 2020).
on the ground and to inform the formulation the actual impact on nutrition status is still un-
of a response plan based on the real needs of af- For more information, please contact Beka
known and therefore caseloads in this exercise
fected communities. In the face of immense Teshome Bongassie at [email protected]
may be over or underestimated.
needs, the prioritisation of areas for nutrition
support was required. This was achieved through Conclusion and References
a comprehensive analysis of multiple available recommendations FSAC (2020) Afghanistan IPC Acute Food Insecurity
Analysis April 2020 – November 2020, Issued in May 2020
data sources to identify the prevalence of acute Despite the limited availability of gold standard - Afghanistan. Retrieved from https://reliefweb.int/report/
malnutrition and aggravating factors contributing data, it is possible to use a wider data set of afghanistan/afghanistan-ipc-acute-food-insecurity-
to malnutrition. In the face of very limited re- proxy indicators to estimate caseloads and un- analysis-april-2020-november-2020-issued
GNC (2020) Lessons Learned Workshop. Nutrition
Humanitarian Needs Analysis Guidance Post Pilot.
Retrived from https://www.nutritioncluster.net/event_
nuthumanitarianneedsanalysisWorkshop
Government of Afghanistan (2013) National Nutrition
Survey Afghanistan (2013) | HumanitarianResponse.
Retrieved from https://www.humanitarianresponse.info/
en/operations/afghanistan/assessment/national-
nutrition-survey-afghanistan-2013
IPC (2019) Acute Malnutrition Version 3 Guidance.
Retrieved from http://www.ipcinfo.org/fileadmin/user_
upload/ipcinfo/manual/IPC_Technical_Manual_3_Final.pdf
NSIA (2019) Afghanistan StatisticalYearbook 2018-19.
Islamic Republic of Afghanistan, National Statistics and
Information Authority. Issue No. 40. July 2109, retrieved
at: https://www.nsia.gov.af:8080/wp-content/uploads/
2019/11/Afghanistan-Statistical-Yearbook-2018-
19_compressed.pdf
OCHA (2020) Internal Displacement due to Conflict |
HumanitarianResponse. Retrieved from
https://www.humanitarianresponse.info/en/operations/af
ghanistan/idps
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Locally-produced fortified
salt on Haitian market
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Field Articles

© USAIDHaiti
HAITI
What we know: Large-scale food fortification of regularly consumed
staple foods can significantly improve the nutritional status of children
and of pregnant and lactating women.
What this article adds: Micronutrient deficiencies are widespread in Haiti.
Food fortification has been shown to be a safe and cost-effective
intervention. In 2017, a panel of experts identified that the fortification of
wheat flour with iron and folic acid ranked second among 85 interventions
that could have the most social, economic and environmental benefits in
Haiti. The same year, the Parliament passed a law making it a requirement
Large-scale food to fortify wheat flour with vitamin B1, B2, B3, folic acid, iron and zinc, salt
with iodine and edible oil with vitamin A. The RANFOSE project is

fortification supporting the implementation of the food fortification law by providing

technical assistance to the Government of Haiti to create a legislative and
regulatory environment that supports the production and importation of
efforts in Haiti fortified foods, to make fortified foods that meet national standards
available and accessible, to establish a system of quality assurance, quality
By Ruth Climat, Yves-Laurent Régis and control and monitoring of sustainable fortified foods and to raise
consumers’ awareness to understand and accept the benefits of fortified
Chrisla Joseph
foods. As a result of these and other efforts, fortified products are
Ruth Climat is a medical doctor with a increasingly replacing unfortified products on the Haitian market despite
Master’s degree in human nutrition. She
constraints such as missing legal application texts to enforce the law, the
has been working in the medical and
nutrition field for more than 10 years in
lack of adoption of a unique food fortification logo and the low capacities
Haiti. She is currently Technical Director of the national testing laboratory.
of the RANFOSE project for Partners of
the Americas.

Yves-Laurent Régis has over 30 years of Malnutrition and (22.7%) suffered from stunting and 6% were
wasted. Sub-optimal infant and young child
experience in the management, micronutrient deficiencies feeding practices in the country contribute
monitoring and evaluation of
programmes for development and
in Haiti to poor nutrition status. The results of the
humanitarian organisations. He is
Deficiencies in micronutrients (vitamins, 2016/2017 DHS showed that only one in
currently the Chief of Party for the food minerals and trace elements), also known four children under six months of age in
fortification project implemented by Partners for Americas as ‘hidden hunger’, have devastating con- Haiti was exclusively breastfed and only
and the Global Alliance for Improved Nutrition (GAIN). sequences on populations, the clinical signs 25%, 40% and 11% of children aged 6 to 23
of which often only become visible after months achieved minimum diet diversity
Chrisla Joseph is a specialist in the deficiency has caused major, often ir- (MDD), minimum meal frequency (MMF)
monitoring and evaluation with over 10 reversible, internal damage. These defi-
years of experience in managing and
and minimum acceptable diet (MAD) re-
ciencies are directly associated with a sig- spectively (IHE & ICF, 2018). The con-
assessing food security and development nificant increase in the risks of morbidity
projects. She is the project coordinator of sumption of foods rich in micronutrients
and mortality and have consequences not such as vegetables and nuts (28 to 62%),
the RANFOSE project.
only for those affected but also for families, dairy products (42 to 35%), meat (14 to
The Ranfòse Abitid Nitrisyon pou Fè Ogmante Sante health services, education systems and so- 38%), eggs (6 to 7%) and food rich in
(RANFOSE) project is funded by the United States Agency cieties in general. Despite the scarcity of vitamin A (23 to 39%) is uncommon (Ayoya
for International Development (USAID). Successes complete and/or recent data, micronutrient et al., 2014). Chronic food insecurity restricts
achieved were made possible thanks to the contribution deficiencies are considered to be a public access to a healthy, diversified and balanced
of the Ministry of Health and the industries fully involved health problem in Haiti. According to the diet and contributes to low diet diversity.
in food fortification in Haiti (Les Céréales d’Haïti, Les latest Demographic and Health Survey According to the latest report from the Na-
Moulins d’Haïti, Carribex, HUHSA, DEKA Group and Bon Sèl (DHS) of 2016/2017, iron deficiency tional Food Security Coordination (CNSA,
d’Haïti). anaemia was present in 49% of non-preg- 2020), nearly four million Haitians are
nant women of childbearing age and in acutely food insecure (Figure 2).
Prevalence of anaemia in 66% of children aged 6 to 59 months
Figure 1 children by department, Haiti (Figure 1) (IHE & ICF, 2018). Furthermore, Ongoing interventions to
nearly 35% of the Haitian population are address micronutrient
considered to be exposed to the risk of
zinc deficiency (Wessells & Brown, 2012)
deficiencies
UNICEF introduced the use of multiple
61% – 63%
and 2006 survey data showed that 32% of
micronutrient powders (MNPs) in Haiti in
children were vitamin A deficient and 25%
64% – 66% 2010 to improve the nutrient quality of
of children aged 6 to 12 years were iodine
67% – 68% complementary foods for children aged 6
deficient (MSPP & UNICEF, 2006).
69% – 70%
to 23 months and since that time the Ministry
Micronutrient deficiencies occur along- of Public Health and Population (MSPP)
side other forms of undernutrition in Haiti. has adopted their use in its national nutrition
A January 2020 Standardised Monitoring policy (Ayoya et al., 2014). Several other
and Assessment of Relief and Transitions interventions, including vitamin A supple-
(SMART) survey revealed that nearly one mentation, prenatal micronutrients distri-
in four children under five years of age bution to pregnant and lactating women
Source: 2016/2017 DHS (IHE & ICF, 2018) ...............................................................................
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30
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Field Articles
and nutritional education, have also been ongoing with vitamin B1, B2, B3, folic acid, iron and zinc, Finance, Customs and the Ministry of Agriculture
in Haiti for decades. Unfortunately, however, the salt with iodine and edible oil with vitamin A. with the objective of strengthening their involvement
coverage and impact of these interventions remains in the implementation of food fortification in
low. According to the latest DHS, only 7% of RANFOSE project Haiti. In addition to the technical support provided
children had received iron supplements in the pre- To support these efforts, in July 2017, the United to companies, the members of the working group
vious seven days, 30% had received a vitamin A States Agency for International Development (US- were connected to the GAIN premix facility for
capsule in the six months prior to the survey and AID) in Haiti launched the Ranfòse Abitid Nitrisyon the acquisition of good quality premixes.
less than half of women of reproductive age (43.2%) pou Fè Ogmante Sante (RANFOSE) project. This
reported receiving iron tablets during their last project is implemented by Partners of the Americas Promotion of food fortification
pregnancy (IHE & ICF, 2018). Although no studies and the Global Alliance for Improved Nutrition Several activities have been organised with different
have been undertaken to clearly identify the reasons (GAIN) in collaboration with the MSPP, the private actors in coordination with MSPP to promote
behind these poor performances, poor access to sector and other partners in order to: food fortification. Advocacy and awareness-raising
health services and the disruption of inputs to • Create a legislative and regulatory environment materials were developed and a radio and television
health facilities are commonly reported. that supports the production and import of communication campaign was launched in July
fortified foods in Haiti; 2020 to raise awareness among the population
The state of food fortification in • Make fortified foods that meet national and industrial users of fortified products about
Haiti standards available and accessible; the consequences of micronutrient deficiencies
Several interventions are capable of reducing mi- • Establish a system of quality assurance, and the benefits of fortified foods. To help cus-
cronutrient deficiencies but food fortification, as quality control and monitoring of sustainable tomers make an informed choice, a food fortifi-
a complement to other interventions, has been fortified foods; cation logo to be affixed to fortified products was
shown to be the safest in terms of the least side- • Educate consumers to understand and accept developed and is awaiting final approval from
effects and to have the most significant cost- the benefits of fortified foods. the Department of Health before it can be deployed.
benefit ratio. Worldwide, the benefits of fortifying
staple foods with iron and salt with iodine are es-
The following activities have taken place in Achievements of the
support of these efforts. programme to date
timated to be USD7.2 billion per year (Horton et
al., 2010). Evidence of measurable improvements Creating an enabling environment The strategies used to support and expand forti-
in the micronutrient status and health outcomes In March 2018, the RANFOSE project launched a fication in Haiti have brought about some successes
in women and children in low- and middle- Food Fortification Working Group (FFWG) made to date. Today, all locally produced foods targeted
income countries through food fortification are up of members of the private sector including for fortification are available in a fortified version
also reported (Keats et al., 2019). wheat flour mills, oil bottling companies, the in the local market and some imported versions
country’s iodised salt plant and various major im- are also fortified. The number of importers who
In 2017, applying the Copenhagen Consensus market fortified products is steadily increasing,
porters of commodities as well as civil society,
method, a panel of experts identified that the for- as described in the next section. Figure 3 below
United Nations agencies, government entities and
tification of wheat flour with iron and folic acid presents the availability of fortified products
consumer associations. Members of the FFWG
ranked second among 85 interventions that could (wheat flour, oil and salt) before and after the im-
meet on a regular basis to discuss the challenges
have the most health, social, economic and envi- plementation of the RANFOSE project.
and progress of fortification. An action plan of
ronmental benefits in Haiti. According to the
the FFWG was developed that includes a set of Wheat Flour
report, spending HTG331 million1 to fortify 95%
activities to coordinate and mobilise all sectors Wheat flour is consumed in several forms in Haiti
of wheat flour would prevent 140 deaths from
and organisations for the reduction of micronutrient including in soups, porridge, pasta, bakery products
neural tube defect and more than 250,000 cases of
deficiencies and gives directives for quality control, and pastries and snacks (bread, candies, cookies,
anaemia each year, with profits of HTG7.9 trillion
the promotion of fortified foods, measurement of pâtés and other sweet or savoury fried dough).
(HaïtiPriorise, 2017). At the same time, it was es-
progress and accountability of all stakeholders According to the Famine Early Warning Systems
timated that USD34 million and USD37 million
could be saved each year by improving iodine and Provision of technical support Network (FEWS NET), in 2018 the annual con-
iron status respectively (Dieneet al., 2014). As a Following the launch of the RANFOSE project, sumption of wheat flour was 14kg/person on av-
result, the MSPP adopted food fortification among assessments of the flour industry and salt and oil erage, or nearly 240-300,000 metric tons of wheat
the five strategic objectives of the national nutrition plants were carried out and technical support pro- flour per year, 72% of which was produced in
policy and pushed for the drafting of a law to vided to local businesses and importers to identify Haiti (FEWS NET, 2018). Two companies fortify
make food fortification mandatory in the country. needs and ensure compliance with the fortification local flour and some imports are fortified, although
This work finally paid off in February 2017 when levels recommended by MSPP and the Ministry adjustments are still underway to adapt the levels
the Parliament passed legislation making it a re- of Commerce and Industry.2 Working sessions of fortification to meet the recommendations of
quirement to fortify wheat flour, salt and edible are organised on a regular basis with the relevant the MSPP. Currently, over three quarters of the
oil imported or produced locally throughout the competent state authorities such as MSPP, the flour available on the Haitian market is actually
national territory. Wheat flour would be fortified Ministry of Trade, the Ministry of Economy and fortified. Two local companies share a total pro-
duction of fortified flour of 217,100 metric tons
per year and a major player imports nearly 12,000
Figure 2 Haitian population in acute food insecurity, September 2020 metric tons of fortified flour per year. In August
2020, another local flour mill officially started
CURRENT AUGUST 2020 – FEBRUARY 2021
production of fortified wheat flour and is intending
000,000 to supply the aforementioned main importer who
Phase 5 People in Catastrophe will therefore replace the imported flour with
locally produced flour.
4M Phase 4 905,471
People in Emergency
Vegetable oil
3,083,497 Two oil mills are bottling imported oil in Haiti
42% of the population analysed Phase 3 People in Crisis
and have been fortifying this with vitamin A since
People facing high acute food 3,02,634
Phase 2
insecurity (IPC Phase 3 and above) People Stressed 1 The ‘gourde’(HTG) is the national currency of Haiti
2 Since October 2020 it has been mandatory for importers of
2,525,541 wheat flour, salt and vegetable oil to obtain a certificate of
IN NEED OF URGENT ACTION Phase 1 People in No Acute Food Insecurity compliance with fortification issued under the Ministry of
Source: IPC analysis, September 2020 (CNSA, 2020) Commerce and Industry.

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Availability of foods fortified in Haiti before and after 2018,
October 2018. One of these mills decided to also Figure 3 in metric tons
enrich the butter and margarine that it produces
as well. These two oil mills represent roughly 50%
of the Haitian market share with a total of 6,500 Iodised
to 8,500 metric tons received in bulk per month. salt 9,500
At the same time, several major importers have
also taken the step to import fortified oil. Today, Fortified
oil 80,000
seven brands of oils are fortified with vitamin A.3
We can therefore estimate that nearly 80% of the Fortified
oil available on the Haitian market is fortified. 229,100
flour

Salt 50,000 100,000 150,000 200,000 250,000

The vast majority of iodised salt available in Haiti
is imported and contains potassium iodide. Ac- Before 2018 After 2018
cording to MSPP, this chemical form is not rec-
ommended for a tropical country like Haiti and
instead industries should use potassium iodate. interruptions to the food supply chain. These ex- micronutrients in oil, salt and wheat flour in
One local factory does produce iodised salt that ternal factors have led to major delays in the im- Haiti. The food vehicles selected for fortification
complies with the MSPP recommendations. This plementation of activities linked to food fortification are widely consumed by the entire population,
factory produces approximately 300 metric tons efforts. For instance, although the legislation re- fortified products are increasingly replacing un-
of iodised salt per month in the form of both garding food fortification was enshrined in law fortified products, routed through the same dis-
coarse salt and fine salt. In August 2020, a new almost four years ago, some essential pillars of tribution channels, and since no price increase
player joined the programme to commercialise the legal framework are still not yet in place, for has been recorded following fortification, we
locally produced iodised salt. This new distributor example legal texts specifying the modalities of expect that these efforts will lead to greater avail-
has the potential to help improve the availability the application of the law, food fortification stan- ability of micronutrients for the population
of appropriately fortified salt which currently rep- dards, rules and guidelines and a logo to clearly throughout the national territory.
resents slightly over 16% of the salt market. identify fortified products for consumers.
Targeted efforts are needed to overcome chal-
Despite the fact that the population has his- Another challenge is that companies that vol- lenges to ensure the full and sustainable rollout of
torically preferred locally produced non-iodised untarily adopt fortification and absorb the asso- food fortification. To this end, RANFOSE will
salt for household use, which is cheaper, sales of ciated costs do not receive any kind of support or continue to advocate for the publication of technical
locally-produced iodised salt have increased re- incentive from government authorities while those legal texts by the Haitian government, improved
cently. This is likely as a result of the promotional who do not fortify their products are not penalised. quality control and collaboration between industries
efforts of the MSPP particularly around the use In the absence of effective control and sanctions, and laboratories to guarantee a sustainable food
of iodised salt in school canteens, supported by company adopters may lose motivation to continue control system and the development and dissem-
RANFOSE, and the promotion of its use via other enriching their products. This needs to be ad- ination of norms and standard operating procedures
organisations such as Fonkoze4 or Projet Santé.5 dressed. A final challenge is that, currently, the for fortification. RANFOSE and its partners will
quality assurance and control system is poorly also continue to invest in communication campaigns
Challenges to food fortification harmonised and inefficient. Some entities of the to raise the population’s awareness of the importance
in Haiti quality control system are not yet involved in of fortified foods to maintain demand and project
In spite of the successes of the national food for- food fortification due to the lack of publication sustainability towards achieving improved health
tification programme in Haiti, there have been of application texts. Furthermore, the capacities and nutrition throughout the country.
major challenges to its progress as a result of the of the national laboratory need to be strengthened For more information, please contact RAN-
prolonged political crisis in the country, often ac- to provide appropriate quality control testing. FOSE at [email protected]
companied by violent street demonstrations and
roadblocks as well as fuel shortages which have Conclusion 3 This latest estimate includes a new company that has been
regularly hindered the transporting of fortified Large-scale food fortification of regularly consumed importing fortified oil since November 2020.
4
Fonkoze is both a financial service (micro-finance) and a
products throughout the country. In addition, staple foods can significantly improve the nutri-
non-profit foundation that provides development services
frequent changes in government have affected tional status of children and pregnant and lactating and programmes to support the ultra-poor, working to
planning and coordination with public entities women. Fortification, if well implemented, has secure financial and technical support for its Haitian partners.
The Fonkoze Foundation is implementing the USAID-funded
and the deterioration of the economic situation the capacity to reach the most vulnerable popu-
“AKSYON” project which builds on their network of community
has limited the population’s access to fortified lations in communities that other interventions health stores to decrease the number of women and children
foods. This situation has been exacerbated by the cannot reach. Efforts in recent years by the gov- under five years of age who suffer from malnutrition.
5 Projet Santé is a USAID-funded project providing integrated
impacts of the COVID-19 pandemic which have ernment, supported by the RANFOSE project,
maternal and child healthcare, including nutrition services
led to a further slowdown of the economy and have considerably improved the availability of and HIV care, in the hospitals and communities of Haiti.

References
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Daniel, E F, Durandisse, E B, Saint-Fleur, J E, Beaulière, J M, Koita, Y, March 2018. Famine Early Warning Systems Network Z (2019) Improved micronutrient status and health
M'mbakwa, B E, Stoltzfus, R J, Pierre, J M (2014) Précis of nutrition (FEWS NET). Available at: https://fews.net/central-america- outcomes in low- and middle-income countries following
of children and women in Haiti: analyses of data from 1995 to and-caribbean/haiti/market-fundamentals/march-2018 large-scale fortification: evidence from a systematic review
2012. Ann N Y AcadSci;1309:37-62. doi: 10.1111/nyas.12373 and meta-analysis. Yearbook of Paediatric Endocrinology.
HaïtiPriorise (2017) HaïtiPriorise Eminent Panel Findings. 10.1530/ey.16.13.17.
Coordination nationale de la sécurité alimentaire (CNSA) Port-au-Prince, May 3
(2020) IPC acute food insecurity analysis. Haiti: Acute Food 2017.https://www.copenhagenconsensus.com/haiti- Ministère de la Santé Publique et de la Population &
Insecurity Situation August 2020 - February 2021 and priorise/haiti-priorise-eminent-panel-findings UNICEF (2006) Enquête sur la prévalence de la carence en
Projection for March - June 2021. http://www.ipcinfo.org/ vitamine A et de la déficience en iode en Haïti. Port-au-
ipc-country-analysis/details-map/en/c/1152816/ Horton, S, Shekar, M, McDonald, C, Mahal, A and Krystene Prince, Haïti. Ministère de la Santé Publique et de la
Brooks, J (2010) Scaling Up Nutrition: What Will It Cost? Population & UNICEF.
Diene, S, Eveillard, R, Kovach, T, Lêlio-Joseph, M, Moses, P, The World Bank, Washington, D.C.
Oot, L, Ralph, B, Sethuraman, K, Sommerfelt, A E (2014) Wessells, K R and Brown, K H (2012) Estimating the global
Reducing Malnutrition in Haiti: Estimates to Support Institut Haïtien de l’Enfance (IHE) et ICF (2018) Enquête prevalence of zinc deficiency: results based on zinc
Nutrition Advocacy – Haiti PROFILES 2013. Washington, DC : Mortalité, Morbidité et Utilisation des Services (EMMUS-VI availability in national food supplies and the prevalence of
FHI 360/FANTA and Ministère de la Santé Publique et de la 2016-2017) Pétion-Ville, Haïti, et Rockville, Maryland, USA : stunting. PloS one, 7(11), e50568.
Population, Haiti. IHE et ICF. https://doi.org/10.1371/journal.pone.0050568
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 Suaahara II staff demonstrating
hand washing steps to children in
Salyan district, Nepal, 2018

Nutrition-sensitive WASH programming

to improve the nutritional status of

© Set Lal Dangi/ Suaahara II

women and children in Nepal
By Keshab Shrestha,
Dhruba Dhital, Yubraj Shrestha,
Dipak Raj Sharma and
Dr Kenda Cunningham
NEPAL
What we know: Despite plausible linkages between malnutrition and poor water,
Keshab Shrestha is hygiene and sanitation (WASH) practices and facilities, there is scant documentation to
water, sanitation and date on the integration of nutrition and WASH programming.
hygiene (WASH)
Manager for the What this article adds: A multi-sector approach is being used by the Suaahara II
Suaahara II programme, programme to reduce undernutrition in 42 of Nepal’s 77 districts. In line with government
Environment and Public priorities to become open defecation free and achieve total sanitation, WASH actions were
Health Organization. integrated across Suaahara II districts to develop a conducive environment for improved
Dhruba Dhital is Division WASH through the coordination and capacity building of local government stakeholders,
Chief, Ministry of better demand and awareness creation for improved WASH facilities and behaviours
Physical Infrastructure, among households and engagement with private sector actors to strengthen WASH supply
Water Supply and chains. Suaahara II prioritises hand washing with soap and water at critical times and the
Sanitation Division, treatment of drinking water which are promoted through multiple behaviour change
Lumbini Province, Nepal. communication activities. In addition, among the total of 3,353 wards where Suaahara II
Yubraj Shrestha is Senior implements activities, 500 very poor wards were targeted with a package of more intensive
Planning Monitoring and WASH-related activities prioritising six WASH behaviours (regular use and cleanliness of
Evaluation Officer, WASH, toilet, hand washing with soap and water, safe drinking water, menstrual hygiene, food
Suaahara II programme, hygiene and peri-home cleanliness). Monitoring data shows the uptake of some promoted
Environment and Public WASH behaviours in non-intensive and intensive WASH areas with a greater change over
Health Organization. time in intensive areas. Key learnings from the programme include the need to address
Dipak Raj Sharma is multiple barriers to behaviour change, to have a multi-level approach, to closely monitor
Private Partnerships and critical indicators and to involve the private sector to address supply barriers.
Digital Promotion
Manager, Suaahara II
programme, Helen
Keller International. Background facilities and practices contribute to sickness and
Nutrition and WASH situation in malnutrition; for instance, in a given two-week pe-
Dr Kenda Cunningham is riod, nearly 8% of children under five years of age
Senior Technical Advisor
Nepal
The prevalence of stunting and underweight among have diarrhoea (MoH Nepal, 2017).
for Integrated Nutrition
and Monitoring, children under five years of age have markedly de- Although it is well-known that poor WASH
Evaluation and creased in Nepal over the last 20 years from 57% to practices and facilities are key drivers for diarrhoeal
Research, Suaahara II 36% and 42% to 27% respectively (MoH Nepal, diseases and associated with environmental en-
programme, Helen Keller International. 2017). Nepal has also made tremendous progress teropathy both of which inhibit the absorption
on several key water, sanitation and hygiene (WASH) and use of calories and nutrients, studies to date
The authors acknowledge the United indicators: basic drinking water services now reach including several well-documented trials have
States Agency for International 95% of households and basic sanitation services shown mixed results of the effect of WASH pro-
Development (USAID) for providing reach 79% of households (MICS, 2019). However, gramming on nutritional status. This is partly be-
support to prepare this manuscript. This further improvements are needed. Child undernu- cause, as trial authors have noted, community
publication was prepared using the
trition continues to be a major public health burden coverage of improved sanitation is crucial in ad-
programme approach, strategies and
and the prevalence of households consuming safe dition to household-level behaviours (Pickering
data for Suaahara II. The contents of this
publication are the sole responsibility of
drinking water, hand washing with soap and water et al, 2019). Implementing programmes across
the authors and do not necessarily at all key times and engaging in other ideal WASH levels (household and community) and across
reflect the views of USAID or the United practices remains low. Almost 20% of households sectors (WASH and nutrition), however, remains
States Government. do not have a fixed place for hand washing and challenging. For instance, integrated programmes
only 47% of households use soap and water for that aim to share new information and change
hand washing (MoH Nepal, 2017). Poor WASH behaviours across multiple sectors can put increased
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33
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pressure on staffing, budgets and the focus and Following the formulation of the Sanitation undernutrition in Nepal, particularly among
time of both frontline workers and households. and Hygiene Master Plan 2011 in Nepal, within mothers and children within the first 1,000 days
Furthermore, unless WASH or nutrition indi- which CLTS principles were central, the adoption of life, with interventions spanning nutrition,
cators are included in project objectives, there of the approach was accelerated across the coun- health and family planning,1 WASH, agriculture
is little incentive to work towards an integrated try. As a result, in 2019, Nepal became the first and markets and nutrition governance.
goal (Teague et al, 2014). South Asian nation declared ODF. Nepal has
The integrated WASH component of Suaahara
since transitioned to a post-ODF approach fo-
Government multi-sector approach cused on total sanitation initiatives. Nepal’s 2017
II initially focused on ODF, in alignment with
The Government of Nepal (GoN) has prioritised national priorities and policies, gradually tran-
Total Sanitation Guideline has multiple WASH
a multi-sector approach to improve the popula- sitioning to a focus on total sanitation initiatives.
indicators at the household, institutional, market
tion’s nutritional wellbeing. Both the Nepal The focus of WASH programming in Suaahara
and environmental levels in recognition of the
Health Sector Strategy (2015-2020) and the II programme areas is now to develop a conducive
need to streamline and ensure the efficacy of
Multi Sector Nutrition Plan (2012-2022) have environment for total sanitation at the local
sanitation and hygiene programming (GoN,
emphasised the importance of collaboration level through the coordination and capacity
2015a). The guideline is based on Nepal’s Sani- building of local government stakeholders, by
with the WASH sector to promote hand washing
tation and Hygiene Master Plan and was devel- creating demand and awareness at the household
with soap at critical times, safe drinking water,
oped for use by government agencies, local level to improve WASH facilities and behaviours
open defecation free (ODF) communities and
bodies, development partners and other WASH and by strengthening WASH supply chains
water safety plans. Development partners have
stakeholders to aid implementation. Scale-up through engagement with private sector actors.
also aligned with these priorities and multi-
has been facilitated by the Department of Water Figure 1 illustrates the key components of the
sector approaches.
Supply and Sewerage Management with budgets Suaahara II total sanitation programme.
Adoption of the community-led total and staffing allocated at local government level.
sanitation (CLTS) approach in Nepal This article describes the experiences of inte- Development of a conducive
There has been a major focus in South Asia in grating WASH programming using a total san- environment
recent years on communities becoming ODF itation approach into a large-scale multi-sector Suaahara II works with all levels of government
primarily using the Community Led Total Sani- nutrition programme in Nepal in line with gov- – federal, provincial, municipal and ward – to
tation (CLTS) approach. Rather than focus ex- ernment priorities. provide technical assistance for the development
clusively on toilet construction, the CLTS ap- of policies and plans, to implement nutrition-
proach, now used in over 66 nations worldwide, Suaahara II integrated nutrition relevant WASH interventions and to advocate
aims to mobilise communities to eliminate open and WASH programming for the allocation of resources. To support this,
defecation by facilitating their own appraisal The Suaahara II programme is a five-year inte- the Suaahara II team has provided support to
and analysis of the situation and taking their grated nutrition programme funded by the reactivate, and form where not available, WASH
own actions to become ODF (Musembi, 2016). United States Agency for International Devel- Coordination Committees, particularly at mu-
In an evaluation of India’s Total Sanitation Cam- opment covering all communities of 42 of Nepal’s nicipal level, and to link these with Nutrition
paign, Spears (2012) found that as the programme 77 districts which began in April 2016 as a con- and Food Security Steering Committees to sup-
intensified, infant mortality reduced, eliminating tinuation of the Suaahara programme. Helen port cross-sectoral collaboration for nutrition.
an estimated one-fifth of infant deaths and in- Keller International is the lead partner for the Suaahara II has also facilitated meetings and
creasing child height by an estimated 0.2 standard programme which is implemented through a led trainings to build the capacity of committee
deviations which is similar to the impact of dou- consortium with six other organisations. The
bling household food consumption per capita. aim of the programme is to reduce widespread 1 https://www.ennonline.net/fex/64/familyplanningnutritionnepal

Figure 1 Key components of the Suaahara II total sanitation programme

- Hand washing with soap and water at six

- Regular use and
critical times
cleanliness of toilet
- Availability of hand washing station
- Availability of toilet
- Menstrual hygiene
cleaning materials
- Other personal hygiene
- Safe disposal of babies’
excreta in toilet
- Solid and liquid waste
management at - Availabilty of improved
household level cook stoves, kitchen and
- Management of animal dish drying rack
shed and chicken coop - Clean kitchen

- Treatment of drinking
water - Cover cooked food
- Safe storage of drinking - Cover silauta/okhali
water - Clean raw food with
- Availability of water treated water before
filter at local market/ consumption
WASH Mart

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Intervention packages on WASH in intensive and non-intensive WASH

An adolescent girl
promoting a reusable
Table 1 communities
sanitary pad prepared by Intervention packages intensive WASH communities Intervention packages in non-intensive
a local tailor in Dhading
WASH communities
district, Nepal, 2018
Promotion of six different WASH behaviours: regular use Promotion of two priority WASH behaviours:
and cleanliness of toilet, hand washing with soap and hand washing with soap and water and
water, safe drinking water, menstrual hygiene, food treatment of water before drinking
hygiene and peri-home cleanliness
Additional WASH specific frontline workers provided to Field supervisors and community nutrition
each ward to support community interventions volunteers carry out community interventions
Intensive activities carried out at local government units Provision of technical support to WASH
to attain ODF or total sanitation status. coordination committees or local government
for ODF or total sanitation status
Intensive household monitoring and follow-up support
Dipak Raj Sharma/ Suaahara II

visits carried out using devised health home checklists

with 22 indicators related to six WASH behaviours
Establishment of WASH marts to increase access to Establishment of WASH marts to increase
WASH materials in remote villages access to WASH materials in remote villages
Training of local tailors to produce reusable sanitary
pads to increase access to menstrual hygiene products

members around WASH programming at provin- on the importance of toilet use and ODF status, Suaahara II uses the WASH intensive wards
cial and municipal levels. 11,336 households invested in constructing their to demonstrate what is possible and to advocate
own toilets across 35 wards in nine districts. with the GoN for replication of these efforts in
In Nepal, nutrition-specific interventions are more communities of Nepal. Many munici-
delivered through the health system. To support Suaahara II has a Core+ package of activities
palities have now, for example, taken ownership
total sanitation, WASH messages have been in- which are additional interventions implemented
of the total sanitation campaign and replicated
cluded in training modules for health workers in disadvantaged communities with the aim of
it in other wards with their own human and fi-
in health facilities and within the maternal, closing equity gaps. As part of this package, in-
nancial resources.
infant and young child nutrition (MIYCN) train- tensive WASH activities were implemented in
ing for Nepal’s female community health volun- programme years one and two. Starting in pro- Private sector engagement to address
teers (FCHVs). The purpose of this has been to gramme year three, due to resource limitations supply side barriers
ensure that frontline health workers reach house- and a desire to provide higher-quality services To complement demand side interventions, Suaa-
holds with the same messages relating to WASH for the neediest communities, WASH intensive hara II also works to address poor WASH product
as well as to maximise contact with individuals interventions were focused on selected Core+ supply chains. Suaahara II works with private
at household level. In order to effectively address areas, identified as the ‘poorest of the poor’. In sector actors to increase access to water filters
deficient WASH services in healthcare facilities, this programme, Suaahara II has supported and and other essential WASH commodities, partic-
Suaahara II has integrated WASH into the fol- implemented the intensive WASH total sanitation ularly in remote communities, by supporting
low-up support provided to health facilities by package in around 500 of its 3,353 programme private sector actors to increase production of
Suaahara II including technical support to wards across 42 districts, delivered through an WASH products, overcome supply chain gaps
improve WASH facilities and services. Further- approach known as the healthy home campaign. and use social marketing to promote uptake of
more, FCHVs have been provided with on-site newly available products. To this end, Suaahara
coaching and mentoring support to improve The healthy home campaign includes 22 in-
II has interacted with more than 10 local, national
their skills and to ensure that they provide WASH dicators relating to six different WASH behaviours:
and multinational companies to explore the pos-
and MIYCN counselling to 1000-days family regular use and cleanliness of toilet, hand washing
sibility of collaboration. Although many private
members through different health platforms. with soap and water, safe drinking water, men-
sector actors showed interest, it has been difficult
strual hygiene, food hygiene and peri-home
to find common benefits and interest. Many na-
Household- and community-level cleanliness. Suaahara II hired additional WASH-
tional and multinational companies already have
interventions specific frontline workers to implement this
their own programmes and local level private
At household level, Suaahara II prioritises two more intensive WASH package. Along with Suaa-
sector actors have limited human and financial
WASH behaviours across its entire programme: hara II’s other cadres of frontline workers, these
resources to contribute. Many private companies
hand washing with soap and water at critical staff participated in health mothers’ group meet-
mainly focus on urban populations whereas
times and the treatment of drinking water. Suaa- ings and other relevant community platforms to
Suaahara II focuses on improving WASH supplies
hara II staff employed by local partner organisa- spread awareness of the behaviours represented
in remote areas. After much exploration, Suaahara
tions in each of the 42 districts implement activities in the 22 indicators. Orientation and sensitisation
II managed to successfully partner with BALTRA,
including multiple types of social and behaviour events were also held in community groups such
a private multinational company, to increase
change approaches targeted to households in the as water users groups, forest users groups and
their reach of water filters into remote commu-
1000-day period (conception until a child reaches homestead food production beneficiaries groups.
nities. Suaahara II identified local shops to
two years of age), sharing information and pro- A monitoring checklist was placed in each house-
become ‘WASH marts’ of which now more than
moting ideal practices spanning health, nutrition, hold to aid regular monitoring and counselling
850 exist across Suaahara II districts. This involves
WASH and agriculture. Key behaviour change by frontline workers during home visits. Moni-
linking shop owners to BALTRA dealers to
platforms include home visits, community plat- toring was carried out jointly by Suaahara II
strengthen the supply chain of water filters and
forms including monthly health mothers’ group frontline workers, community leaders and local other essential WASH materials such as soap,
meeting discussions, mass media including use health workers to increase ownership of the buckets, jugs and toilet cleaning materials to
of the Bhanchhin Aama radio programme and, campaign and help to facilitate community par- improve household sanitation.
more recently, text messages and social media ticipation in the changes made. A comparison
(YouTube and Facebook). Following a campaign between WASH activities in intensive and non- Suaahara II designed an instructional booklet
by Suaahara II to sensitise community members intensive communities is provided in Table 1. and developed taglines and messages in Nepali
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1000-days mothers ever participating in Households practicing correct use of drinking

Figure 2 Suaahara II community events Figure 3 water treatment technologies

70 66 20 19

% of 1000-days households
participating in Suaahara II

practicing correct drinking

% of 1000-days mothers

treatment technologies
60 53 15 15
community events

50 15

40
10
30 7
20
11 16 5
10
0 0
2017 (N=228, 3413) 2019 (N=380, 3266) 2017 (N=228, 3413) 2019 (N=380, 3266)

WASH intensive wards WASH non-intensive wards WASH intensive wards WASH non-intensive wards

Change over time (WASH non-intensive: 37pp; WASH intensive: 55pp; Change over time (WASH non-intensive: 4pp; WASH intensive: 8pp;
difference WASH non/intensive:0.01: P:<0.001)) difference WASH non/intensive:0.00: P:0.305)
Source: Suaahara II Annual Monitoring Surveys, 2017, 2019 Source: Suaahara II Annual Monitoring Surveys, 2017, 2019

for the promotion and marketing of BALTRA For example, Figure 2 demonstrates a large in- lack basic WASH infrastructures such as tap
water filters to support this activity. Various crease in 1,000 day mothers engaging in com- water supply, hand washing stations, chicken
communication materials were created with key munity events between 2017 and 2019, both in coops and animal sheds without which improving
messages around water filters including posters WASH intensive and non-intensive wards, with WASH and nutrition behaviours are very difficult.
and stickers and large notice boards for streets, a particularly marked increase in WASH-intensive Behaviour change therefore requires a more ho-
all of which identified the WASH marts so that areas. This achievement highlights the benefit listic, multi-level approach. In a large, multi-
households knew where they could purchase of increased programmatic investments and sector programme, identifying and addressing
WASH materials. specifically that having more frontline workers barriers that are different for each behaviour
facilitates greater intensity of exposure to inter- and vary across communities is an immense
Suaahara II has also supported the social ventions among target populations. Figures 3 challenge. In the context of this programme,
marketing of bio-sand filters, produced by en- and 4 show that these differences are also this required training nearly 40 sub-partner or-
trepreneurs in the terai (lowland plains), which reflected in WASH behaviours which improved ganisations and nearly 2,000 staff to implement
can remove iron and arsenic from water. Addi- over time, particularly so in WASH intensive activities to improve behaviours across between
tionally, 1,500 local tailors were trained to areas compared to WASH non-intensive areas. five and 10 sectors each with between five and
produce reusable cotton cloth menstrual pads Qualitative data also shows early signs of the 20 behaviours and each with multiple and some-
and about 400 local masons to produce improved adoption of new behaviours and perceived pos- times conflicting determinants. While the mul-
cook stoves with lower levels of smoke emission. itive results (Boxes 1 and 2). In time, programme ti-sector nature of large scale programmes like
Suaahara II also helped tailors to brand the evaluation will capture quantitative data on this are key to achieving high impact, their
new reusable sanitary pads as “Sangi Pad” and changes in WASH knowledge, attitudes and be- nature magnifies the complexity of truly ad-
produced and distributed related posters for haviours, as well as health and nutrition outcomes. dressing all key barriers for all key behaviours.
social marketing. Priority was given to remote
areas where these WASH commodities and serv- Implementing this nutrition-sensitive WASH Secondly, developing indicators related to the
ices are not available or affordable. component in the Suaahara II programme has desired behaviours is necessary to generate pro-
led to several important lessons learned. Firstly, grammatic focus on critical WASH behaviours
Early results and lessons learned improved knowledge and awareness alone often and devoting the necessary time and continuous
Data is not yet available to show the impact of does not result in behaviour change. Systematic action. While the list of indicators was long (22),
Suaahara II interventions on WASH outcomes efforts are needed to identify and, in turn, investment was made in various health cadres to
or to link WASH interventions with health and address barriers to ideal behaviours including enable their implementation. This took initial
nutrition outcomes. Monitoring data, however, habits, socio-cultural stigma and access to and training, continuous monitoring and follow-up
reveals encouraging signs of increased partici- the affordability of WASH materials and infra- and the involvement of local government to ensure
pation in WASH-related activities over time. structure. For example, many rural communities ownership of the campaign. The list of indicators

Households with soap and water at a handwashing Suaahara II frontline workers

Figure 4 station commonly used by family members filling healthy home checklist
in a household in Kanchanpur
70 62 district, Nepal, 2019
with soap and water at hand
% of 1000-days households

60 54
washing station

50
40 37
30
30
20
10
0
Dipak Raj Sharma/ Suaahara II

2017 (N=228, 3413) 2019 (N=380, 3266)

WASH intensive wards WASH non-intensive wards

Change over time (WASH non-intensive: 25pp; WASH intensive:24pp;

difference WASH non/intensive:0.04: P:0.267)
Source: Suaahara II Annual Monitoring Surveys, 2017, 2019

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Quote from a female community health volunteer on also set a helpful benchmark to households and motivated them to strive
Box 1 the reduction of diarrhoeal disease after healthy home towards achieving them which supported behaviour change.
campaign
Another important learning is that it is vital that local governments
“Among various changes that the Total Sanitation campaign has brought take the lead for nutrition-sensitive WASH programmes to ensure
about, one of them is reduction in the number of diarrhoeal diseases. Before ownership and sustainability. Their replication of and scaling-up of
the implementation of the programme, on average, 6-7 people used to come Suaahara II activities requires building skills and networks for better
to me every month for ORS [oral rehydration solution]. But now the number collaboration between actors in the WASH and health sectors. For
has significantly dropped to 1-2 people per month. I think change in the
sustainability of the programme, Suaahara II has been advocating
behaviour of hand washing and drinking treated water are the two major
with the local governments and providing technical support, particularly
reasons for which the trend of diarrhoeal disease has decreased. People have
developed the practice of hand washing with soap and water at all critical
during their annual planning and budgeting, for nutrition-sensitive
times. Also all households either boil or filter water prior to drinking. With the WASH investments. Some municipalities have already internalised,
gradual change in behaviour of community people, the number of cases of replicated and scaled up the healthy home campaign, for instance, in-
diarrhoeal diseases is decreasing.” tegrating the Suaahara II approach. As can be clearly seen in the early
results, the WASH-intensive package achieved higher community en-
Mrs. Urmila Lawati Chemjong
gagement and behaviour change than the non-intensive package. The
Female community health volunteer, Chilingdin, Panchthar
adoption of this kind of programme into the government system will
require support to local government during annual planning and

Bikas Banjara/ Suaahara II

A 1000-days mother buying a water filter from a WASH
mart established through Suaahara II support and budgeting, as well as targets set at national level for total sanitation to
facilitation in Western Rukum district, Nepal, 2019 drive local government. National government should replicate the in-
tensive drive for ODF nationwide, putting similar focus and efforts
behind a drive for total sanitation.
Finally, private sector actors are important stakeholders for improving
WASH behaviours as they can address supply side barriers. It takes
time and compromise, however, to ensure that goals converge and
interests align between development objectives and private sector
actors. The partnership with BALTRA presented challenges including
staff turnover in key positions within the company, a lack of a common
understanding for collaboration between BALTRA dealers and Suaahara
II field staff and physical challenges to reach geographically remote
areas by the dealers. Increased demand for WASH commodities created
by development programmes in remote rural areas will facilitate an in-
Case story: Water filter at wholesale rate for 1000 days creased interest by private sector actors to expand their services into
Box 2 mothers these areas in spite of their geographical remoteness. Increased demand
and supply must go hand in hand.
Mr. Keshabraj Belwase is an owner of a utensils shop, ‘Namuna Swochataa
Pasal’, located in Banganga Municipality - 7 of Kapilvastu district where, Conclusion
supported by Suaahara II, he now sells WASH products including water Suaahara II integrated WASH activities into its multi-sector nutrition
filters at wholesale rate to 1,000 day mothers. Between July 2019 and programme prioritising two WASH behaviours, hand washing and
January 2020, Keshabraj sold 100 water filters (35 to 1,000 day mothers). drinking water treatment across its entire programme and promoting
He has also now begun to sell toilet cleaning brushes, potty pans, buckets, additional WASH behaviours in WASH-intensive areas. Developing a
cleaning liquid and other toiletries and sanitation materials to support
conducive environment through capacity building and technical
positive WASH behaviours.
assistance for government actors and engagement with the private
Keshabraj remarked, “I used to think only health professionals are responsible sector to address supply side barriers were an integral part of this pro-
for betterment of public health. I never had a thought, I, as a local retailor can gramme. These integrated and intensive programming efforts have
play a key supporting role to improve family health. Being a local retailor, I can shown promising results in the uptake of WASH practices but more ev-
earn profit from other products. Since, it is directly concerned with public idence on the effectiveness of this approach will emerge from a
health, I am selling the filters in wholesale rate for particular families. Because forthcoming programme-wide evaluation. Scaling up evidence-based,
good deeds are always important for the well-being of community”. nutrition- sensitive WASH interventions to improve WASH and nutrition
Urmila Chaudhary, a 1,000 day mother from Banganga - 8 said, “We can get indicators requires advocacy and collaboration with government actors
same filter in lesser price in Namuna Swochataa Pasal compared to other at every level. Suaahara II will continue to lobby and advocate for the
shops. It is also easier for us to buy filter there as it is located in the central healthy home campaign to improve WASH behaviours in Nepal.
market. I have bought one filter and have been drinking filter water since then.
I am assured that my family are now safe from diarrheal diseases”. For more information, please contact Keshab Shrestha at
[email protected]

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Public and International Affairs, Research Program in diarrhoea. Lancet Glob Health 2019;7: e1139–46
Monitoring the situation of children and women, Central
Development Studies. DOI:https://doi.org/10.1016/S2214-109X(19)30268-2
Bureau of Statistics, National Planning Commission,
Government of Nepal, National Planning Commission Government of Nepal. National Planning Commission, Teague, J et al. (2014) Water, sanitation, hygiene, and nutrition:
(2012) Multi-sectoral Nutrition Plan: For accelerating the 2018. Multi-sectoral Nutrition Plan II (2018-2022), successes, challenges, and implications for integration. International
reduction of maternal and child under-nutrition in Nepal. Kathmandu, Nepal. Journal of Public Health. DOI: 10.1007/s00038-014-0580-8.

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Streamlining SMART KENYA

survey processes in What we know: Standardized Monitoring and Assessment of
Relief and Transitions (SMART) methodology is widely used in

support of a high quality, Kenya by governments and partners, in both arid and semi-
arid areas, in nutrition surveillance and early warning systems.

nationally owned What this article adds: From 2013 onwards, the processes for
conducting SMART surveys in Kenya were streamlined,
harmonised and institutionalised under the coordination and
nutrition information leadership of the national Nutrition Information Technical
Working Group (NITWG). Key actions to streamline processes

system in Kenya included the development of guidelines and standard processes,

capacity building, the development of task forces, the setting up of
systems to validate all survey methods pre-survey and preliminary
By Lydia Ndung’u, Lucy Maina-Gathigi, Lucy Kinyua, results post-survey and the management of a common data
Hassan Ali Ahmed, Kibet Chirchir and repository. The result of these actions has been increased capacity
Samuel Mahinda Murage among government staff at both national and county level,
Lydia Ndung’u is a public health nutritionist, currently improved capacity for the coordination of resource mobilisation
working as SMART advisor for East Africa, Southern and joint planning and survey training. Overall results achieved are
Africa and Yemen. Lydia has over 10 years of extensive the greater national ownership of survey management and results
experience in managing, implementing and evaluating (including greater government funding), government-led survey
programmes in Africa in humanitarian and implementation, data that is comparable over time and between
development contexts for both government and non-
geographic areas and the use of data to inform timely nutrition
governmental organisations.
actions as well as to inform other sectors and the overall situation
Lucy Maina-Gathigi is a nutrition officer with UNICEF analysis in the country. Key drivers of this success include the
Kenya, specialising in nutrition information systems. commitment to capacitate national staff at all levels, succession
She is the co-chair of the Kenya Nutrition Information
planning, consistent stakeholder communication and the
Technical Working Group and holds an MSc in Applied
Epidemiology and a BSc in Food Nutrition and Dietetics. availability of complementary data for situations (such as in
COVID-19) when SMART surveys could not be undertaken.
Lucy Kinyua is a nutritionist working with the Kenyan
Ministry of Health as a monitoring and evaluation
manager and is the secretary of the Nutrition Background
Information Technical Working Group. She holds an MSc Kenya has set out a vision to transform into a globally competitive and
in Applied Human Nutrition. prosperous nation with a high quality of life by 2030. Poor health and
nutrition status are major setbacks towards realising this vision, with huge
Hassan Ali Ahmed is the Associate Director for Nutrition disparities in the distribution of malnutrition observed across the country
at Action Against Hunger Canada and a lead for the (Figure 1). The nutrition situation quickly deteriorates during drought
Global SMART Initiative. He has worked with Action periods in many parts of Kenya with critical and extremely critical levels of
Against Hunger since 2014 in emergency contexts undernutrition regularly recorded in arid counties (Turkana, Mandera,
before joining the SMART global project in Jordan. Wajir and parts of Marsabit counties). A national Nutrition Information
Hassan holds an MBA in Strategic Management from System (NIS) is critical to providing up to date nutrition surveillance and
the University of Nairobi.
monitoring information to inform a timely, high quality nutrition response.
Kibet Chirchir is a public health and monitoring and
evaluation practitioner, currently working for the
Prevalence of wasting in children 6-59 months
United Nations Office for Project Services (UNOPS) as a
Nutrition Support Officer, strengthening nutrition
Figure 1 across the 47 counties in Kenya
information systems at national and sub-national levels
in Kenya.
Samuel Mahinda Murage is a Health Records and
Information Officer working with the Kenyan Ministry of
Health. He has over 20 years of experience working in
various levels of the healthcare system from service
delivery to the policy level.

The authors recognise the leadership and commitment of the

Government of Kenya at national and county levels in improving the
quality of the Nutrition Information System. In particular, the authors
express sincere thanks to Veronica Kirogo, Head Division of Nutrition and
Dietetics, Ministry of Health, for her leadership and guidance as well as to
the Nutrition Information Technical Working Group (NITWG) members
and their respective agencies, including Action Against Hunger Kenya
and World Vision for their tenures as NITWG chair. The authors also
recognise UNICEF and other partners for the financial support towards
integrated SMART surveys and Action Against Hunger Canada which has
acted as the SMART Project Convenor since 2009.

The views of Lucy Maina-Gathigi and Kibet Chirchir incorporated in this

article are their own and do not necessarily represent the views of
UNICEF, its executive directors or the countries that they represent and Source: Kenya Demographic and Health Survey, 2014
should not be attributed to them.
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© Calvince Anino / World Vision Kenya

Figure 2 The Kenya Nutrition Information System

Dissemination NIS resources:

and use: Standard tools, M&E
Kenya nutrition website, framework, guidelines,
High level meetings, manuals, NITWG with
Program TWGs TORs, M&E/NIS plans

Information Products: Indicators:

briefs, reports, maps, Demographic profile,
databases/templates, nutrition specific and
corecards sensitive indicators
Data Data
management: sources:
review at county Coverage
review and validation assessments, capacity
national level, common assessments, SMART
central repository/ surveys, DHIS2, CHIS, LMIS,
storage, data clinics, EWS, mass screening,
data collation and seasonal assessments,
analysis national surveys,
other studies

Use of mobile data collection in SMART surveys as opposed

to manual data collection: one of the steps taken by NITWG
to improve data quality, Baringa Country, Kenya, 2015

In recent years, the Kenya NIS has been response and, in recent years, in non-emergency jectives #9 and #10 of the National Nutrition
better defined, as represented in Figure 2 and contexts. Prior to 2013, surveys were largely fi- Action Plan 2012-2017 to strengthen nutrition
clear guidelines, tools and standardised method- nanced, technically supported and conducted surveillance, monitoring and evaluation systems
ologies and processes have been developed to by international partners, often with the support and to enhance evidence-based decision-making.3
support national nutrition monitoring and eval- of international consultants from UNICEF or
Due to the varied capacities and skills within
uation. Data sources for key indicators have other implementing partners, with minimum
the NITWG, different task forces were formed
also been better defined and nutrition Stan- government involvement. This led to a lack of
based on the group's needs and in line with its
dardized Monitoring and Assessment of Relief standardisation in processes, methodologies,
terms of reference including SMART surveys,
and Transitions) (SMART) surveys have been tools and indicators as consultants and agencies
coverage, infant and young child feeding as-
identified as the key source of data on the preva- worked with their own interpretations. For ex-
sessments and routine information task forces
lence of acute malnutrition at population level ample, there was no guidance on the number of
among others. The main objectives of the task
(Box 1). indicators to be added to SMART surveys which
forces were to fast-track protocol approvals, val-
led to compromised quality of anthropometric
In Kenya, SMART methodology was first idate results and build the capacity of the NITWG
data and/or to the collection of indicators without
implemented in 2008. Since then, many surveys members and affiliates in each respective area.
an adequate sample size to inform programming.
have been conducted, especially during emer-
This article describes the processes undertaken Since 2013, the NITWG has carried out
gencies, as part of surveillance and to inform
in Kenya to streamline SMART survey2 processes annual nutrition ‘data clinics’ as part of its
to contribute to a high quality, nationally-owned quality assurance activities. The main objective
Box 1 SMART survey methodology and led NIS. of these clinics is to critically review all nutrition
indicators across every source of nutrition in-
Launched in 2002 by a network of organisations Establishing mechanisms for formation (SMART surveys, routine health in-
and humanitarian practitioners, SMART survey coordination and quality formation system, sentinel sites), standardise
methodology1 is widely accepted within the assurance tools and methods and provide guidance to all
nutrition community for use in all settings key partners and stakeholders. A secondary ob-
The 2007/2008 emergency situation triggered
(development, emergency, displaced
by the post-election violence (PEV) in Kenya jective is to strengthen linkages with other work-
populations) for assessing the prevalence of
demonstrated a heightened need to better co- ing groups to improve data collection, analysis
different types of malnutrition and/or the
nutritional impact of a project. ordinate information systems in order to ensure and dissemination, including partners from
a more effective response. After reviewing lessons other sectors (Water, sanitation and hygiene
The methodology was originally developed as a learned from the evaluation of the PEV response, (WASH), food security and health).
tool to improve the monitoring, reporting and the nutrition sector formed the Kenya Nutrition
evaluation of humanitarian interventions. It has a
Technical Forum led by the Ministry of Health Actions to improve SMART
strong focus on ensuring high quality data by surveys
(MoH), under which several technical working
controlling the quality of data collection, entry
groups were formed, including the Nutrition A key function of the NITWG has been to im-
and analysis. SMART methodology was designed
Information Technical Working Group prove the quality of the data collected through
to address issues of common interest to many
organisations working in humanitarian assistance (NITWG), set up in 2008. The agreed role of SMART surveys across Kenya. To this end,
including the need to i) standardise survey the NITWG was to review and validate data several important actions have happened since
methodologies among organisations conducting collection methodologies to ensure the availability 2013 as follows:
nutrition surveys, ii) strengthen the technical of timely, quality nutrition information to guide
1 https://smartmethodology.org
capacity of all partners with user-friendly tools programme response. The functions of the 2 Additional indicators from other sectors such as food
and iii) establish comprehensive, collaborative NITWG have since expanded to ensure the es- security, health and WASH were added to anthropometry
systems to ensure good quality and reliable data tablishment and sustainability of a functional and mortality core indicators
3 Now covered under key result #16 of the Kenya National
is used for reporting and decision-making. NIS through the actualisation of strategic ob- Nutrition Plan 2018-2022
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Achievements
Table 1 Government SMART survey funding 2018/2019, in Kenyan Shillings (KSh) Increased government funding to
Government Government conduct SMART surveys
Timelines County Total cost (KSh)
contribution (KSh) contribution (%) Following the actions described, the processes
July 2018 Marsabit 6,192,280 974,000 15.7%
relating to SMART surveys are now clearer, re-
source mobilisation efforts are better coordinated
July 2018 Wajir 4,200,660 1,796,800 42.8% and there is no more duplication. Stemming
July 2019 Garissa 4,697,300 854,700 18% from an overall effort to increase capacity and
ownership, the Government of Kenya has also
July 2019 Wajir 2,729,433 1,513,100 55%
significantly increased its financial investment
July 2019 West Pokot 2,585,550 190,550 7% in surveys over the years. County governments
July 2019 Turkana 7,894,500 488,500 6% are now directly investing funds and leading on
the mobilisation of funds for surveys as part of
their annual plans. Table 1 reflects the investment
Mapping partners and needs ods used. As an example, Turkana county au- made in surveys by the Government of Kenya
The NITWG supported counties to carry out thorities initiated a targeted county level training in 2018 and 2019. While in some counties per-
an inventory of NIS related capacity strength- that focused on government and partner staff centage contributions are still low, the actual fi-
ening, support and resource mobilisation actions directly involved in the implementation of a nancial commitment made has increased from
carried out by partners to enable joint coordi- planned survey, thus giving trainees theoretical previous years.
nation and planning. The NITWG also supported knowledge as well as practical experience.
Government-led survey
counties to map out surveillance needs, including
when and where SMART surveys should be
Validating survey methods and results implementation
To ensure the quality and standardisation of The streamlining of processes has resulted in
conducted, based on the mapping of seasonality
nutrition surveys, the NITWG has also put in increased capacity among government staff at
and trend analysis. This resulted in a survey
place a system to review and approve survey both national and county level including better
calendar to support better coordination and re-
methodologies ahead of survey implementation. capacity for the coordination of resource mo-
duce duplication of partner activity. This process
This applies to all surveys and must be done bilisation, joint planning, survey trainings and
also considered the importance of linking with
before any fieldwork begins. It includes a review implementation. This has resulted in greater
other sectors and aligning with other key as-
of the survey’s objectives, rationale, methodology, government ownership of survey management
sessments to ensure the optimal use of data, for
training plans (days, venue, topics, facilitators), and results. Government staff at county level
example to allow the results of SMART surveys
data collection tools and analysis plans. After are also now leading surveys with minimal ex-
to feed into seasonal assessments.
survey implementation, the survey report with ternal support. This includes overall survey
Developing guidelines and the preliminary results must be submitted by management, coordination, protocol develop-
standardising processes the survey coordinator to the NITWG with a ment, presentation for validation, training, data
To ensure the standardisation of all surveys at plausibility report attached. The NITWG then collection, analysis, reporting and dissemination.
the national and county level, guidelines and provides a final validation of the results after a
thorough review of the data and final survey Timely preparedness and response
global standards were adapted and contextualised
report. To be considered of good quality, the The availability of SMART survey data has al-
to the Kenya context. This included the devel-
survey plausibility check report must show that lowed the early detection of a deteriorating sit-
opment of standardised versions of the ques-
data is of good quality, i.e., all criteria from the uation in the country to prompt an early re-
tionnaires (available in different formats to ac-
plausibility check report are within acceptable sponse. For example, in 2017, as a result of the
commodate both paper-based and mobile data
values,4 the sample size is above 80% of target nutrition analysis conducted in August 2016,
collection), survey protocols, preliminary find-
children and the number of clusters included the nutrition response action began even before
ings and reports. As surveys were implemented
should be above 90% to ensure that the results the drought was officially declared. The Gov-
by multiple organisations with the support of
are of high quality before being shared. This ernment of Kenya was therefore able to anticipate
multiple consultants, it was important to give
quality assurance process was previously com- needs and allocated USD7,540,000 to the nu-
clear guidance, for example, on the maximum
pleted by partner staff and consultants. To trition response.
number of indicators to add to the integrated
SMART survey questionnaire, and to give a strengthen national capacity and ensure sus- Comparability over time and space
clear definition of each indicator and how to tainability, this process is now conducted by Because processes and field procedures are stan-
collect against it to avoid individual interpretation officers from the MoH. dardised, data generated over time is now com-
of methods. This clear guidance aimed to avoid parable. SMART surveys for every survey zone
Management of a common repository
historical poor practice, for example, one 2012 are consistently conducted during a specific sea-
The absence of a data repository in the past
multi-sector survey included 130 questions son, indicating when a situation is improving
made it difficult to access raw data from con-
leading to survey team and respondent fatigue, or deteriorating. As an example, Figure 3 illus-
sultants and individual agencies and made it
thereby compromising the data quality against trates the changes in acute malnutrition over
impossible to provide oversight on data quality.
core nutrition indicators. The NITWG team time per survey zone in Turkana County where
The NITWG agreed to have a common repository
also developed templates for reporting prelim- nutrition surveys are conducted annually towards
of raw datasets which include Emergency Nu-
inary results to guide stakeholders and to ensure the end of the long rains in the month of June.
trition Assessment files, questionnaires, method-
that results were submitted for validation in These survey results also feed into the ‘long
ologies and reports in both Word and PDF.
standard formats. rains assessments’ conducted biannually (in
After the NITWG has approved them, all survey
reports are uploaded on a nutrition website June and in February towards the end of the
Capacity building activities short rains). Persistently high global acute mal-
Training on SMART surveys was carried out in managed by the government.5 The dissemination
of findings through this website and survey nutrition / levels (exceeding the World Health
2014 and 2015 with support from the UNICEF
regional office. A cascade approach was used to dashboard allows access to information for any 4 Those criteria are: % flagged data, sex ratio, age distribution,
reach the field level government staff imple- validated nutrition surveys in the country by all digit preference for anthropometric measures, standard
interested parties, allowing for real time pro- deviation of WHZ, shape of the distribution (skewness/
menting surveys with a focus on the ASAL kurtosis/index of dispersion)
areas. This ensured the standardisation of meth- gramming and decision-making. 5 http://www.nutritionhealth.or.ke/

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Organization emergency threshold of 15%) in Trends in global acute malnutrition in Turkana county (SMART Surveys
the past decade highlight no obvious recovery Figure 3 2010-2019)
from the persistent shocks from drought, floods
and conflict facing the community living in the 40%
county. Figure 3 also displays the similarity of
the two episodes of drought that Kenya experi- 35%

Level of Acute Malnutrition

enced in 2011 and 2017 30%

Quality data is available and used 25%

Before surveys were coordinated and regulated,
20%
survey reports would be shared without an in-
dication of data quality. Since estimating data 15%
quality is now a key requirement for any survey
10%
to be validated, the vast majority of surveys
currently conducted in Kenya demonstrate the 5%
highest level of rigour, reliability and quality,
therefore making Kenya a ‘centre of excellence’ 0%
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
on NIS. This has led to stronger collaborations
beyond nutrition survey planning. For instance, Turkana North Turkana South Turkana West Turkana Central
the NITWG was engaged for the first time in
the Kenya Demographic Health Survey in 2014
and provided support conducting the standard- WhatsApp groups, by reviewing documents on- Kenya has multiple sources of information
isation test, a technique from SMART method- line and even volunteering to provide support that complement each other. Besides SMART
ology that consists of ensuring high data quality during contract breaks. surveys, an early warning system is run by the
for anthropometric measurements. National Drought and Management Authority
A core mandate of the NITWG is to ensure and routine information is generated by the
To ensure that SMART survey results con- succession planning and mentorship. The support,
tribute comprehensively to situation analysis in MoH. These sources provide data that can
mentoring and coaching of new NITWG mem- generate trend analysis over time to complement
Kenya (such as the integrated phase classification bers/teams through the documentation and
(IPC)), multiple sectors (food security, health SMART survey results, ensuring no data gaps.
sharing of lessons learned have allowed new Even during the COVID-19 pandemic when
and WASH) were consulted to identify key in- entrants to continue to build on what has gone SMART surveys were halted, Kenya was still
dicators to be systematically included in the on before. Over the years, the forum has re- able to conduct IPC-acute malnutrition analysis
standard nutrition surveys. SMART surveys are mained vibrant and, as a result, this has ensured due to the availability of these other sources
therefore now considered a reliable/valid source that a high level of expertise and capacity remain of data.
of data by other sectors and the nutrition sector in the country.
is now perceived as the most coordinated sector Conclusions
from which up to date information is always Consistency is key. Since 2013, NITWG meet-
ings have been held on the last Thursday of Overall, the Kenya NIS has benefitted from
available. This has raised the profile of the nu- having a clear monitoring and evaluation frame-
trition sector and provided a space for multi- every month. This schedule has not changed
work and well-defined coordination and quality
sector engagement. The counties also use SMART despite many competing priorities such as the
control bodies. Key actions to improve SMART
survey data for baseline and planning information biannual IPC analysis that mostly happens to-
survey data quality included the streamlining
when developing County Integrated Development wards the end of the month. The country has
of data collection methodologies, the capacity
Plans6 and County Nutrition Work Plans. continued to hold virtual meetings consistently
building of government and partner staff, the
during this current COVID-19 pandemic period,
setting up of task forces, validating all survey
Lessons learned making it easier for members to plan and block
methods and results and managing a common
Investment in a government owned and sustained dates and for the planners to organise the meet-
data repository. From our experience, the key
monitoring and evaluation framework for nu- ings in advance. Teams that are planning to
ingredients for other countries to consider for
trition has formed the backbone of the now have surveys and protocols validated can easily
a sustainable NIS include strengthening the ca-
high-quality NIS infrastructure in Kenya, con- fit into this schedule.
pacity of government staff, succession planning
tributing to key result #16 of the Kenya Nutrition
System wide capacity building is critical. Fo- and mentorship, coordinating efforts and re-
Action Plan. NIS standardised tools and method-
cusing on government staff capacity building sources and maintaining high standards and
ologies have served to streamline capacity-
helped to strengthen the ownership of processes quality control frameworks. The COVID-19
building efforts and have allowed for compara-
while the standardisation of tools and method- pandemic affected NIS, just like all sectors, due
bility of results over time which was not previ-
ologies enabled uniformity, data availability and to the cessation of all household surveys, in-
ously possible.
quality. Leadership and ownership by government cluding SMART surveys, for 2020. Availability
Although high staff turnover has proved to and the institutionalisation of processes has as- of complementary data sources ensured conti-
be challenging, training government staff has sured better results, ownership of the products nuity of information in the face of this unforeseen
enabled the NITWG to retain a pool of technical and sustainable strategies. It is therefore important gap in the availability of survey data. This ex-
staff who are able to pass on knowledge to new to continue efforts to maintain high quality perience provides useful insights for other coun-
entrants. The formation of task forces, including data. This can be achieved through scheduled tries looking to enhance the use of SMART
a SMART survey task force, has improved turn- data clinics and coordinated survey implemen- survey methodologies, and indeed other forms
around time, allowed deeper interrogation of tation. It is also crucial to continue capacity of nutrition surveillance, to contribute to a
methods, processes and procedures and has en- support especially to government officials from high quality, nationally owned NIS.
abled targeted support where needed. Task forces counties that are not considered to be arid nor
also include members who have transitioned semi-arid areas. Engaging them during SMART For more information, please contact Lydia
from NITWG and are now engaged as interna- training, survey implementation, data clinics, Ndungu at [email protected]
tional experts on SMART surveys, many of IPC analysis, NITWG meetings and any other
whom remain engaged and able to provide tech- NIS learning events are ways to keep them en- 6
A CIDP is a plan prepared by all counties to guide
nical support to the team when called upon via gaged and updated. development over a five-year period.

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©UNICEF209769_ Abela Ralaivita

Remote Integrated
Phase Classification
during the COVID-19
pandemic:
experiences from
Madagascar
By Smaila Gnegne, Moussa Moctar,
Andrianianja Raonivelo, Desire Rwodzi,
Mara Nyawo and Douglas Jayakasekaran A child has her arm measured to screen for
wasting in Southern Madagascar, 2020

Smaila Gnegne is a health statistician with over nine

years’ experience in the monitoring and evaluation
of health and nutrition interventions. He is currently
working with UNICEF in Madagascar on nutrition
monitoring and previously worked with the
National Statistical Institute and Médecins Sans MADAGASCAR
Frontières (MSF) in West Africa. What we know: The Integrated food security Phase Classification
Moussa Moctar is a Nutrition Analyst with the (IPC) provides information to decision makers to address food
Integrated Phase Classification (IPC) Global Support insecurity; COVID-19 related movement restrictions meant that
Unit (GSU) hosted at the Food and Agriculture normal IPC methods could not be used.
Organization (FAO) in Rome, Italy where he provides
technical support to countries on IPC implementation. What this article adds: In May 2020, the Madagascar Ministry of
Health, UNICEF and other nutrition partners, together with the IPC
Andrianianja Raonivelo is an agricultural engineer Global Support Unit (GSU), leveraged existing technologies to
with two postgraduate diplomas in agronomy and conduct a virtual IPC analysis for acute malnutrition in six drought-
risk and disaster management. He has 12 years’
prone southern districts in Madagascar. Adaptations made to the IPC
experience working in the National Office of
Disaster and Risk Management (BNGRC) and is
methodology for the COVID-19 context featured the inclusion of
Chairman of the IPC Technical Working Group and already trained team members to reduce the length of orientation,
the National Vulnerability Assessment Committee of Madagascar. utilisation and re-analysis of data collected just prior to lockdown to
overcome challenges in data collection and the shifting of meetings
Desire Rwodzi is a former Knowledge Management
Officer with the Nutrition Section in UNICEF’s
from in-person to virtual. A number of assumptions were built into
Eastern and Southern Africa Regional Office. the analysis given the COVID-19 context including the likely negative
impact on food systems and access to health services in the post-
harvest period. Results of the analysis hypothesised the likely
deterioration of the nutrition situation in all six districts beyond
Mara Nyawo is a Nutrition Specialist with the August 2020 with two districts being classified as IPC phase 3 or 4.
UNICEF Eastern and Southern Africa Regional Office. The IPC analysis was largely deemed a success as a result of strong
She has worked for over 15 years in humanitarian
political will and support from nutrition partners and the IPC GSU.
and development contexts in sub-Saharan Africa.
However, numerous challenges were noted including a reliance on
historical data, a lack of global guidelines on remote facilitation at the
Douglas Jayakasekaran is a Consultant Nutrition time and internet connectivity challenges.
Specialist with IPC GSU. He has over 15 years of
experience working in health and nutrition in both
humanitarian and development contexts Background
throughout Asia and Africa.
The Integrated food security Phase Classification (IPC) is a widely accepted
The authors would like to thank all those who contributed to
mechanism for improving food security and nutrition analysis and decision
providing information for this article including colleagues from the making (http://www.ipcinfo.org/). Originally developed in 2004 in Somalia
National Office of Disaster and Risk Management (BNGRC), the by the Food and Agriculture Organization's Food Security and Nutrition
National Nutrition Office, Nutrition Service under the Ministry of Analysis Unit (FSNAU), IPC has evolved over time and currently includes a
Health in Madagascar, UNICEF and FAO Madagascar. Most importantly, range of classification scales, namely Acute Food Insecurity (IPC-AFI),
we would like to thank the dedicated IPC Acute Malnutrition analysts Chronic Food Insecurity (IPC-CFI) and Acute Malnutrition (IPC-AMN)
in Madagascar who carried out the analysis exercise on which this with each scale informing specific types of action needed to address food in-
paper is based. We would also wish to thank the European Civil security and malnutrition (IPC, 2019). IPC results inform humanitarian
Protection and Humanitarian Aid Operations and the United States response planning and are the main source of data for the Global Food Crisis
Agency for International Development for their generous and
Report.1 The IPC-AMN analysis provides decision-makers with key information
continued contributions and support for IPC analysis in Madagascar.
The findings and conclusions in this report are those of the authors and 1 https://www.wfp.org/publications/2020-global-report-food-crises
do not necessarily represent the official position of UNICEF or the IPC. ...........................................................................
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times virtually using Zoom with technical and

Figure 1 IPC analysis for acute malnutrition financial support from UNICEF. Data was
collated on the immediate and underlying causes
of malnutrition including population prevalence
of key diseases, food security and dietary intake.
Survey data for the period February to April
2020 was available for the six selected districts
1. Planning 2. Preparation 3. Analysis 4. Wrap-up of the Greater South. For three of the six districts,
• Communication with • Composition of analysis • Working group sessions after • Presentation of IPS existing data collected just prior to the lockdown
internal and external team and assign areas one hour refresher training analysis results was available from a national survey on women’s
stakeholders for analysts & facilitators on key points on IPC guideline • Draft IPC acute
• Planning on modalities • Develop an agenda for • Presentations and plenary malnutrition report nutrition and vitamin A coverage from February
the virtual analysis sessions
to March 2020. This data was re-analysed to
calculate GAM rates. Data for the remaining
three districts was directly available.
Data was projected for May to August 2020
and September to December 2020 based on IPC
guidelines (IPC, 2019) using historical data on
outcome indicators and trend data on contributing
to support activities that aim to decrease the acute malnutrition (IPC-AMN) for six districts factors derived from the national health man-
prevalence of acute malnutrition. Specifically, of the Greater South in May 2020 (these six agement information system (HMIS) and other
it provides guidelines for the classification of districts out of the 10 districts in the region were sources. All projections were informed by as-
areas in terms of the prevalence of global acute selected based on the level of data availability). sumptions based on the IPC GSU guidance note
malnutrition (GAM) (thresholds for weight- This article highlights how the IPC-AMN analysis on developing assumptions for projection analysis
for-height z-score (WHZ) and mid-upper arm was conducted virtually in order to obtain an in the context of COVID-19 (IPC, 2020). Other
circumference (MUAC)), estimations of the understanding of the level of malnutrition in the indicators were drawn from district-level surveys,
numbers of acutely malnourished children (by Greater South region of Madagascar. food security assessment reports, disease trends
WHZ, MUAC and/or both), classifications of provided by the Demographic and Health In-
geographical areas in terms of severity of acute
The approach
A four-stage approach was followed as described formation Software II (DHIS-2), coverage survey
malnutrition and the identification of the key reports, SMART surveys and Link Nutrition
in Figure 12 with each stage described below.
drivers of acute malnutrition. Causal Analysis (Link NCA) surveys conducted
The general approach for conducting IPC Stage One: Planning over the last three years.
analysis is for stakeholders at national-level to Typically each year, a planning exercise is con-
The likely impact of COVID-19 on acute
gather primary and secondary data on food se- ducted between country IPC Technical Working
malnutrition was also considered, drawing from
curity and nutrition, after which they converge Groups (IPC-TWG) and the IPC GSU in order
IPC GUS technical guidance (IPC, 2020). Path-
to discuss the results, facilitated by and together to determine the number and timing of IPC
ways for impact were explored including the
with technical support from IPC experts. How- analyses for the year. This planning meeting
likely negative impact on food systems and
ever, this approach has not been feasible in took place towards the end of 2019 between
access to health services in the post-harvest pe-
many contexts since the outbreak of the COVID- Madagascar’s IPC-TWG and the Nutrition Clus-
riod. The tools, data and indicators were subse-
ter, after which it was agreed that an analysis
19 pandemic due to restrictions on travel and quently made available online for the working
would be conducted in October of 2020. Due to
gatherings which, at the same time, have resulted groups during the analysis.
COVID-19, the planning was rapidly adjusted
in widespread increases in food insecurity due
at the request of the Nutrition Cluster and the Composition of analysis team
to reduced livelihood activities and household
MoH to enable an analysis of the nutrition situ- The virtual IPC-AMN analysis team included
incomes and disrupted supply chains. Four days
ation in districts affected by drought. The virtual 23 participants, comprising 18 locally based
after Madagascar first reported a case of COVID-
methodology was jointly proposed by UNICEF partners3 and five external IPC experts including
19, in March 2020, the country was put on total
and the IPC GSU and approved by the country four Cross Country Learning Exchange (CCLE)
national lockdown which included a ban on all
IPC-TWG. This was the first time that such an participants (from the Ministries of Health in
regional and international travel and a total
approach had been piloted globally. Burkina Faso and Niger, UNICEF West and
shut down of all non-essential activities in the
cities of Antananarivo and Toamasina. It was Under normal circumstances, IPC analysis Central Africa Office (WCARO) and CILSS4)
therefore critical to find possible ways to un- usually takes 10 days (including four days of and an IPC-GSU focal person based in Rome.
derstand the food security and acute malnutrition training at the beginning). To shorten the process, The 18 locally based participants formed the
situation within this novel context. previously trained and certified participants group that usually participated in IPC-analyses
were selected to make up the team which reduced in-country, however there was more external
The 10 southern-most drought-prone districts participation (CCLE participants) in this analysis
the length of the process by four days. This was
in the Greater South (Grande Sud) of Madagascar to support the virtual methodology used. The
helpful to ensure that the participants remained
have historically had chronically high levels of motivated and committed during the analysis four CCLE participants shared their experiences
both stunting (classified as very high at above while using virtual means of communication.
30%) and wasting (GAM levels classified as medi- 2 This follows the normal historical process for conducting
IPCs in Madagascar but was held online, and therefore the
um-high nationally at 5-10%, with some districts Stage two: Preparation for analysis duration was shorter and there was no in-person training.
reaching 10-15%) (MICS, 2018). Given the chronic A country core group, comprised of one IPC- 3 These 18 participants included 10 ten nutrition and health
nature of nutrition vulnerability of populations GSU focal point and four national staff as part focal points from districts level government, central MoH
and Action Contre la Faim (ACF), four food security focal
in the southern parts of Madagascar, the Ministry of the national IPC-TWG (representatives from points from FAO, WFP, three wash and social protection
of Health (MoH) and nutrition partners, including MoH, the National Nutrition Office, UNICEF focal points from ACF and CARE International and one
UNICEF, and together with the IPC Global and the National Office of Disaster and Risk 4
disaster risk management focal point.
CILSS = le Comité permanent inter-États de lutte contre la
Support Unit (GSU), leveraged existing tech- Management), prepared relevant tools, data and sécheresse dans le Sahel (Permanent Inter-state Committee
nologies to conduct a virtual IPC analysis for indicators for analysis. This group met three for drought control in the Sahel)
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Box 1 IPC-AMN analysis steps Figure 2 IPC-AMN Madagascar key results, June 2020

Step 1: Context and analysis parameters KEY FIGURES FEBRUARY - DECEMBER 2020
Step 2: References for evidence
Step 3: Analysis outcomes Severe Acute Malnutrition (SAM) 19,554
Step 4: Analysis of evidence on
119,674
contributing factors and other issues the number of 6-59 months children
Moderate Acute Malnutrition (MAM) 100,120
Current

acutely malnourished
Step 5: Phase classification
IN NEED OF TREATMENT Global Acute Malnutrition (GAM) 119,674
Step 6: Key drivers
Step 7: Limitations of analysis
Step 8: Priority response objectives Stage three: analysis groups’ deliberations and conclusions for vali-
Under normal circumstances, IPC analysis is dation within the wider group.
Analysis of evidence on contributing
Projection

factors and other issues conducted with a group of three to four persons
per district (or unit of analysis). Groups usually
Stage four: Wrap-up
Analysis of outcomes The results of all the group analysis per district
travel to one location for the analysis and remain
were validated in plenary sessions after which
Risk factors to monitor together for the duration of the training and
they were presented to the national Nutrition
analysis. There is a designated facilitator for each
Cluster by the chair of the country IPC-TWG
group to assist with technical questions, monitor
on nutrition indicators and virtual analysis for clearance. This was a similar process to a
the progress and act as spokesperson to IPC
and learned from Madagascar’s experience. typical IPC analysis, although validation took
technical leads and documents are shared via
Commitment was given from each of the mem- place online. The analysis team finalised the
USB flash drives. For the virtual process, a similar
ber organisations to fully attend the entire IPC report according to IPC guidelines and this
process was used but working group sessions
virtual process. was then presented virtually to the cluster after
were conducted virtually (using Skype and Zoom),
which comments and feedback were integrated
At the start of the virtual sessions, participants administered by BNGRC (supported by the pro-
into the report before submission to the IPC-
were assigned to one of six working groups vision of data bundles for each participant) and
GSU for review. The final version was then offi-
each focusing on one of the districts, ensuring a files were shared using Dropbox. The MoH pro-
cially released by BNRGC.
spread of technical expertise and organisational vided participants with full online access to the
affiliation. Each working group was led by a country’s HMIS and nutrition-related indicators. Results
focal person from a different organisation in- UNICEF and the IPC-GSU focal person, as tech- The results of the Madagascar IPC-AMN analysis
cluding Action Contre la Faim (ACF), CARE nical leads, created and sent out calendar invita- estimated GAM prevalence to be between 10.5-
International, the Food and Agriculture Organ- tions to participants and meeting reminders 30 16.8%, severe acute malnutrition (SAM) preva-
ization (FAO), MoH, the National Nutrition minutes prior to each session. lence was estimated to be between 1.6-3.7% and
Office under the Prime Minister’s Office (ONN), The participants of each working group spent moderate acute malnutrition (MAM) was cal-
the National Office of Disaster and Risk Man- about three to four hours in working sessions culated to be between 9.0-14.4%.5 Based on
agement (BNGRC) and UNICEF. A local country on Skype each day. Working groups made their these estimates, it was calculated that 119,674
facilitation team was comprised of three experts own arrangements with their group facilitator children 6-59 months of age would need treat-
to oversee the working groups which were com- on how to complete assigned activities which ment for acute malnutrition between February
prised of national experts experienced in IPC typically included two to three IPC-AMN steps and December 2020 (Figure 2). Out of these,
methodology with extensive knowledge of the per day out of the total eleven IPC-AMN analysis 16% would need treatment for SAM.
local context (from BNGRC, MoH and UNICEF). steps (Box 1). The most common arrangement
The IPC-GSU also provided two facilitators Results estimated that the nutrition situation
was that participants took turns to take breaks would likely deteriorate in all six districts
from its pool of global and regional experts. At when needed while the other participants con-
different stages of the analysis, focal persons beyond August 2020 due to the agricultural
tinued to work. lean season and the effects of COVID-19 (Figure
from each of the six districts were consulted for
knowledge of the local context. Support to dis- There was a one-hour lunch break every day 3). Such factors were expected to result in a
trict-level participants in the form of data bundles followed by a Zoom plenary session for all the 5
Note this is a combined prevalence estimate, i.e., according
was provided to facilitate internet access and working groups, during which the group’s des- to weight for height and/or mid-upper arm circumference
participation in online sessions. ignated rapporteur presented on the working and/or oedema presence anthropometric indicators.

Figure 3 IPC AMN results maps. The full report can be accessed on the IPC website here

1 - Acceptable

2 - Alert

3 - Serious

4 - Critical

5 - Extremely critical
Phase classification
based on MUAC
Areas with inadequate
evidence
Areas not analysed

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 Field Articles

slight deterioration in four districts (Toliary- As this was the first remote IPC-AMN analy- • If there is poor internet connectivity, a virtual
II, Ampanihy, Beloha and Tolagnaro) without sis conducted during the pandemic, there were IPC analysis may lead to decreased partici-
changing their global classification of IPC Phase no existing global guidelines to support remote pation of key authorities and partners at
3 – ‘serious’. However, results estimated that facilitation; the in-country team therefore had decentralised levels. It is, however, vital to
Betioky district would likely move into the se- to develop their own ways of working. The include district level participants to ensure
rious phase category (IPC Phase 3) and Am- team faced difficulties coordinating the facili- inclusion of deeper insights and knowledge
bovombe district into the ‘critical’ phase (IPC tation of plenary sessions and supervising work- of the areas under analysis. Provision of
Phase 4) requiring special attention and an ing groups in a way that would ensure rich dis- adequate internet bundles can help to support
urgent and targeted response. Full results are cussion and debate between participants. As participation of all partners.
provided in the report.6 noted previously, keeping participants engaged • High quality online facilitation is needed to
and committed for many hours per day was ensure good participation from all group
Discussion not easy. To overcome this, plenary sessions members, in particular ensuring that every
Key success factors were limited to just one hour a day and the participant has a chance to contribute. For
The IPC-AMN team in Madagascar leveraged process was kept to no longer than five hours this, the use of all the features of the online
existing local opportunities and prevailing po- per day. These challenges were further overcome tools was helpful including screen sharing
litical will to organise a virtual IPC-AMN by ensuring an adequate number of experienced and the use of breakout rooms with facilita-
analysis, the first remote IPC acute malnutrition IPC facilitators. Internet connectivity was a no- tors moving between rooms.
analysis conducted globally. Key success factors table challenge throughout which, at times, led
were a dynamic and motivated country team, to reduced engagement by district-level partic- Conclusion
openness, the willingness and participation ipants. This was addressed by providing internet The lessons learnt through this exercise have
of national and district level representatives shown that, with good levels of supervision
bundles to participants which to some extent
of three key government institutions (the Na- and with support to facilitate internet connec-
helped to overcome the issue.
tional Nutrition Office, the BNGRC and the tivity, it is possible to carry out high-quality
MoH) and full sharing of the national HMIS Another challenge was that, at the time of IPC-AMN analyses remotely in the context of
platform. In addition, the IPC team enjoyed a planning the IPC-AMN analysis, there was a Madagascar. Adapting to carry out this process
healthy working relationship with the food limited understanding of the potential impact remotely was critical to ensure the continuity
security, social protection, WASH and health of COVID-19 on malnutrition estimates and a of IPC-AMN analyses in the context of a
clusters which enabled the sharing of important lack of clarity on how to develop appropriate national lockdown prompted by COVID-19.
hypotheses. This was overcome through technical The results accurately predicted a decline in
contextual information. Another key factor
guidance provided by the IPC-GSU focal point, the nutrition situation and informed a nation-
was the technical support provided by the IPC
drawing from the latest IPC technical guidance, al-level nutrition response. The results of the
GSU and IPC CCLE participants who were
although there remained many unknowns due initial virtual IPC-AMN analysis were presented
able to participate remotely from Niger, Burkina
to the evolving nature of the pandemic. at UNICEF's East and Southern Africa regional
Faso and Rome. Overall, the use of virtual
meeting in June 2020 as a successful example
meeting methods enabled the participation of Lessons learned of continuity of activities despite COVID-19
a high calibre of local and international experts This experience has provided rich learning. Spe- for other countries to learn from and replicate.
that allowed a high-quality process in line cific lessons learnt include the following: Since this presentation, another online exercise
with IPC guidelines. • Planning and preparation of a virtual IPC was carried out in November 2020 in Mada-
Data collected via a national nutrition survey analysis requires sufficient time – at least gascar and the experience was also replicated
just prior to the lockdown that included an- seven days prior to the intended start date. in Uganda, Chad, Kenya, Somalia, Burundi
thropometric data was available and helped This is more than is typical during a face- and Yemen.
form a reliable basis for the baseline IPC pro- to-face analysis and is required to ensure
jections. While the nutrition assessment was the availability of as much necessary data 6 https://www.wfp.org/publications/2020-global-report-
not directly representative of each unit of analy- and information as possible for the working food-crises
7 https://reliefweb.int/report/madagascar/madagascar-
sis, it was possible to re-calculate nutrition groups to enable them to carry out the deterioration-humanitarian-crisis-grand-sud-dg-echo-wfp-
outcomes per unit of analysis informed by analysis in a shorter time frame. unicef-fao-echo

IPC-GUS guidance. This was important as it • It is possible, despite the challenges, to use
allowed for the use of recently collected, existing existing available data with re-analysis to References
data to ensure a robust and credible analysis. the relevant level of unit of analysis. This IPC Global Partners (2019) Integrated Food Security Phase
Projections from this analysis have proved to process, however, requires a high level of Classification Technical Manual Version 3.0. Evidence and
Standards for Better Food Security and Nutrition
be accurate, as Southern Madagascar is now technical support for the statistical analysis
Decisions. Rome.
facing great increases in levels of child wasting and additional time to recalculate nutrition http://www.ipcinfo.org/fileadmin/user_upload/ipcinfo/ma
across the region.7 indicators. nual/IPC_Technical_Manual_3_Final.pdf
• The use of team members previously trained IPC (2020a) COVID-19 IPC Technical Guidance Note. Rome.
Challenges in IPC analysis saves time and ensures http://www.ipcinfo.org/fileadmin/user_upload/ipcinfo/do
Organising an IPC-AMN analysis exercise quality input for the analysis. If this is not cs/documents/IPC_Technical_Guidance_to_Build_AMN_A
ssumptions_in_Covid19_Context.pdf
without up-to-date nutrition survey data seemed, possible, an online training could be carried
IPC (2020b) Madagascar: Acute Malnutrition Situation
at first, to be a daunting task and required ad- out to build the capacity of less experienced
February - April 2020 and Projections for May - August
ditional work to recalculate available data. The participants prior to the analysis, however, 2020 and September - December 2020:
fact that recent data was only available for this would considerably lengthen the time http://www.ipcinfo.org/ipc-country-analysis/details-
three districts was problematic and required taken for necessary online engagement map/en/c/1152677/?iso3=MDG
strong statistical capacity within the country which should be taken into account. UNICEF (2013) Improving Child Nutrition: The achievable
core team to perform appropriate recalculations • Optimising the capabilities of video- imperative for global progress. United Nations Children’s
Fund; 2013. p. 4 (https://www.unicef.org/media/files/
of all nutrition indicators at district level before conferencing solutions for working group nutrition_report_2013.pdf )
the data could be integrated into the analysis. interactions, discussions and plenary UNICEF (2018) Enquête nationale sur la situation socio-
The most recent IPC Technical Manual sup- presentations kept participants engaged démographique des ménages (MICS), Madagascar.
ported this process. throughout the exercise. https://mics.unicef.org/surveys
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Fabiola Niyonkuru feeds
her 2-year-old daughter,
Diella, a healthy diet

©UNICEF/UNI354877/Kanobana
A risk communication and community engagement
(RCCE) response to support maternal, infant and young
child nutrition in the context of COVID-19 in Rwanda
By Annet Birungi, Ken Limwame,
Desire Rwodzi and Youssouf Koita
Annet Birungi is an
experienced
RWANDA
Communication for What we know: Risk communication and community engagement (RCCE) is essential
Development Specialist at to ensure the continuity of uptake of nutrition services and optimal infant and young
UNICEF Rwanda where she child feeding practices in the context of COVID-19.
is responsible for the
design, management, execution, monitoring What this article adds: In Rwanda, two sub-committees were established within the
and evaluation of behavioural change and Nutrition Sector to lead nutrition-related RCCE activities, building on a previous
social mobilisation interventions for national RCCE strategy developed as part of Ebola preparedness efforts. Nutrition-related
nutrition. RCCE needs were identified through a review of existing data from available government
Ken Limwame is currently reports and mainstream media and social media reports and in consultation with
working on the COVID-19 Nutrition Sector partners through the sub-committees. Related key messages to address
RCCE in the Middle East myths and misconceptions were subsequently developed. Capacity strengthening and
and North Africa with training activities for community health workers leading on RCCE activities were
UNICEF Regional Office. conducted via Zoom, WhatsApp, email and telephonically. Key messages were
Previously he has worked disseminated through print and electronic media channels as well as via community
in various Communications for Development
radio stations. Parliamentarians were also engaged to expand the reach of messages.
(C4D) roles within UNICEF including at the
Eastern and Southern Africa Region Office Measuring the impact of RCCE activities has been challenging although changes in
and in Liberia during the Ebola crisis. practices were monitored through social media and community-level monitoring systems
and the uptake of services was measured through routine indicator tracking. Increases in
Desire Rwodzi is a former
service uptake were noted and positive behaviour changes were reflected within feedback
Knowledge Management
Officer for the Nutrition
mechanisms. As a next step, the Government of Rwanda intends to conduct a rapid
Section with the UNICEF qualitative and quantitative assessment to further understand the impact of RCCE
Eastern and Southern nutrition-related activities.
Africa Regional Office
(ESARO). Desire has over 10 years’
experience working on public health issues
in Eastern and Southern Africa and Asia and Background MoH on nutrition programme adaptations. The
the Pacific. At the onset of the COVID-19 outbreak in early guidelines provided a list of nutrition activities
Youssouf Koita is the Chief March 2020, the Government of Rwanda, with and measures to be taken to ensure safe service
of Nutrition Section at support from UNICEF and other United Nations provision as well as to reduce risks as far as
Rwanda Country Office. He agencies and development partners, established possible to community health workers (CHWs),
has a wealth of nutrition- the National COVID-19 Joint Task Force. The government and partner staff. These measures
related knowledge and task force, led by the Ministry of Health (MoH) enabled the continuity of growth monitoring serv-
experience through his ices including routine screening for malnutrition,
and the Rwanda Biomedical Centre (RBC), was
work supporting governments in several the admission and treatment of children suffering
countries to fight against all forms of
vital to inform the national COVID-19 response
and implemented a number of key measures to from severe acute malnutrition (SAM) and broader
malnutrition in both development and
mitigate and manage the pandemic. maternal, infant and young child nutrition (MIY-
humanitarian contexts.
CN) activities such as counselling on appropriate
The authors would like to thank the broader One such measure, following a directive from complementary feeding and exclusive breastfeeding.
UNICEF Rwanda team as well as UNICEF’s the MoH, was that nutrition interventions at com- Maternal nutrition, infant and young child feeding
Eastern and Southern Africa Regional Office munity-level were instructed to continue. To (IYCF) and food safety and hygiene messages
for their support in developing this work. inform this, clear guidelines were issued by the were also integrated into the Standard Operating
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 Field Articles

Headline findings of the The development of a clear RCCE strategy and resentatives from other UN agencies, the United
Box 1 nutrition RCCE review plan of action was critical to ensure that people States Agency for International Development
had, and continue to have, access to the right (USAID) and non-governmental organisations
The review identified evidence of the information, delivered in the right way and in a (NGOs) engaged in the Nutrition Sector as well
following concerns to be addressed through as with CHWs and frontline health workers.
timely fashion. RCCE, in the context of COVID-
RCCE activities:
19, aimed to empower people to adopt infection This review helped to identify gaps in knowledge,
• Existence of myths and misconceptions
around the prevention and spread of
and prevention control (IPC) measures to protect attitudes and perceptions in relation to nutrition
COVID-19 with some likening the disease to themselves and to avoid the spread of myths and COVID-19. Findings (Box 1) generated a
Ebola. For example, some frontline health and misconceptions about the disease and its good understanding of the populations at risk
workers were separating children from effects. This article documents the RCCE activities and existing communication channels and ulti-
mothers suspected of having, or confirmed undertaken by the Government of Rwanda, with mately informed the objectives of the COVID-
to have, COVID-19 which contradicted support from UNICEF, to address issues related 19 nutrition-related RCCE activities. As an on-
COVID-19 guidance (although to maternal nutrition and IYCF in the context going assessment of communication needs, gov-
recommended for Ebola). of COVID-19. ernment supervision and CHWs’ weekly and
• Rural populations suspected that COVID-19 monthly reports were adapted to include gath-
was an urban issue and they therefore did Implementation of a RCCE ering information on community concerns,
not follow the required prevention response to support MIYCN feedback and myths and rumours relating to
measures for MIYCN during the pandemic.
• Caregivers/mothers were not aware of the
Location of RCCE coordination nutrition and COVID-19.
guidance on the continuation of breast- The planning, management and coordination
Based on the available evidence, nutrition-
feeding in the context of COVID-19. of nutrition-related RCCE activities within the
related RCCE activities were designed to support
• There was limited knowledge on safe COVID-19 response was led by the MoH in
the maintenance of healthy diets for pregnant/lac-
feeding for pregnant and lactating mothers, collaboration with Nutrition Sector partners
tating mothers and children under five years of
safe complementary feeding of children and UNICEF. Two sub-committees were set- age, encourage uptake of IPC measures in the
under five years of age, household food and up, one focusing on nutrition data management context of IYCF, provide information on optimal
drinking water safety and how to help keep and the other, social behaviour change and com-
family members healthy during the COVID-
nutrition including breastfeeding and comple-
munication (SBCC). mentary feeding while practising good respiratory
19 pandemic.
• Caregivers were unsure as to whether to Development of RCCE strategy and and hand hygiene, support the continuity of
keep taking their children for routine planned activities growth monitoring and promote nutrition coun-
immunisations, regular growth monitoring Rwanda already had a national RCCE strategy, selling, micronutrient supplementation (including
and promotion sessions and what to do
initially developed as part of Ebola preparedness vitamin A and micronutrient powder (MNP))
if/when a child fell sick. and SAM management activities while imple-
efforts that included nutrition-related activities
• Pregnant and lactating mothers did not menting protection precautions.
know the recommended precautions to
and was further developed in light of COVID-
take to avoid exposure to COVID-19 for 19. Support was provided to the MoH by Capacity strengthening and training
them or their babies. UNICEF’s Communication, Advocacy and Part- Capacity strengthening and training were essential
nerships (CAP) section’s Communication for to ensure the rollout of RCCE activities. Facilitators
Development (C4D) programme to ensure that from the MoH, supported by UNICEF, developed
Procedure (SOP) for inpatient and outpatient national and community-level nutrition inter- simplified MIYCN digital training materials that
management of children under five years of age ventions were clearly defined and in line with were distributed via WhatsApp and email to
with SAM. The integration of MIYCN into the the East and Southern Africa Regional Office’s frontline health and nutrition workers. Remote
SOP also aimed to protect, promote and support RCCE guidance on COVID-19. training sessions, primarily via Zoom, were then
safe and optimal feeding practices for both held to discuss key learnings from the training
Nutrition-related RCCE needs were identified
breastfeeding and non-breastfeeding infants and material. Training sessions were attended by 47
through a review of existing data from available
young children in light of COVID-19. participants initially and an additional 547 par-
government reports as well as mainstream media
ticipants when lockdown was lifted in June 2020.
An important focus throughout the COVID- and social media reports and in consultation
Participants included directors of national hos-
19 nutrition response has been risk communi- with Nutrition Sector partners through the sub-
pitals, health centre staff, nutritionists working
cation and community engagement (RCCE) in committees. Assessment methods included
with CHWs, case management staff and IPC
response to numerous communication and in- virtual meetings and/or telephone conversations
teams. These capacity strengthening activities
formation challenges surrounding the pandemic. with selected government representatives, rep-
played a critical role in ensuring a high-quality
nutrition response during the pandemic, partic-
Figure 1 Target groups for RCCE activities ularly in relation to RCCE activities.

Development of key nutrition messages

MIYCN key messages and information, education
Decision-makers, including those from the MoH, district hospitals, health and communication (IEC) materials were de-
Decision-makers
centres, the National Early Childhood Coordination Programme, local veloped by the SBCC sub-committee in consul-
authorities, civil society organisations (CSOs) and the media, were targeted
at tertiary level. tation with members of both sub-committees.
This process was informed by the results of the
The secondary target audience were frontline health workers, including CHWs needs assessment (Box 1) and feedback on com-
Frontline health and health providers, who typically play a role in influencing the nutrition munity concerns, myths and rumours around
workers behaviour of caregivers. Tailored messages were developed for CHWs as they
had direct access to caregivers and parents of children under five years of age. child feeding practices gathered through CHW
weekly and monthly reports. Regional and global
The primary target group for the nutrition-related RCCE activities were
guidance was also reviewed and adapted including
Caregivers or
parents caregivers or parents of children under five years of age as well as UNICEF and World Health Organization (WHO)
broader family members.
MIYCN counselling cards. IEC materials were
developed for health workers, essential workers
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 Field Articles

Themes of the MIYCN IEC copies of the posters were distributed through of ad hoc information, for example, monitoring
Box 2 materials WhatsApp and group emails. This was followed the separation of mothers with COVID-19 from
up with virtual/ telephone briefings through an their infants and the cessation of breastfeeding.
1) The differences between COVID-19 and MoH WhatsApp and email group for all directors Supervision reports for CHWs were also collated
Ebola and the fact that mothers should
of district hospitals, health centres and nutri- to explore the extent to which CHWs understood
continue breastfeeding even if they have
tionists within hospitals. Telephone follow ups the adapted recommendations. It is planned
suspected/confirmed COVID-19
2) Precautions for pregnant and lactating were also made to brief staff in the use and dis- that rapid qualitative and quantitative assessments
mothers to avoid being exposed to COVID-19 semination of the materials. will be conducted in the coming months to
3) Recommended practices to feed and care collect further information on the impact of
To ensure information reached those with
for a newborn with suspected/confirmed RCCE activities in relation to changes to the
low connectivity, the MoH also made use of the
COVID-19 diets of pregnant women, mothers and children
Internet of Good Things (IoGT) – a UNICEF-
4) Additional precautions needed during during the pandemic as well as aspects such as
delivery and immediately after birth led initiative that hosts mobile packaged, public
overall breastfeeding rates and to learn more
5) Precautions to be taken during breast- health content information for free even on
about communities’ knowledge, attitudes and
feeding to keep babies safe from COVID-19 low-end mobile devices. This was initially aimed
perceptions regarding MIYCN in the context of
6) When and why a mother should express at frontline healthcare workers but, in time,
COVID-19.
breastmilk content was expanded to the general public.
7) How to practice safe complementary Virtual meetings led by MoH, on platforms Results
feeding for children 6-24 months of age such as Zoom and Skype, were also used when
8) Food safety, handwashing and sanitation
Influence on nutrition indicators
disseminating messages to stakeholders. Service uptake was monitored to indicate the
during the COVID-19 pandemic
9) Caring and appropriate feeding for infants Mass media communication channels were influence of RCCE interventions. HMIS routine
and young children in the context of IPC also used. Bi-weekly nutrition messages were data on nutrition indicators noted that total
aired on community radio stations with a popu- SAM admissions increased from 9,200 admissions
lation coverage of 99%. Additionally, nutrition in April 2020 to 10,022 in February 2021. In the
and CHWs as well as parents/caregivers. Messages same timeframe, the coverage of growth moni-
messages during the COVID-19 pandemic were
were adapted to guide caregivers and parents toring services grew from 82% to 87% and the
incorporated into the renowned radio drama,
with intellectual disabilities. Tools were subse- coverage of distribution of MNP to children
‘Itetero’. Parliamentarians were used to channel
quently piloted and refined as needed. The main aged 6-23 months increased from 42% to 44%.
information over local radio stations as is described
themes of the final IEC materials are outlined While there are many other factors at play and
in Box 3. Nutrition messages continue to be dis-
in Box 2. these figures should be read with caution given
seminated bi-weekly through Radio Rwanda and
Testimonials from mothers who had recovered its five affiliated community-based radios which the challenges of data collection during this
from COVID-19, and who had continued breast- have a wide and broad population listenership. time, these findings point to some degree to the
feeding or had given birth to healthy babies, success of the RCCE efforts as community mem-
were subsequently featured as community cham-
Monitoring impact of the RCCE bers clearly continued to utilise nutrition services
pions through media channels. This helped to activities during the pandemic.
address rumours and misinformation.1 Indicators from Rwanda’s Health Information
Management System (HMIS) were used as proxy Changes in practices
Channels for communication measures for the effectiveness of the RCCE pro- Social media and community-level monitoring
The MoH leveraged all existing channels to dis- gramme of activities including indicators around revealed that mothers reported washing their
seminate key messages including print and elec- participation in growth monitoring, MNP dis- hands with soap and running water more frequently
tronic media. A total of 11,000 printed posters tribution and admissions and treatment for than prior to the COVID-19 pandemic. A GeoPoll
aimed at health workers were distributed to all SAM and moderate acute malnutrition (MAM). survey for April 2020 indicated that 98% of re-
48 district hospitals and 500 health centres, in- Social media dashboards were also periodically spondents took measures to protect themselves
cluding refugee camps and isolation centres, reviewed by UNICEF to monitor and track from exposure to COVID-19 and 37% of respon-
and 70,000 booklets were distributed to CHWs. ‘mentions’, hashtags, notifications and trends to dents prioritised increasing hygiene practices.2
Hard copies of IEC materials were distributed gather information and manage rumours re- Reach of communications targeted to
in conjunction with existing essential medicine garding COVID-19 and nutrition. Additional
and nutrition commodities. In addition, soft monitoring was conducted through the collection
and via health workers
The December 2020 report from the RBC indi-
cated that all frontline staff, including nutritionists,
received the posters with nutrition messages
Box 3 Engaging with parliamentarians to support MIYCN messaging that were disseminated. A total of 60,000 CHWs
At the beginning of the pandemic and in parallel to RCCE activities, UNICEF began engaging with a
received the booklets and qualitative feedback
group of dedicated members of parliament (MPs) to expand the reach of messages on MIYCN in the within the RBC report demonstrated that CHWs
context of COVID-19. MPs were used to disseminate public health messages to caregivers of children were using the booklets within growth monitoring
under five years of age through local radio stations. Messages focused on the importance of sessions and during household visits. The RBC
nutrition, specifically in relation to exclusive breastfeeding and dietary diversity for children 6-59 also reported that, across all 30 districts, 67% of
months of age. CHWs were confident in conducting MIYCN
counselling, growth monitoring sessions and
The group of MPs were also able to invite representatives of relevant government institutions to
speak to radio listeners on what they were doing to improve MIYCN and food security in the context home visits during the COVID-19 pandemic as
of COVID-19. These talk shows enabled two-way communication whereby listeners could call in, pose a result of following social distancing protocols.
questions, share comments and obtain timely feedback from the panel of government It was reported that 85% of caregivers of children
representatives. Working with parliamentarians to champion advocacy and social mobilisation to
improve nutrition at all levels was critical to support RCCE initiatives. A major challenge was that 1 ‘COVID-19: A Good Friday as New Cases in Rwanda Decline
parliamentarians tended not to have extensive technical knowledge of nutrition. To mitigate this, and a Baby is Born’ https://www.ktpress.rw/2020/07/covid-
19-a-good-friday-as-new-cases-in-rwanda-decline-and-a-
UNICEF produced a set of key MIYCN messages in light of COVID-19 for MPs and also held virtual baby-is-born/
briefings to guide related discussions. 2
https://www.geopoll.com/resources/palladium-rwanda-
case-study/
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 Field Articles

under five years of age were reached with MIYCN sulted in some mothers being separated from Identifying supporters/collaborators for RCCE
messages through non-digital methods. The re- their infants for the two-week isolation period. activities on nutrition early on in the response,
ports also showed that the use of mobile platforms Although no quantitative data was available to including other ministries, public institutions
allowed CHWs, social workers and nutritionists understand the degree to which this was hap- and civil society organisations (CSOs), was noted
to continue to provide dietary diversity messages pening and the subsequent impact on breast- to be a critical element for developing and dis-
and nutrition education to caregivers/parents. feeding rates, supervision reports indicated that seminating harmonised nutrition messages.
this was a significant issue which resulted in
In refugee camps, RCCE activities were mon- some mothers being unable to relactate when Wide dissemination of appropriate evidence-
itored on a weekly and monthly basis through united with their infants. To mitigate these chal- based RCCE nutrition messaging through mul-
reports and participation lists provided by CHWs lenges, sensitisation of frontline health workers tiple channels helped to build the capacity of
and partner NGOs. Those lists provided the was conducted through face-to-face and virtual caregivers/parents to protect themselves and
number of refugees who had attended the RCCE meetings and printed materials with clear mes- their children in light of COVID-19. Adaptation
sessions, participated in growth monitoring serv- sages were disseminated. of available regional and global guidance to
ices and received MNP and children who received support message development on nutrition in
treatment for wasting. Reports showed that, by Considerable delays (up to a month) were the context of COVID-19 was seen to be an
the end of 2020, approximately 8,300 caregivers experienced in approving messages and com- effective starting point for developing contex-
had received nutrition services including messages munication materials for dissemination in both tualised key nutrition-related RCCE activities.
on MIYCN best practices in the context of print and digital form. Consistent engagement
COVID-19. Feedback collection, rumour tracking with stakeholders enabled their eventual approval Due to the country’s total lockdown, strength-
and complaints were compiled through weekly and dissemination. Additional human resource ening the capacity of frontline health workers
and monthly reports which would also feed into capacities were posted to MoH, with UNICEF to improve child nutrition in the country’s hard-
the abovementioned processes. support, and contributed to addressing some of est-to-reach areas and to promote and support
the challenges. Two staff members from appropriate MIYCN in the context of the pan-
Reach of mass media communication UNICEF’s CAP section and one staff member demic was a challenge. This was overcome during
By the end of May 2020, the COVID-19 MIYCN from the Nutrition Section were recruited to the facilitation of remote online training and
and IPC messages were estimated to have support additional needs and challenges. follow-up.
reached over three million people through the
Despite correct messages having been dis- Given movement restrictions and social dis-
medium of radio. Community feedback sug-
seminated widely, limited access to resources, tancing requirements, conducting rapid assess-
gested that most caregivers appreciated the
such as face masks, other personal protective ments to understand communities’ knowledge,
radio talk shows and counselling by CHWs re-
equipment (PPE), clean running water, soap attitudes and perceptions in relation to MIYCN
garding how best to feed infants and young
and alcohol rub, hindered CHWs from providing in the context of COVID-19 was not possible.
children in the context of COVID-19. It was
timely nutrition counselling services which As a result, developing appropriate RCCE content
noted that they understood that poor diets
threatened the adoption of the recommended was challenging. The RCCE nutrition needs as-
have the potential to exacerbate pre-existing
MIYCN practices. sessment exercise helped to overcome this gap
conditions, putting mothers and children at el-
and enabled the rapid identification of gaps in
evated risk of contracting COVID-19. One Some radio talk show discussions and social knowledge, attitudes and perceptions around
community member shared, media communications demonstrated that myths nutrition. Similar exercises focusing on key
"You know before, we feared that Corona and misconceptions around IYCF and COVID- areas such as breastfeeding practices could be
[virus] was like Ebola, but I learnt [through the 19 continued and spread throughout the pan- used to further guide messaging.
radio show] that it’s different, we now know how demic. To address this issue, UNICEF has started
to protect ourselves and the children. The radio supporting the Government to partner with Conclusion
programmes are helping us to protect our families, agencies such as the Rwanda Red Cross to As COVID-19 continues to impact the lives of
and that makes me feel safe. I learnt that my analyse feedback through existing complaints many, adapting appropriate RCCE messages and
family, especially young children, need to eat nu- mechanisms, track rumours and misconceptions exploring alternative communication channels
tritious food every day to provide energy and nu- and monitor the reach of RCCE activities. Within is vital to ensure it has an impact on targeted be-
trition to keep them strong". the partnership with Rwanda Red Cross, for haviours. More research is needed to explore
example, data in relation to handwashing prac- the critical context-specific factors responsible
Use of Twitter, Facebook and other social tices, the use of masks and broader social dis- for improving the diets of women and children
media platforms offered numerous opportunities tancing and prevailing rumours and myths is and those that may act as barriers for the uptake
to deliver MIYCN messages to reach target au- collected. This data is used to inform the gov- of nutrition services. As a next step, the Gov-
diences with key information and elicit engage- ernment response. ernment of Rwanda intends to conduct a rapid
ment that related to changes in behaviour. In qualitative and quantitative assessment to learn
addition, UNICEF developed a video called Lessons learnt more about the communities’ knowledge, attitudes
‘You can trust these tips from a UNICEF Nutrition Establishing a coordination structure through and perceptions regarding MIYCN for children
Expert’ which aimed to raise awareness of the the development of sub-committees, where roles under five years of age in light of COVID-19,
importance and benefits of breastfeeding and and responsibilities were clearly defined, was how COVID-19 has affected children’s nutrition,
optimal complementary feeding. The video gen- an effective way to harmonise nutrition RCCE communication patterns and channels as well
erated 69.7k views, 70 shares and 2.2k likes on and ensure the efficient use of resources in the as the impact of the pandemic on nutrition serv-
Facebook. Social media, however, also enabled context of COVID-19. The creation of the sub- ices. Such assessments will help the government
the continued circulation of myths and mis- committees was noted to be effective in bringing to understand the extent to which RCCE messages
conceptions (as discussed below). together and coordinating a wide range of stake- have impacted on behaviour and to further de-
holders in relation to nutrition RCCE messaging. velop optimal RCCE interventions for nutrition,
Challenges It further helped to identify potential gaps in
forming part of the country’s comprehensive
In spite of strong MIYCN messaging to the con- the RCCE response, facilitated the sharing of
COVID-19 response strategy.
trary, myths and misconceptions around the information to enable the development of key
breastfeeding of infants when a mother was a messages and appropriate IEC materials and For more information, please contact Annet
suspected or confirmed COVID-19 patient re- helped to avoid duplication. Birungi at [email protected]
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©AGREA, 2020
Growkits disribution to urban farmers

Localising food
supply chains PHILIPPINES
What we know: The COVID-19 pandemic and the subsequent country
during the COVID-19 lockdowns have had a large impact on food systems, particularly in
relation to supply chains. This has necessitated the strengthening of

pandemic: An local supply chains.

What this article adds: In the Philippines, a local non-governmental

example from the organisation, AGREA, developed the Move Food Initiative which aimed to
move food from farms to consumers and to reduce food waste during the
pandemic by using an online fresh food ordering platform and developing
Philippines, Move ‘rescue kitchens’ which repurposed fresh produce that would otherwise go
to waste. While working closely with farmers, AGREA was able to see
Food Initiative first-hand some of the problems farmers faced, particularly in the area of
post-harvest losses, and have now begun empowering farmers to diversify
By Natalie Sessions and Christine Jodloman crops and implement additional measures to reduce post-harvest losses.
AGREA has also helped to foster a greater understanding for consumers of
Natalie Sessions is a Senior Nutritionist at where their food comes from.
ENN. She has recently been responsible for
the global coordination of ENN’s Knowledge
Management work for the Scaling Up
Nutrition (SUN) Movement and also supports Background The Department of Agriculture (DA)
the work of the Global Nutrition Cluster mobilised to try to mitigate the effects
As a measure to limit the spread of
Technical Alliance as well as the Wasting and Stunting of the ECQ on agricultural activities
Technical Working Group.
COVID-19 in the Philippines, strict lock-
downs, known as community quarantines including developing a food resilience
Christine Jodloman is the Associate Director were imposed in many parts of the coun- protocol. A number of mitigation meas-
of AGREA Foundation, and has been working ures were put in place such as developing
try. The strictest of these began on the
in AGREA for two years. She came from a food passes that enabled trucks carrying
family of farmers, has seven years of
16th March 2020 when an enhanced
community quarantine (ECQ) effectively food and agricultural products to pass
experience in designing and implementing
shut down most parts of the country, re- through quarantine checkpoints, in-
capacity-building programs for rural farming
communities, and occasionally writes agriculture features. stricting movement except for when es- creasing efforts to promote urban agri-
sential. In Metropolitan Manila, the quar- culture through the distribution of seeds
This article is based on a series of interviews conducted with and planting materials and developing
the AGREA team as part of the development of a SUN
antine led to challenges in obtaining
‘price freeze’ policies to manage unrea-
Movement ‘Solutions Brief’. Interviews were conducted with fresh produce with supermarkets and
sonable and excessive price increases of
Cherrie Atiliano; CEO, AGREA; Sef Carandang; Move Food wet market stalls1 struggling to meet de-
basic necessities during the ECQ. How-
Initiative Volunteer/ Gender Specialist, United Nations; Sonia mand. In other parts of the country,
ever, recognising that the DA was not
Gonzales, Business Operations Manager, AGREA; Benjamin farmers faced challenges in selling their
Jorge Cadag, Agribusiness Manager, AGREA; Caroline de Leon, able to act as quickly as it would have
produce, there were logistical problems
Mindanao Logistics Officer, AGREA; Mary Ann Reyes, liked given the necessary bureaucratic
in transporting produce from farms to
Administration and Finance Manager, AGREA and William Dar, processes within the government, the
cities and, with restaurants closed, Filipino
Secretary of the Department of Agriculture, Philippines. The
authors are grateful for the support of the SUN Movement
farmers were left with few people to sell 1
A wet market is a marketplace selling fresh meat,
fish, produce and other perishable goods as
Secretariat for identifying this story and for the support in their harvest to, leaving fresh produce distinguished from dry markets that sell durable
developing and disseminating the broader ‘Solutions Brief’. going to waste. goods such as fabric and electronics.
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©AGREA, 2020
DA welcomed public-private partnerships to
support agriculture activities during this time.
AGREA was one such partner, led by its
CEO, Cherrie Atilano. AGREA aims to support
the empowerment of local farmers by imple-
menting sustainable agricultural practices and
creating inclusive agribusiness livelihood pro-
grammes. This article explores how AGREA re-
acted to the challenges brought about by the
ECQ and tells the story of AGREA’s Move Food
Initiative, an initiative to move food from farms
to consumers and to reduce food waste during
the pandemic. This article is based on interviews
held with the AGREA team in the development
of a Solutions Brief which was published jointly
by Emergency Nutrition Network (ENN) and
the Scaling Up Nutrition (SUN) Movement.

Moving food from farms to the

city
Three days after the ECQ was imposed, Atilano
received a call from one of the farmers who
AGREA works with who had 15,000 pineapples
he had just harvested about 60 kilometres from
the capital city. He was unable to transport the Supporting women farmers
fruit to markets given the imposed quarantine.
Through its wide network and support system,
AGREA was able to source a truck owned by the produce when it arrived in Metropolitan tancing guidelines. In some areas, as a result of
the local municipal government that was able Manila. This included a list of the available fresh advocacy by AGREA and the DA, these restric-
to pass through the stringent checkpoints and produce as well as the amount available and the tions reportedly reduced and more people were
transport the pineapples to Metropolitan Manila. price. To determine the price, AGREA used the allowed to support in the harvesting of crops.
By posting on Facebook and again using the price freezing standards set by the DA to ensure
networks that AGREA already had, they were that farmers and consumers were not taken ad- Financial payments
able to sell 3,500 pineapples in just three days. vantage of. Customers were requested to indicate Paying farmers was another emerging challenge
on the form what that they would like to purchase and required flexibility. Typically, AGREA paid
Seeing the success of this initial opportunity,
and to share the details of where the food would farmers in person with cash but the limitations
AGREA began receiving more calls from farm-
be delivered to. Given the logistics of delivering of the ECQ meant that AGREA had to shift
ers asking for help to move their produce so
to individual consumers, AGREA instead targeted from cash payments to bank transfers. Many
decided to launch the Move Food Initiative to
the building of communes, homeowners associ- farmers did not have access to bank accounts
support this effort.
ations and businesses where food would be de- and were not able to open one due to not having
As with the first call, AGREA relied on Facebook livered to a central point and one volunteer would an Identity Document (ID) so therefore creative
to communicate information about the initiative be responsible for moving food to individual ways of sending money had to be found. In
as this is a social media platform that is widely consumers and households. These volunteers, some instances, rural banks or the bank accounts
used in the Philippines. From the very beginning, known as ‘movers’, would subsequently set up of relatives or friends were used or, in areas
word spread quickly through the social media stalls or mini-markets in building communes where there were no ATMs, at times AGREA
platform and people started to respond with offers (observing strict social distancing measures) to paid local government officials in central locations
of help. AGREA’s Facebook page already had a pass produce on to those who had ordered it. and the officials would then distribute the money
dedicated audience of farmers with whom they Movers were generally well known in their com- directly to the farmers. AGREA would subse-
had worked for the last five years who were made munities and by consumers and hence already quently follow up with the farmers to check
aware of the initiative and who reached out when had a level of trust for those buying the produce. that they had received the money and if they
they had harvested their produce. This network had distributed it amongst the farming cooper-
also included those who were interested in sup- Emerging issues atives as per the agreements.
porting the agricultural sector and who were As the initiative progressed, a number of emerging
willing to volunteer when needed. For example, issues were noted that required creative solutions Working with different communities
from AGREA. As AGREA worked with ever-increasing numbers
when a call was posted relating to the need for
of farming communities across the country,
trucks to transport food, one furniture company
ECQ restrictions and harvesting they realised that ways of working were different
offered the use of a delivery truck. This was re-
purposed for the pick-up and delivery of agricultural challenges in each community. The team had to contextualise
In some areas, only two to three people were al- the approach based on the farming community
produce. Private trucks and cars were offered by
lowed to harvest produce at a time as a result of involved. For example, an indigenous farming
friends and acquaintances across farming regions
the ECQ. Although no quantitative data was community was identified as needing support
and restaurants that had temporarily closed due
collected, this reportedly led to huge delays in to sell raw honey produced on ancestral land.
to the quarantine were made available to be used
harvesting and subsequent post-harvest losses. Working with this community required a different
as storage depots.
To solve this, AGREA spent time advocating way of working to build trust and to ensure that
An online fresh food ordering platform, using with mayors to enable more people to support traditional practices were protected. AGREA
a simple Google form, was set up to distribute the harvesting while still adhering to social dis- relied on a volunteer who had an in-depth
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ies, soups, salad dressings and many other prod-

©AGREA, 2020
ucts depending on what surplus was available.
Products were designed to be seasonal (based
on what was grown at the time), artisanal (hand-
made), intentional (designed out of foods that
would otherwise be going to waste) and limited
(in supply).
Like many countries, food loss is a major
issue in the Philippines. Before the pandemic it
was estimated that 30% of produce was lost
post-harvest and during the pandemic this rose
to almost 60%. This challenge became a priority
for the Move Food Initiative. The products pro-
duced by the ARK were well received and
demand has grown over time. The ARK also
donated fresh produce and seasonal products
to frontline and other essential workers.
Additional campaigns were developed to
limit food going to waste. These included ‘Hero
Drives’ where consumers were encouraged to
Watermelon delivery
buy fresh produce in bulk for a discount and
the ‘Being Crate-ful’ Drive where crates filled
with assorted available vegetables were sold to
knowledge of this community and was able to challenging given the need to move fresh produce consumers. The ‘Crate-ful’ Drive, launched in
facilitate AGREA offering support. as quickly as possible to prevent it spoiling. August 2020, was the Move Food Initiative’s
This challenge was also very noticeable when way of extending gratitude to key workers. Con-
Transportation of food using land transportation as the trucks being sumers were told that for every crate of fresh
One challenge of transporting the food using used were not made for fresh food conveyance. and healthy fruit and vegetables purchased,
vehicles that were not municipal government They were poorly ventilated and lacked proper AGREA would set aside a food parcel for selected
vehicles was the negotiation required at quar- air conditioning. As such, food orders were beneficiaries, particularly jeepney (local bus)
antine checkpoints. The team had to secure prone to spoiling during the journey. Since there drivers and garbage collectors. In just five days,
food passes from an Inter-Agency Task Force (a was not much that the AGREA team could do all the fruit crates had sold out, making it
special inter-government taskforce set up in to address the challenges in transportation, it possible to deliver food parcels to 84 jeepney
light of COVID-19) which verified that their became vital that open communication was drivers and 12 garbage collectors. ‘Donate a
vehicles were carrying essential food commodi- maintained with consumers so that they too vegetable’ campaigns were also developed in
ties. These passes were often challenging to understood the realities and challenges of trans- which AGREA promised that, for every 300 kg
obtain and required support from local DA offi- portation and were prepared for delays or for of produce ordered, 15 kg would be donated to
cials and government actors who were able to when stock was not of a high quality. This helped kitchens that supplied frontline workers.
push the processes forward. AGREA had to garner a sense of trust with consumers as they
spend a lot of time utilising local contacts and Supporting farmers in the ‘new
felt that nothing was being hidden from them
leveraging strong working relationships built in the process. Furthermore, when journeys normal’
prior to the pandemic to gain the support of were very long, the DA supported and provided While working closely with farmers, AGREA
government actors to secure the food passes. cold storage to keep the food fresh while awaiting was able to see first-hand some of the problems
The DA was instrumental in supporting AGREA delivery in Metropolitan Manila. farmers faced particularly in the area of post-
in this regard. harvest losses. Farmers appeared to lack the
Tackling food waste skills and know-how to reduce these. AGREA
As the initiative grew, AGREA began receiving
The biggest emerging issue was that of food built such factors into a brief capacity-building
calls from farmers further afield who also needed
spoilage and food waste. In April, it became ap- training that was conducted over the telephone
to move their food. Considering that the Philip-
parent that a surplus of tomatoes would go to and has worked hard to help farmers to better
pines is an archipelago of 7,107 islands, both
waste if not used. There was also a growing plan their harvests to avoid losses. Creative
sea and air transportation were needed along
supply of so-called ‘ugly’ foods which consumers ideas and practices to prolong the life of food
with land transportation. During the ECQ, such
were more reluctant to consume as well as a from farmers themselves were also tapped into
transportation also required special permission
recognition that AGREA was having to throw and shared among other farming communities.
and came with its own challenges which is why
away food that arrived in Metropolitan Manila One reason for post-harvest losses was the lack
the bulk of transportation was undertaken via
already spoilt. of diversity in crop planting – communities
land transportation. Sea transportation took
tended to produce the same crops that were
time (up to five days) and was subject to weather On the other hand, there was the challenge harvested at the same time leading to a produce
challenges. Estimating the time that sea trans- of restaurants being shut and chefs and restaurant surplus. In light of this, AGREA and the DA
portation would arrive in port was also difficult workers being out of work. As a result, the have started working with farming communities
and meant that members of the AGREA team Move Food Initiative decided to partner with to diversify the produce grown in provinces.
had to wait at the port for many hours. Air chefs to develop products made from these
transportation was much quicker (typically only oversupplied and misfit foods, naming the ini- A further realisation that AGREA had was
one to two hours). However, the new restrictions tiative the AGREA Rescue Kitchen (ARK). Ini- the fact that farmers lacked the skills for and
within airports meant that once a plane had tially, Pomodoro sauces and tomato jams were understanding of effective pricing models for
landed, it took many hours to complete the pa- developed and this expanded to a broad range their produce. Instead, in the past they have
perwork and secure the food. These delays were of produce including other types of jams, smooth- tended to rely on middlemen who take a cut of
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their profits. AGREA has slowly started working farmer had produced the fruit and vegetables initiative had impacted their lives such as the
with farmers to help them to understand how and what it took to bring produce to the market. very first pineapple farmer who was able to pay
to cost their produce and how to budget their back his loans and pay for his child’s school
income so that they are less reliant on taking Building off the successes of the fees. The initiative has been recognised within
out loans and working with middlemen in order initiative the DA and further afield with Atilano and
to keep their farms operational. The Move Food Initiative was subsequently AGREA winning numerous international and
adapted in light of a series of typhoons that national awards.
Supporting consumers in the affected the country in October 2020 (Typhoons
‘new normal’ Quinta, Rolly and Ulysses) to support farmers Lessons Learnt
The biggest impact of the quarantine was the in the affected communities through a ‘Rise Up Several lessons were learnt during the process
realisation by the public of the need to think and Recover’ drive to support their recovery. of rolling out the Move Food Initiative and
about how they obtain their food. In an in- One aspect of the drive was the ‘Buto ng Pag- were, in part, key to its success. These included:
creasingly industrialised world, people have asa’ or Seeds of Hope Initiative, where customers 1. The need to be creative and agile: The
largely lost the connection to people growing could sponsor a set of seeds that would cover process of moving food around the country
their food and the pandemic has offered the 1,000 square metres of land. was entirely new to AGREA and the team
opportunity for consumers to engage in a new had to learn as they went along, adapting
The Move Food Initiative and the broader and adjusting based on the emerging needs.
way going forward. As a result, AGREA has
efforts by the DA have led to greater investments Agility was needed to work differently with
also been promoting ‘grow kits’, urban gardening in agriculture by the Government of the Philip- different farming communities and creativity
kits that include seedlings, potting mixes, seedling pines. Amid the pandemic, efforts by the gov- was needed in order to overcome some of
trays and a grow manual to encourage people ernment and partner organisations have focused the challenges.
to grow things at home, no matter how limited on localising food supply chains to prevent food 2. The importance of leveraging one’s network:
their space is. This is in line with the DA’s ‘Plant, waste and also to feed families. From the beginning, the Move Food Initiative
Plant, Plant’ programme that includes the dis-
The Move Food Initiative has also been shared relied on AGREA’s wide network of allies.
tribution of seeds and planting materials as well
widely as a success story in the midst of the Across Atilano’s and AGREA’s network,
as the establishment of community gardens.
pandemic, including through the SUN Move- volunteers were engaged at both ends of the
Home gardening was also promoted during the
ment, to promote the generation of ideas in spectrum. Volunteers dedicated large amounts
pandemic as a productive family activity that
other countries that are dealing with food waste of personal time to support the initiative
could be done during the ECQ.
and struggling to move food during lockdowns. and helped to ensure food moved from farm
Another lesson from the Move Food Initiative to consumer. Facebook has played a critical
was the need to connect consumers to farmers. Results role in this mobilisation. From the very
During the pandemic, there was a renewed By 1 June 2020, the day the Philippines began beginning, word spread quickly through the
focus on where food was coming from and lifting quarantine measures, the Move Food Ini- social media platform and people started to
AGREA was able to educate consumers on the tiative had shipped over 160,000 kg of fruit and respond with offers of help.
process involved in getting food from farms to vegetables from more than 7,400 farmers to 3. The need to complement government efforts:
their homes. The Move Food Initiative Facebook nearly 52,000 families. By the end of November AGREA has always aligned to government
page facilitated engagement with the wider con- 2020, 191,447 kg of fruit and vegetables had goals and objectives and maintains strong
sumer community and helped to connect farmers been delivered, 28,122 farmers had been part- communication links with the DA who it
and consumers. By sharing farmers’ stories on nered with and fruit and vegetables had been kept continuously informed of its plans during
the platform, consumers were able to get a sense served to 78,177 families and 4,690 frontline the pandemic.
of where their food was coming from, which workers. Farmers reported stories of how the 4. Contextualising the approach: The Move
Food Initiative looked different in each
farming community and each consumer
community. As such, there was not a logistical
©AGREA, 2020

blueprint but instead the model was adapted

as needed. The ways of working with farmers,
the ways of transporting goods and the ways
of paying farmers were all adapted based on
the unique needs of each farming community.
A similar process of contextualising approaches
was also noted at the consumer end.

Conclusion
While the pandemic has brought unprecedented
suffering and challenges across the globe, it has
also offered an opportunity to rethink practices
and food consumption patterns. The Move Food
Initiative is a small-scale example of a response
to some of these large challenges. It is farmer-
focused, community-based and sustainable. In
addition, it provides a model that other countries
can adopt, on a bigger scale, for a more sustainable
future food system.
For more information, please contact
Christine Jodloman at
[email protected]
A turmeric farm

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Sa'dia Mohamed
Adapting infant
and young
child feeding
interventions
in the context
of COVID-19 in
Somalia
IYCF counsellor conducting a home visit
By Sahra Moalim Ahmed,
Bishar Osman Hussein and
Emmanuel Barasa
Sahra Moalim Ahmed is an
Infant and Young Child
Feeding Officerat Concern
SOMALIA
Worldwide Somalia based in
What we know: The COVID-19 pandemic and resulting infection prevention
Mogadishu with 12 years of control (IPC) measures have required nutrition programmes to adapt to ensure that
experience in nutrition services can continue.
programing, reproductive health and midwifery.
What this article adds: Adaptations were required to the Concern-supported infant
Bishar Osman Hussein is a and young child feeding (IYCF) programme in Somalia to ensure that caregivers of
Health and Nutrition Program infants under two years of age continued to access vital IYCF individual and group
Manager at Concern
counselling services, tailored to the COVID-19 context, in a way that minimised the
Worldwide Somalia with over
risk of transmission of the virus. Adaptations included the translation and
13 years of healthcare
leadership and programme dissmemination of key IYCF COVID-19 messages, the training of health workers on
management which, for the last nine years, have IYCF in the COVID-19 context, IPC measures implemented in individual and group
been in nutrition, maternal and child health counselling sessions, a reduced number of participants at group counselling sessions
programming in Somalia. (and an increase in the number of sessions held and IYCF counsellors per health
facility to support this), an increased number of handwashing stations at health
Emmanuel Barasa is the Health
and Nutrition Programme facilities and the inclusion of people recovered from COVID-19 into counselling
Coordinator at Concern sessions to help to address the stigma and rumours associated with the virus in the
Worldwide Somalia based in community. Programme data shows that the number of beneficiaries reached during
Mogadishu. Emmanuel is a 2020 increased compared to 2019 as a result of the adaptations made. A key challenge
public health professional with was the huge effort required to promote and support many behaviour changes in a
nine years of experience working in the short space of time among health staff and beneficiaries and the need for additional
humanitarian sector in South Sudan, Ukraine funds, made possible by the realignment of budgets and flexible donor funding
and Somalia.
arrangements.
The authors acknowledge the support and help
of the Concern Country Programme Director,
Health and Nutrition Programme Coordinator,
Programme Manager, Programme Officers, in Background will suffer from the pandemic's direct and
charge nurses, community health workers and Somalia is the second most fragile country in indirect impacts in 2021. Access to healthcare
infant and young child feeding (IYCF) the world, with around 69% of the population remains very limited in Somalia due to the
counsellors, as well as the Concern HQ technical scarce availability of skilled health professionals
living below the poverty line. Somalia's hu-
team, for their valuable inputs, technical
manitarian situation has worsened in recent and a dilapidated public health infrastructure,
expertise and guidance throughout the period
of writing this article. Special thanks is also given years due to the devastating combination of particularly in rural areas, resulting in some of
to the Somalia Nutrition Cluster for the guidance conflict and increasingly erratic weather and the world's worst health outcomes.
on nutrition programme COVID-19 adaptations climate shocks including drought. Three addi-
which were very useful as a guide while drafting tional shocks – a desert locust upsurge, extensive Child malnutrition remains one of Somalia's
this article. This programme would not have flooding and the COVID-19 pandemic –deep- major issues and, in most cases, internally dis-
been possible without the generous support of ened the scale and scope of the humanitarian placed persons (IDPs) are the worst affected.
our donors including EU Humanitarian Aid, the crisis in 2020, the consequences of which will Somalia's Food Security and Nutrition Analysis
UK Foreign Commonwealth Development Office, exacerbate humanitarian needs in 2021. In Unit (FSNAU) has estimated that approximately
Irish Aid, the Vitol Foundation, UNICEF and the 840,000 children under the age of five will be
March 2020, the COVID-19 caseload surged
World Food Programme. We also thank the
to 7,518 confirmed cases and, by March 2021, wasted in Somalia in 2021, including 143,000
global Infant Feeding in Emergencies Core
Group team for giving us an opportunity to stood at 3,284 active cases with 249 confirmed who will likely be severely wasted (FSNAU,
present the case study at the global conference deaths. According to a World Health Organi- 2021). Concern Worldwide Somalia admissions
and to publish this article. zation (WHO) global estimate, 20% of Somalis data reveals a stark increase in admissions of
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 Field Articles

wasted children from January to December 2019 service providers and community health workers delivery modality to ensure the continuity and
compared to 2020 (16,140 versus 33,807) which (CHWs) so that they will, in turn, be able to provision of quality IYCF (E) interventions in
demonstrates a worsening nutrition situation. provide timely, relevant and quality IYCF coun- this new context. The adjustments aimed to
selling support to mothers, caregivers and other allow the counsellors to provide IYCF counselling
Protecting and promoting safe and appropriate
key community influencers. The target group sessions to targeted beneficiaries to address rou-
infant and young child feeding (IYCF) practices
for the counselling sessions are mothers/caregivers tine challenges, as well as those that presented
is essential for preventing and treating malnu-
of children 6-24 months of age and pregnant as a result of the pandemic, in a way that posed
trition. The Somalia Micronutrient Survey 2019
and lactating women who attend the health the minimum risk of virus transmission.
by the Federal Ministry of Health (FMoH) and
facility for community-based management of
UNICEF Somalia revealed very poor IYCF prac-
acute malnutrition services, vaccination, antenatal Translation and dissemination of
tices in Somalia with only 5.3% of children less WHO/UNICEF key IYCF COVID-19
care, postnatal care or any other health services.
than six months of age exclusively breastfed messages
The counselling sessions are conducted by a
and only one-quarter of newborns experiencing All the key IYCF messages/recommendations
trained CHW who administers a general screen-
early initiation of breastfeeding. Inadequate in the context of COVID-19 were translated
ing question to identify issues/challenges related
knowledge and attitudes in the community into the local language and widely disseminated
to appropriate infant feeding practices to help
around exclusive breastfeeding and the intro- and shared with the health facilities supported
to focus counselling on the topic/s presenting a
duction of pre-lacteal feeds remains a major by Concern and its partner organisations.1
challenge. Subsequent sessions mainly follow
challenge in achieving optimal IYCF practices
up on the advice given to support the resolution
in IDP camps in the country (SAF-UK Interna-
of the problem after which the CHW moves on
Training of health workers on IYCF in
tioal, 2016). Complementary feeding practices
to any other challenges that present. Group the COVID-19 context
are also often sub-optimal with children intro- At the initial outbreak of the COVID-19 pan-
counselling sessions are also organised at facili-
duced to semi-solids, solids and animal milk demic March 2020, routine interaction with
ty-level on every morning of the outpatient
either too early or too late. Mothers in Somalia programme staff and beneficiaries revealed a
therapeutic programme day. Prior to the COVID-
also have limited access to information and lot of misconceptions, fear and stigma associated
19 pandemic, group counselling involved two
health facilities are often the only place to access with the disease and its mode of transmission.
female community workers to facilitate a group
support for optimal IYCF practices (SAF-UK In order to address these uncertainties and mis-
session with five to 20 caregivers. Female facil-
International, 2016). information, a series of trainings were provided
tiators are used based on the findings of a
previous assessment that found that pregnant to all health facility staff and CHWs on the in-
Concern Somalia IYCF troduction of COVID-19, infection prevention
and lactating women and caregivers were more
programming likely to build a positive and responsive rela- control (IPC) measures and risk communication
The health and nutrition component of the and community engagement messages around
tionship with the facilitator and feel more com-
Concern Somalia programme encompasses COVID-19, specifically COVID-19 and IYCF
fortable discussing their issues (including barriers)
health and nutrition service delivery through practices. The aim of the training was to ensure
with other women (FSNAU, 2016).
fixed and mobile services as well as demand that all staff and CHWs were equipped with the
creation through community mobilisation and Programmatic adaptations in appropriate knowledge and skills to reduce the
the promotion of positive behaviour changes in risk of transmission within health facilities, deal
the context of COVID-19
health, nutrition and hygiene practices. Currently, with the fear and social stigma prevalent in the
The Concern team faced several challenges at
Concern supports 20 health and nutrition community and support optimal ICYF practices
the onset of the COVID-19 crisis to enable
facilities including one national referral stabili- in this new context. In total, 181 health staff
these essential IYCF counselling activities to
sation centre (14 fixed and six mobile facilities) and CHWs received training across different
continue. Initially, caregivers did not visit the
where IYCF counselling is integrated within the programme locations. Job aids were also provided
health facilities as frequently as normal due to
health and nutrition component. Five of these to each health facility (such as laminated infor-
the fear of COVID-19 infection and were not
facilities are directly implemented by Concern mation, education and communication materials
comfortable attending the counselling sessions
Worldwide, five through the government health for use during counselling) and additional on-
when they did visit. There were also widespread
system with strengthening support provided the-job mentoring and support was provided.
rumours related to breastfeeding and COVID-
and 10 facilities are implemented by Concern
19 risk that needed to be addressed urgently. Infection prevention control measures
Worldwide partners.
Therefore, following the guidance from FMoH
implemented during individual
The primary objective of the IYCF activities and the Somalia Nutrition Cluster, Concern
made the following adaptations to the service counselling
is to improve the knowledge and skills of health
Protocols were put in place to ensure that the
IYCF counsellor and caregiver maintained a min-
Number of participants reached with counselling sessions per month
Figure 1 January 2019 to February 2021 imum distance of one metre between them at all
times. Counselling took place within a well ven-
tilated room, caregivers and counsellors washed
,
their hands before entering counselling rooms,
, counsellors and beneficiaries wore face masks
throughout counselling and greetings involving
, physical contact were avoided. These protocols
were made clear to all caregivers on arrival.

Reduced number of participants at

group counselling sessions
Protocols were also put in place to reduce the
number of participants attending support group
meetings and group promotion sessions to three

1
https://www.humanitarianresponse.info/en/operations/
somalia/document/covid-19-iycf
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 Field Articles

to five per session (compared to the up to 20 Discussion coordination of national-level Nutrition Cluster
participants per session pre-COVID-19). Num- The quick adaptation of the IYCF programme communications and engagement with other
bers were determined based on the availability in Somalia enabled the continuation of essential key government players. In addition, the FMoH
of space at each facility to ensure that all bene- services in the COVID-19 context and enabled has revitalised the national IYCF technical work-
ficiaries were able to maintain a one metre dis- support for caregivers to mitigate the potential ing group, of which Concern Somalia is a key
tance from each other. In order to ensure that, negative effects of COVID-19 myths and mis- member, to enable communication, alignment
at a minimum, the same number of beneficiaries conecptions around infant feeding practices. with national and global level recommendations
could be reached, the number of group coun- Data shows that, as a result of the adaptations and the sharing of programme adaptations and
selling sessions was increased from approximately made, particularly the addition of extra staff experiences in the COVID-19 context. This has
100 sessions/month/facility pre-COVID-19 (four capacity and the increased frequency of group been an important vehicle for the learnings
sessions per day) to 180/per month/facility sessions, more caregivers were reached with from the experiences described in this article to
(around seven sessions per day). Health facility IYCF messaging than in the previous pre- be shared with other partners engaged in ICYF
records show that pre-COVID-19 (2019) the COVID-19 year. This has been a positive outcome programming in Somalia and to support similar
total number of sessions held was 6,436 while of the adpations made. As adaptations were put programme adaptations across the country. Ef-
15,642 sessions were held post COVID-19 (2020). in place and after initial variations due to infra- forts have also been made to align and coordinate
Figure 1 shows the number of participants at- structural changes and training, the number of COVID-19 mitigation measures across the differ-
tending group counselling sessions per month participants at group sessions increased showing ent sectors, via the nutrition, health, food security,
during 2019 and 2020. The figures show an that the adaptations were successful which Water, sanitation and hygiene and protection
initial drop in participants after the pandemic allowed the programme to reach a high number clusters, to enable a harmonised response. This
hit around April 2020, as caregivers lost confi- of caregivers. It is too early at this stage to level of coordination has enabled the sharing of
dence in attending the health facilities but an measure the impact of the programme on IYCF IYCF messages in the COVID-19 context to all
overall increase in attendance across the year practices in the community. However, data shows beneficiaries for greater impact. The Government
with some variation by month initially as training that cases of acute watery diarrhoea dropped in of Somalia must continue to support these
and infrastructural changes were carried out in 2020 compared to 2019 (622 cases recorded efforts to enable optimal IYCF programming
each facility. Overall, the number of participants April to June 2019 compared to 436 cases April across all sectors moving forward.
at group sessions increased from 31,752 in 2019 to June 2020) which is likely associated with the
to 41,245 in 2020. To support the increased adoption of IPC measures in the community
Conclusion
number of counselling sessions held, new coun- Individual and community-level IYCF counselling
and at health facilities.
selling staff were recruited so that each facility is critical to support optimal IYCF practices,
had three trained IYCF counsellors compared The adaptations made to the Concern-sup- including the provision of timely support to the
to two pre-COVID-19. ported IYCF programme in Somalia were an carers of newborns to facilitate the early initation
immense challenge for programme management of breastfeeding and exclusive breastfeeding and
Increased number of handwashing and staff. Much advocacy was required to bring support to improve the dietary diversity and
stations at health facilities all staff on board right down to facility-level ongoing breastfeeding of infants aged 6-23
Pre-COVID-19, Concern-supported facilities and to provide the support needed to ensure months. The COVID-19 pandemic has uniquely
only had one hand washing station. To facilitate that necessary adaptations were made and re- challenged the ability of IYCF counsellors to
increased hand washing, infrastructural support mained in place, even up until now. The necessary reach the intended beneficiaries at a time when
was provided to all facilities to increase the changes were not accepted instantly by staff and optimal IYCF practices are challenged by myths
number of hand washing stations to three. This beneficiaries who were, for example, hesitant as and misconceptions around the disease. To address
served to reduce overcrowding around hand to the need for reduced numbers of participants this, rapid adaptations were required to the Con-
washing points and ensure that hygiene protocols at the sessions, the increased numbers of sessions cern-supported IYCF programme in Somalia to
could be followed. Caregivers themselves played and the use of IPC measures. It has taken much ensure that caregivers could still be reached with
an important role in many health facilities in effort to continually engage staff and beneficiaries adapted, targeted IYCF-related messages and tai-
ensuring that other caregivers made use of the to ensure that the need for these changes is un- lored support in a way that ensured the mimium
hand washing points on entry to the facilities. derstood and that health staff are equipped with risk of transmission of the virus. This required
the knowledge and skills needed to implement additional funds, made possible through the flex-
Addressing the stigma and rumours them. A key lesson learnt, therefore, is that even ibility of donors, to support an unprecedented
associated with COVID-19 in the COVID-19 context, behaviour change effort to train and recruit additional staff, make
Community feedback at the onset of the pan- takes time and requires much effort and constant infrastructural changes at health facilities and
demic indicated that many people did not believe engagement to be successful. provide the support needed to beneficiaries.
that COVID-19 was real as they did not know While not without challenges, the increased num-
There were many additional costs associated
anyone who had had the virus or did not see ber of beneficiaries reached during 2020 compared
with the programme adaptations made, for ex-
stories in the media about people who had been to the previous year is an early indicator of the
ample for the procurement of personal protective
affected. Stories that did appear in the media positive impact of the adaptations made. Learning
equipment, the recruitment of and payment for
tended to feature politicians or famous people is still taking place and ongoing efforts to capture
extra staff members, extra training and mentoring
who had caught the virus, adding to the belief the impact of the programme on IYCF practices
of health staff, translation and printing costs of
that only rich, influential people who travel in the COVID-19 context will provide important
the adapted IYCF materials and the infrastructural
were affected by the disease. This misconception lessons in the future.
costs associated with providing additional hand-
directly impacted beneficiaries' willingness to
washing facilities and triage and counselling For more information, please contact Bishar
comply with COVID-19 specific IPC measures
spaces. In order to support the extra costs, Osman Hussein at [email protected]
and IYCF guidance recommendations, such as
budgets were realigned, a key enabling factor
wearing face masks while breastfeeding. To com-
that was only possible thanks to the flexibility References
bat this, training and support was given to IYCF
of Concern’s donors.
counsellors to include the sharing of stories of FSNAU (2016) Somali infant and young child feeding
local people who had recovered from COVID- Support from the government was also an assessment report
19 in group counselling sessions to show that important enabling factor. At national-level, the SAF-UK (2016) Kismau IDP infant and young child feeding
the disease was real and could affect anyone. Somalia FMoH has played a leading role in the knowledge, attitude and practice survey KAP in 2016
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©Sa'dia Mohamed
Infant and young child feeding in
emergencies: Programming adaptation
in the context of COVID-19 in Lebanon
By Bayan Ahmad
Bayan Ahmad is Senior Field Officer IOCC gratefully acknowledge the support of UNICEF for funding
at International Orthodox Christian the project activities and the salaries of staff and for continuously
Charities (IOCC), where she is working on building the capacity of their implementing partners.
responsible for overseeing IOCC’s IOCC also acknowledge the Ministry of Public Health Maternal
health and nutrition programmes. and Child Health Department, the National Infant and Young
She holds a Master’s degree in Child Feeding Committee and the Nutrition Sector for supporting
Lactaction specialist providing IYCF nutrition, dietetics and food management. and facilitating the implementation of the programme.
individual counselling session

breastfeeding include breast and nipple pain, latch

LEBANON difficulties, sleep deprivation and exhaustion. These
difficulties are often compounded by maternal em-
What we know: During emergencies, promoting adequate infant and young child ployment, inadequate family support or the lack of
feeding (IYCF) practices saves lives. professional advice which are known barriers to
What this article adds: International Orthodox Christian Charities (IOCC) IYCF breastfeeding success.
activities that already targeted both refugees fleeing conflict in Syria and vulnerable
Lebanese families were adapted in response to the COVID-19 context. Volunteer
IYCF programming by
educators and lactation specialists were mobilised to scale up awareness raising and International Orthodox
one-to-one and group counselling, both remotely and in person with infection Christian Charities in Lebanon
prevention control measures in place, and a national hotline was established. IOCC International Orthodox Christian Charities (IOCC)
lactation specialists reached more than 11,000 pregnant and lactating women in 2020 has been actively involved in nutrition-related ac-
with IYCF counselling (versus 3,000 in 2019) and IOCC educators and volunteers tivities in Lebanon both in schools and communities
reached more than 24,000 caregivers with IYCF education (compared to 1,500 in 2019). since 2001. Activities to improve IYCF practices
IOCC supported the Lebanese government to ensure breastmilk substitutes were only have been prioritised both in normal times and in
provided according to the national legal framework. Challenges included the lack of emergency situations, with specific IYCF-related
internet access for some women, an increase in workload and the need for additional activities targeted to both refugees fleeing conflict
resources. Lessons learned include the need for preparedness plans pre-emergency, the in Syria and vulnerable Lebanese families.
need for sustained support for IYCF programming in Lebanon including investment in In 2011, a national IYCF programme was es-
community volunteers, lactation specialists and training for health workers, the need to tablished by the Ministry of Public Health (MoPH),
adapt IYCF messages according to prevailing myths and misconceptions and targeting with support from IOCC and World Vision, and
women as well as other household and community decision-makers, the need to invest a sub-committee on IYCF in emergencies (IYCF-
in the promotion of the national hotline and advocacy to ensure that laws protecting E) was created, mainly supported by IOCC. In
optimal IYCF practices in emergencies are enforced. 2018, the MoPH, with support from UNICEF and
IOCC, developed and launched a National Policy
on Infant and Young Child Feeding to guide
strain on the country’s economy, public services actions to promote optimal IYCF to support the
Background healthy growth and development of infants and
Infants, young children and their mothers are vul- and local infrastructure. In addition, during the
young children in the country. The policy defines
nerable, particularly during humanitarian emergencies. year 2020, the country went through severe eco-
the responsibilities of the Lebanese government,
Improving infant and young child feeding (IYCF) nomic challenges, exacerbated by the COVID-19
its partners and all relevant stakeholders in pro-
practices1 according to the World Health Organization pandemic and the blast in the port of Beirut on
moting, protecting and supporting IYCF.
(WHO) recommendations is key to improving child August 4, 2020 that caused more than 200 fatalities
survival and to promoting healthy growth and de- and 6,500 injuries. During this succession of crises, IOCC is a member of the IYCF national com-
velopment. Rates of optimal IYCF practices in ensuring optimal breastfeeding amongst refugees mittee and works through the national IYCF pro-
Lebanon are very low. Data shows that only 14.7% and the host community became an even greater gramme to implement IYCF-related activities.
of infants less than six months of age are exclusively priority given the importance of breastfeeding as Through its UNICEF-funded project launched in
breastfed (Central Administration of Statistics, 2009) a life-saving intervention. 2020, IOCC provides IYCF counselling and support
and around 13% of infants aged 6-23 months meet to 10,000 pregnant and lactating women and through
Misconceptions and inadequate IYCF practices its team of community health educators, IOCC
the minimum acceptable diet for complementary
are commonly found among both refugees and conducts education and awareness activities on op-
feeding (UNICEF, 2016). Field experience reveals
Lebanese families. Programme staff often report timal IYCF practices in all governorates to reach
that the main barriers to optimal breastfeeding in
that the introduction of water for thirst and tea for 9,000 caregivers. Mothers with lactation difficulties
Lebanon include the lack of both awareness and a
colic, illness or to relax the baby is customary and are referred to IOCC’s pool of qualified and skilled
supportive environment for breastfeeding.
commonly initiated soon after birth. The early in- lactation specialists who provide one-on-one coun-
Ten years into the Syrian crisis, Lebanon remains troduction of complementary foods is also customary selling. Lactation specialists also provide support
the country hosting the largest number of refugees with mothers commonly starting to give their to ensure optimal IYCF practices in hospitals,
per capita. According to United Nations High infants small amounts of food from three to four primary healthcare centres and at community level.
Commission for Refugees estimates, there were months of age. Infant formula is also commonly
1
https://www.who.int/news-room/fact-sheets/detail/infant-
855,172 registered Syrian refugees dispersed across given to infants soon after birth when mothers feel and-young-child-feeding
Lebanon by the end of March 2021.2 The presence that they are not producing sufficient milk to meet 2
UNHCR Operational Portal:
of such a large refugee population places enormous their baby’s needs. Women’s reasons for discontinuing https://data2.unhcr.org/en/situations/syria/location/71

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IYCF counselling card Case study of support provided to a breastfeeding mother during COVID
Figure 1 adapted to COVID-19 Box 1 pandemic
Samah, age 35, was unsuccessful in breastfeeding her breastfeeding and provide support several times
first two children and was pregnant in her third before she left the hospital. Although Samah
trimester with her third child when she was diagnosed experienced nipple soreness and bleeding and the
with COVID-19. Samah was not planning to breastfeed physician suggested she use formula
her baby and had heard a lot of myths and miscon- supplements, she continued exclusively
ceptions around the need to avoid breastfeeding breastfeeding, adjusting the latch and adopting
during the pandemic and to feed her infant with good position to overcome the initial difficulties.
formula milk as a safer alternative. While still pregnant,
Samah was approached by Amal, an IOCC lactation Later, when the time came for Samah to return to
specialist. Amal helped to both improve Samah’s work, Amal counselled her, giving guidance on
knowledge about breastfeeding and build her how to express and store her breastmilk and
confidence in her ability to breastfeed. She provided provided her with a manual pump. Samah said,
In addition, IOCC monitors and supports hospitals the mother and her partner with information about “We live in a culture where breastfeeding is
in Lebanon enrolled in the Baby Friendly Hospital the benefits of breastfeeding, breastfeeding initiation undervalued and bottle feeding is viewed as the
and positioning, the importance of exclusive normal and safe way to feed babies, especially
Initiative programme through on-the-job coaching breastfeeding and the prevention and treatment of during this pandemic. I learned a lot from my
and monitoring adherence to the ‘10 steps to suc- common breastfeeding problems. experience with Amal. She helped me fix the
cessful breastfeeding’, identifying and addressing breastfeeding difficulties I faced and corrected the
Education and counselling sessions were conducted
challenges and supporting them towards certification misconceptions that I had about breastfeeding. She
by Amal remotely through WhatsApp and Zoom. Amal
with the Baby Friendly Hospital label from the also coordinated with the midwife at the hospital to also helped me save money, which was good
MoPH. Other activities include the development ensure that Samah was supported to initiate especially with the worsening economic situation. In
of materials on complementary feeding and building breastfeeding within the first hour after her baby was addition, online consultations were highly
born and that the baby was placed skin-to-skin on his convenient and time savvy; it was easy and fast to
the capacity of the healthcare providers working in
mother’s chest to encourage him to breastfeed more. communicate with Amal by using WhatsApp. I’m still
nurseries to use these materials, as well as the mon- exclusively breastfeeding my baby. I now in turn raise
itoring of violations against the International Code Amal then followed up closely with Samah through awareness on breastfeeding and correct
of Marketing of Breast Milk Substitutes (BMS). video calls following the birth to observe her misconceptions within my community.”

During the multi-faceted crisis that occurred

in Lebanon, including movement restrictions as a level, as well as through social media (including frequent handwashing were adopted during
result of COVID-19 imposed from March 2020, WhatsApp). They also advocated with local au- all individual meetings.
IOCC worked to adapt existing programming ap- thorities and influencers (mayors, mukhtars and
proaches to ensure that the most vulnerable preg- In support of the optimal nutrition of children
religious leaders) to engage in the dissemination
nant and lactating women would be able to access aged 6-59 months, in 2020 IOCC also distributed
of the key messages. Over two months, the volun-
IYCF support. Programmatic adaptations were micronutrient supplements to more than 5,000
teers were able to cover more than 120 of the vulnerable children in this age group. This was
made in line with the WHO, UNICEF and the 1,108 municipalities across the country.
Lebanese MoPH guidelines, supported by additional carried out through outreach at the community
level conducted by the educators and lactation
funds reallocated from existing programme budgets. Supporting mothers to practice specialists. Supplementation targeted both refugee
This article outlines the programme adaptations optimal IYCF
made and lessons learned. and vulnerable host community children and was
As a response to the COVID-19 pandemic, IOCC carried out over this period in coordination with
lactation specialists began consulting and following the Mother and Child Health Department of the
Programmatic adaptations up with pregnant and lactating women with either MoPH and the Nutrition Sector.
Promotion of optimal IYCF practices confirmed or suspected COVID-19 infection using
at community level the IYCF counselling card that was adapted for Protecting IYCF through legislation
Initially, IOCC educators provided group education COVID-19 by UNICEF (Figure 1). Despite the existence of a national law (Law 47/2008)
sessions on a daily basis, following a pre-defined that legislates upon the International Code of Mar-
curriculum of topics. Caregivers were gathered in Box 1 provides an example of the support pro- keting of BMS, IYCF is still undermined, particularly
one location and sensitised on IYCF topics. In the vided to a nursing mother. Support continued to in emergencies. Due to the economic crisis, the
context of COVID-19, IOCC expanded its team of be provided by lactation specialists for mothers COVID-19 pandemic, the heavy refugee burden
educators to reach more people and adapted its with lactation difficulties referred by educators. and, in addition, the blast at the port of Beirut,
awareness activities to cover both IYCF and COVID- As a response to the COVID-19 emergency, calls for infant formula donations from the com-
19. IOCC also mobilised volunteers across the alternative modalities to delivering support to munity increased. Several grassroots initiatives and
country for a duration of two months to help and mothers were put in place including the following: organisations accepted donations and distributed
support the educators in awareness raising activities. • As many education and support sessions as these through a general distribution scheme without
possible were provided remotely over the phone, having the capacity or knowledge to follow global
Based on the materials and guidelines developed
via social media or remotely through Zoom, guidance for humanitarian aid.
at national level, existing educators and volunteers
worked to raise awareness of IYCF and COVID- Skype and/or WhatsApp. IOCC identified the organisations and the formula
19 within their communities, targeting community • Where necessary and possible, individual milk providers involved and contacted them to
members with key messages that aimed to limit meetings were conducted face-to-face while provide them with legal information to ensure that
the spread of the virus, mitigate its impact and using personal protective equipment (PPE), artificial support was administered in line with the
correct misconceptions about IYCF in this context. physical distancing and frequent handwashing. law.3 In addition, as a member of the IYCF national
They provided municipalities with preventive in- • The number of people attending awareness committee, IOCC supported the development of
formation and guidelines on home isolation, guid- sessions in person was limited to five and sess- IYCF Standard Operating Procedures (SOPs) to
ance on regular hand washing and hygiene, social ions were conducted in open or well-ventilated guide and inform national and international agencies
distancing, the symptoms of COVID-19, when to areas with strict physical distancing measures and on how to ensure appropriate, timely and safe IYCF
seek medical care, how to buy groceries and a requirement to wear face masks. As a result, support for families. IOCC also contributed to the
disinfect them, when to use a face mask and how the frequency of sessions was increased to enable development of an infographic for the SOP to com-
to use it appropriately as well as myth busters the same or greater reach. When lockdown municate information quickly and clearly, translated
around IYCF/nutrition and COVID-19. Educators measures meant that approval needed to be
and volunteers helped to disseminate key national given before sessions could be held, educators 3
The Law recommends that infant formula is strictly targeted
messages through the distribution of flyers and transferred to online modalities. to infants who require it and have no viable breastmilk
options. https://www.ennonline.net/operationalguidance-
posters to shops, pharmacies and at household • The use of PPE, physical distancing and v3-2017
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 Field Articles

this into Arabic and disseminated it across agencies time, largely driven by the incredible effort of munity level and lactation specialists to provide
and sectors. IOCC then conducted workshops for IOCC volunteers and staff, as well as the use of specialist counselling and support. Building the
organisations and small groups that were providing online platforms which enabled many women to capacity and strengthening more health facility
milk formula distribution to vulnerable families in be reached swiftly. In terms of the hotline, over staff on IYCF-E counselling in the COVID-19
all Lebanese governorates to inform them about 700 calls have been received since its launch in context is also needed to sustain the gains made
the IYCF SOP, discussing how to provide nutrition September 2020 with more than 85% of the calls and further scale up quality IYCF programming.
support in a way that was in line with the global being referred to a lactation specialist. Five violations
The understanding of myths and misconceptions
and international guidance on IYCF-E. of the BMS Code were reported through the hotline.
related to IYCF and the tailoring of messages ac-
In coordination with the IYCF national com- Challenges cordingly, and the inclusion of key decision-makers
mittee, IOCC set up a IYCF hotline number to re- A major challenge with working remotely was in- within the family structure (fathers, mothers-in-
port violations of the BMS Code and to receive ternet access. Some caregivers in rural areas had law) and influential members of society (midwives,
referrals for mothers in need of follow-up from poor connections while others did not have any doctors, dietitians, religious authorities, mayors),
lactation specialists. Various channels, including connection at all. This limited their ability to in awareness activities were important aspects of
the development of a flyer and social media, were engage with some activities. the programme. This should be considered by
used to promote the hotline to agencies working IYCF programmers going forward.
across different sectors as well as caregivers. Infants The programme adaptations described resulted
in an increased workload, training needs and lo- The IYCF hotline number provided another
and young children less than 24 months of age
gistics within IOCC. Staff were provided with reg- important platform for pregnant and lactating
who were identified as needing support were re- women to access remote support services. The
ferred for a full assessment conducted by a lactation ular additional trainings on infection prevention
and control measures to ensure they were able to hotline needs to be promoted to reach its full po-
specialist and given either skilled IYCF support tential. The national IYCF committee, in coordination
or artificial feeding support as appropriate. share key messages and answer common questions
on COVID-19. Many more materials were also with the Lebanese government and UNICEF, is
preparing a campaign on IYCF that aims to raise
Discussion developed, printed and distributed by IOCC which
awareness on IYCF and promote the IYCF hotline
The lockdown measures introduced in Lebanon resulted in staff time and budget implications. To
support this, the budget reallocations had to be with an official launch planned in June 2021.
in March 2020 to reduce the spread of COVID-19
resulted in a rapid change in circumstances for done in coordination with the donor to support IOCC and partner actions to address unethical
pregnant women, new mothers and their infants. additional activities. breaches of the International Code of Marketing of
Lactation specialists noticed that the changing The surge in calls to the IYCF hotline proved BMS were a critical part of the response. Further
and uncertain circumstances, the prevalence of challenging during 2020. In response, in 2021, advocacy is needed so that Law 47/2008, which
misconceptions and myths surrounding breast- two IYCF monitors were recruited to support the aims to protect and promote breastfeeding, and the
feeding and COVID-19, combined with reduced national IYCF hotline and meet the additional International Code of Marketing of BMS, are actually
face-to-face support from family, friends and peers surge in needs. enforced in all emergency responses including during
negatively affected women's perceptions and ex- and after the COVID-19 pandemic. A legal framework
periences of breastfeeding and their ability to Lessons learned and recommendations supported by the MoPH is needed to ensure full
overcome practical challenges. Furthermore, the Prior to the COVID-19 outbreak, IOCC worked adherence to the BMS Code to make sure that do-
deterioration of the economic situation and the on a preparedness plan that involved identifying nations for and the marketing and promotion of
loss of income associated with the closure of small resources, determining roles and responsibilities, formula milk are neither sought nor accepted.
businesses affected the ability of many families to developing policies and procedures and planning Further recommendations are made for donors,
purchase nutritious foods, altering the economic adaptations to programme activities in order to embassies, international organisations, non-govern-
basis for infant feeding decisions. The prevailing be able to respond promptly and effectively to a ment organisations and grassroots organisations in
context in Lebanon, where infant formula is re- pandemic. This meant that the planned programme a call for action that was developed by the Nutrition
garded as an essential commodity and infant adaptations could be implemented swiftly after Sector in the response to the Beirut explosion.4
feeding with formula milks is regarded as ‘nor- the first case of COVID-19 was confirmed in
mative’, also presented extra challenges, driving Lebanon. This kind of preparedness planning is Conclusion
the soliciting of donations of BMS and feeding essential in driving an appropriate emergency re- Adapting IYCF programme activities in the context
equipment for untargeted distribution. sponse. In future, greater alignment and coordi- of COVID-19 and the economic situation in Lebanon
nation in mitigation plans across sectors (nutrition, proved challenging. Progress has been made but
The government, UNICEF and professional
health, food security and livelihoods, agriculture, programmes and services to protect, promote and
health organisations were advised to maintain
water hygiene and sanitation, social protection support optimal early and exclusive breastfeeding
mother-infant contact and to encourage and support
and mental health and psychosocial support) is and age-appropriate and safe complementary foods
breastfeeding, including when a mother had COVID-
needed to improve the reach and support of all and feeding practices should remain a critical com-
19 provided she was well enough and precautions
pregnant and lactating women and their infants ponent of the programming and response for young
were taken to minimise transmission to her infant
and maximise opportunities across all services. children in the context of COVID-19. Coordination
during feeding. Global and national guidance was
with other sectors is also needed to focus on reaching
released and IYCF programmes had to adapt quickly Despite the challenges, the merging of online
and prioritising pregnant and lactating women and
in order to provide scaled-up support to protect support with in-person support enabled IOCC to
infants and young children.
and promote optimal IYCF in this context. reach a large number of pregnant and lactating
mothers with essential IYCF support services in a For more information, please contact Bayan
Achievements short space of time. However, breastfeeding and Ahmad at [email protected]
As a result of the programme adaptations by IOCC complementary feeding practices in Lebanon re-
described in this article, between the end of February main poor. Along with the worsening economic
4
Call for action on Infant and Young Child Feeding and
Nutrition in the response to the Beirut port explosion,
and the end of December 2020, lactation specialists situation and the increased demand for formula September 2020 - https://fscluster.org/sites/ default/files/
were able to reach more than 11,000 pregnant and milk, programmes and services to protect, promote documents/ lebanon_nutrition_taskforce_final.pdf
lactating women to provide them with IYCF coun- and support optimal feeding practices should re-
selling and support, as compared to around 3,000 References
main a critical component of the programming
in 2019. IOCC educators and volunteers were also Central Administration of Statistics (Lebanon) (2009)
and response for young children in the context of Lebanon Multiple Indicator Cluster Survey 2009. Accessed
able to reach more than 24,000 caregivers (compared COVID-19 and more funding for IYCF-E activities at: http://ghdx.healthdata.org/record/lebanon-multiple-
to 1,500 in 2019) with education on IYCF especially is still needed. There is also a need to invest in the indicator-cluster-survey-2009
in the context of COVID-19. This demonstrates a training and mobilisation of more community UNICEF (2016) Baseline survey. Accessed at:
considerable growth in reach at this challenging health volunteers to run IYCF-E activities at com- https://data2.unhcr.org/en/documents/download/49509
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© ACF survey Team

Adaptations to SMART
surveys in the context
of COVID-19 in Cox’s
Bazar, Bangladesh
By Md. Lalan Miah, Bijoy Sarker,
Jogie Abucejo Agbogan, Brigitte Tonon,
Mary Chelang'at Koech and
Md. Shahin Emtazur Rahman
Md. Lalan Miah is the Nutrition Surveillance Survey team leader taking anthropometric
Manager for Action Against Hunger measurements, Cox’s Bazar
Bangladesh. He has seven years’ experience
leading the nutrition surveillance project in
both host communities and refugee camps and
leads the Nutrition Sector Assessment and
Information Technical Working Group (AIM-TWG). BANGLADESH
Bijoy Sarker is a Public Health Nutritionist What we know: Nutrition programming, including nutrition
currently working as SMART Regional Advisor
surveys, has faced significant disruption as a result of the
for Asia with Action Against Hunger Canada. He
has nearly a decade of emergency nutrition and
restrictions in movement arising from the COVID-19 pandemic.
surveillance experience from Bangladesh, South What this article adds: Adaptations to the Standardized Monitoring
Sudan and Sierra Leone and as a roving health and Assessment of Relief and Transitions (SMART) survey
and nutrition expert for the South Asia region.
methodology and operations were made in the context of Cox’s
Jogie Abucejo Agbogan is the current Nutrition Bazar refugee camps in Bangladesh during 2020 to enable data
and Health Head of Department for ACF collection to continue in the COVID-19 context. Adaptations
Bangladesh. She has over 12 years’ experience included reducing the number of indicators, reducing sample size,
working in nutrition and health in Myanmar, addressing myths and fears around COVID-19 through pre-survey
South Sudan, Ethiopia and Bangladesh for ACF
community sensitisation; using experienced enumerators to shorten
and previous experience with other
humanitarian agencies in sub-Saharan Africa.
pre-survey training; and use of infection prevention control (IPC)
measures by the survey team during the survey. Team members and
Brigitte Tonon is the ACF France Regional Health household members were screened for COVID-19 symptoms
and Nutrition Technical Advisor for Asia. She has regularly and excluded if symptoms were declared. The overall non-
many years of experience working across
respondent rate was very low (5.4%-8.3%) and exclusions due to
multiple countries and HQs for ACF, Première
Urgence Internationale and Médecins du
COVID-19 were low at 1.5%. Adaptations worked to allow the
Monde in health and nutrition. collection of high-quality data. An additional 3 to 5 minutes were
required per household to allow for implementation of IPC
Mary Chelang'at Koech is a nutrition and food measures. The experience shows that context-specific adaptations
security officer for the United Nations High
and community sensitisation and mobilisation can enable safe,
Commission for Refugees (UNHCR) Cox’s Bazar
sub-office supporting the nutrition and food
quality data collection in the COVID-19 context.
security programmes. She has worked in
nutrition for 12 years across Kenya, Rwanda,
Tanzania, Ethiopia and Bangladesh. Background
Md. Shahin Emtazur Rahman is a Public Health Cox’s Bazar nutrition context
Nutritionist and Senior Nutrition and Food Cox’s Bazar (CXB) is a highly disaster-prone coastal district in Bangladesh and
Security Associate for UNHCR. He has nine years’ one of 20 of Bangladesh’s 64 districts identified as vulnerable with an estimated
experience working in nutrition, particularly in poverty prevalence rate of 16.6% (Government of Bangladesh, 2017). The CXB
refugee camp contexts. district has a host population of 2,290,000 and an additional estimated population
The authors acknowledge the following for their technical and
of 871,924 refugees residing in 32 makeshift and two registered refugee camps
operational support and collaboration: National Nutrition across Ukhia and Teknaf (sub-districts) (Government of Bangladesh-UNHCR,
Services (NNS), the Institute of Public Health Nutrition (IPHN), the 2021). Since the influx of refugees in 2017, the Nutrition Sector in CXB has been
Ministry of Health and Family Welfare Bangladesh, the providing comprehensive nutrition services to address the underlying causes of
Bangladesh Nutrition Sector Assessment and Information malnutrition across all camps targeting children under five years of age, children
Management Technical Working Group and implementing over five years of age, adolescent girls and pregnant and lactating women.
partners. The authors also thank Md. Saiful Islam Talukder and Although the protracted crisis in CXB has stabilised to some extent, the COVID-
G.M. Mosharaf Hossain and the survey team, the Action Against 19 pandemic has had a significant impact, limiting access to services, which has
Hunger Bangladesh Mission, Jana Daher, the Global SMART necessitated adaptations to nutrition programmes. Adaptations to community-
Initiative and Action Against Hunger Canada.
based management of acute malnutrition (CMAM) programmes in CXB have
Funding support was provided by UNHCR, the Bureau of been outlined in recent Field Exchange articles.1
Population, Refugees and Migration, the Directorate-General for
European Civil Protection and Humanitarian Aid Operations and 1
https://www.ennonline.net/fex/63/cmamcxbcovid19adaptations and
the Swedish International Development Cooperation Agency. https://www.ennonline.net/fex/63/cxbvitaminasupplementation
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Field Exchange issue 65, May 2021, www.ennonline.net/fex
60
 Field Articles

Population representative nutrition to include only those critical for programme deci- upper arm circumference (MUAC) tapes were
surveys sion-making including anthropometric data, a used for each household and those previously
Action Against Hunger (ACF) Bangladesh, with few health indicators and mortality data. Indicators used were left with each caregiver for use within
the support of ACF France, the ACF Canada related to food security, anaemia and health aspects, the Family MUAC approach.4 Additional time
SMART team and the ACF UK coverage team, which are usually included, were omitted to simplify was allocated to each house-hold to ensure
regularly monitor the nutrition and health situa- the approach and limit the interview time in order safety measures could be carried out.
tions in both refugee camps and host communities. to reduce the contact time and minimise the risk • Well-functioning vehicles with enough space
ACF currently leads the implementation of nu- of COVID-19 transmission. were hired for the survey teams to ensure
trition surveys in CXB and chairs the Nutrition social distancing during the field travel and
For sampling, the precision level was kept at these were disinfected regularly. All drivers
Sector’s Assessment and Information Management the minimum acceptable level as per the SMART
Technical Working Group (AIM-TWG). At the were also provided with a face mask and
guidance3 to limit the sample size thereby reducing hand sanitiser.
national level, ACF is supporting the formation further non-essential contacts with the population.
of a National Assessment Technical Working A relatively higher non-response rate (NRR) was In consultation with the AIM-TWG and gov-
Group. Since 2009, ACF has conducted 85 nutrition factored in for refugee populations (Makeshift ernment officials, additional measures over and
surveys in Bangladesh including 60 Standardized camp:18%, Nayapara Registered camp:12% and above the global guidelines were also put in place
Monitoring and Assessment of Relief and Tran- to further reduce the risk of COVID-19 trans-
Kutupalong Registered Camp: 18%) compared
sitions (SMART) surveys, six rapid SMART sur- mission for these specific surveys including those
to similar past surveys to account for the possible
veys, six Standardized Expanded Nutrition Surveys conducted in camps. Those additional adaptations
refusal and exclusion of households due to
(SENS), seven coverage assessments (SQUEAC/ were as follows:
COVID-19 related issues.
SLEAC), three Link Nutrition Causal Analyses
(Link NCA) and three health facility assessments. Operational adaptations Pre-survey preparations
Of these, 54 surveys were conducted in CXB. A number of adaptations were made to survey • The COVID-19 situation was closely moni-
protocols as advised by global guidance, as follows: tored and survey fieldwork was only permitted
SMART surveys by ACF Bangladesh collect during periods when positive confirmed
data on anthropometry, mortality, morbidity, nu- Pre-survey training cases were low (according to the World
trition supplementation, food assistance, infant • All survey enumerators, team leaders, survey Health Organization(WHO) Health Sector
and young child feeding practices, food security managers and advisors were tested for epidemiological update).
and livelihoods and Water, sanitation and hygiene COVID-19 (using a PCR test) three days • Because of fear/stigma/mistrust due to
(WASH). The data collected informs the formu- prior to training. COVID-19, extra efforts were made when
lation of the joint response plan and multi-sector • Adequate health and safety measures (use of conducting advocacy and sensitisation with
and integrated humanitarian interventions. personal protective equipment (PPE), health camp leaders and camp-in-charges (govern-
Following the release of interim global oper- screening and maintaining proper physical ment officials) and community mobilisation
ational guidance on population level surveys and distancing) were taken during training. prior to the start of each survey. Special
household level data collection in the COVID- • A special session on the COVID-19 pandemic emphasis was placed on avoiding any confu-
19 context,2 ACF Bangladesh, in consultation and necessary infection prevention control sion, misinformation, rumours and fear in
with the Nutrition Sector and government au- (IPC) measures was included in the training. the community, therefore ensuring maximum
thorities, adapted the methodology for conducting participation and cooperation both from the
Survey implementation camp management and communities.
SMART surveys and tested this in refugee camps • During field implementation, all survey team
and host communities in CXB between November • While field testing the questionnaire and
members were provided with surgical face methodology, special emphasis was given to
2020 and February 2021. The objective of this masks and hand sanitiser. Measurer assistants
article is to capture the experiences and key the team comprehension and appropriate
were also provided with hand gloves to dis- implementation of IPC health and safety
lessons learned while implementing this interim infect anthropometric equipment between
guidance in three refugee camps to support its procedures (e.g., wearing PPE, ensuring
interviews to avoid skin contact with disin- physical distancing, administering COVID-19
further development and implementation in other fectant. Each team carried a safety disposal
contexts given that most countries globally have screening checklist etc.) as those were intro-
bag for used PPE which was properly disposed duced for the first time due to the pandemic.
to adapt their surveys due to COVID-19. of at the end of data collection each day. • Coordination took place with the United
Adapting surveys in CXB in the • All team members sanitised their hands Nations High Commission for Refugees
immediately before entering a household and (UNHCR) health unit to provide the necessary
COVID-19 context after completing each household data collec-
Necessary technical, operational, logistical and PPE for the survey team to avoid unwanted
tion using alcohol-based hand sanitiser with procurement delays.
HR adaptations were made in order to minimise
at least 60% alcohol.
the risk of COVID-19 transmission for the targeted Survey team measures
• During the interview, the interviewer and
surveyed populations and survey teams during • The assessment mainly used highly experi-
respondent maintained a distance of at least
the implementation of three SMART surveys. enced measurers (who had previously part-
one metre (when possible in the confines of
The assessment method was endorsed by the Na- icipated in at least two surveys and had
household spaces), even if wearing a mask,
tional Nutrition Services (NNS), the Institute of passed the standardisation test in the last 12
and the number of persons present during
Public Health Nutrition (IPHN) through the months) in order to skip the standardisation
the interview was limited to a maximum of
CXB District Civil Surgeon’s Office and the Office test as recommended by the SMART interim
three. Respondents and all children over the
of the Refugee Relief and Repatriation Commis- guidelines in order to shorten the training
age of two years were also given a mask to
sioner. All adaptations, outlined below, were period from five to three days to minimise risk.
wear during the interview.
comprehensively discussed and agreed in a series
• Anthropometric measurements were mostly
of meetings, webinars and email exchanges with
taken outside in an open, shaded area with 2
https://smartmethodology.org/smart-survey-guidance-covid-19/
AIM-TWG, the Nutrition Sector, NNS, the Civil 3
SMART Manual 2.0, 2017 https://smartmethodology.org/
enough space for proper physical distancing
Surgeon’s Office and the global SMART team at survey-planning-tools/smart-methodology/smart-
and air circulation. methodology-manual/
ACF Canada and ACF France headquarters.
• Anthropometric equipment (weighing scales, 4
Family MUAC was already implemented within CXB whereby
caregivers are trained to screen their own children for
Methodology adaptations height boards and blank wooden boards) were wasting using MUAC tapes with self-referral to nutrition
The number of indicators collected was reduced disinfected between each household. New mid- centres if severe or moderate wasting is indicated.
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Field Exchange issue 65, May 2021, www.ennonline.net/fex
61
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met any of the four conditions as explained in

Table 1 Health screening checklist for survey team Table 2, the household was excluded from the
Conditions Morning Evening
survey. If any household had multiple eligible
(Y/N) (Y/N) children but at least one child without fever or
other COVID-19 signs/symptoms and no other
Most common 1. Did the staff and/or any team member have a high
and mild temperature (≥100.4F/38°C) without a dry cough, tiredness? family history of COVID-19 infection, these
symptoms households were included in the survey. Any
2. Did the staff and/or any team member have high a
other household members with a high fever or
temperature (≥100.4F/38°C) with dry cough, tiredness?
other signs or symptoms were asked to isolate
Mild and less 3. Did the staff and/or any team member have a high temperature from the survey team but this was not considered
common (≥100.4F/38°C) without a sore throat, diarrhoea, conjunctivitis,
symptoms headache, loss of taste or smell, aches and pains?
a household exclusion criteria.
(treated from Data collection and supervision
4. Did the staff and/or any team member have a high temperature
home)
(≥100.4F/38°C) with a sore throat, diarrhoea, conjunctivitis, • Data was collected on tablets (Lenovo Tab)
headache, loss of taste or smell, aches and pains? using the Open Data Kit (ODK) application
Serious symptoms 5. Did the staff and/or any team member have a running nose, to reduce the time spent entering data and
(take immediate sneezing, shortness of breath, chest pain or pressure, loss of to check for data quality. All teams carried a
medical attention) speech or movement? back-up tablet and hard copies of the ques-
tionnaire in the event of tablet failure.
• The number of survey enumerators was • All survey team members monitored their • Survey teams were supervised daily using a
reduced to a minimum of three persons per health using a health-screening checklist supervision checklist with a minimum of one
team (one team leader and lead measurer, one developed by ACF Bangladesh twice per day supervisor or survey manager per team on a
measurer assistant and one interviewer) to (morning and evening) during the survey rotating basis to ensure consistency in data
limit exposure and allow physical distancing period. If any individual met any of the con- collection across all teams. All data was up-
measures. ditions outlined in Table 1, they were requested loaded and reviewed daily in order to monitor
• An additional six team members were trained to go into mandatory quarantine and were the quantity and quality of the data collected.
and kept on standby to recall at any point if a replaced by a member of the reserve team. • A daily feedback session using a digital platform
team member showed COVID-19 symptoms, was held but reduced from 30 to 10 minutes.
Participant screening
was placed into quarantine or tested positive. A standard health-screening checklist for inter- Findings
• All survey team members were put in a viewees was developed jointly in consultation All three surveys reached the sufficient number
residential hotel with full board and were with the Nutrition Sector and AIM-TWG members of households and children, well above the mini-
restricted from going outside and interacting for the inclusion and exclusion of children and/or mum requirement as per SMART survey guidelines
with others during the whole training, field households. Body temperature was measured (90% of clusters and 80% of children) to ensure
testing and data collection to minimise the using an infrared digital thermometer and questions data quality and representativeness (Table 3).
risk of infection. were asked as described in Table 2. If any household
The overall NRR was very low (5.4 to 8.3%)
and much lower than anticipated and used for
Table 2 Health screening checklist for household inclusion/exclusion
the sample size calculation (12 to 18%) at the
protocol development stage. Table 4 shows the
Conditions Response (Y/N) different causes of non-response. This indicates
1. Did eligible children (6-59 months) have a high temperature (≥100.4F/38°C) and/or that household exclusion due to COVID-19 ex-
others symptoms of COVID-19 (e.g., dry cough, sneezing, shortness of breath, chest clusion criteria was very low (1.5%) in the
pain or pressure, loss of speech or movement etc.?) Makeshift camp with no exclusions in the other
2. Did anyone in this household test positive for COVID-19 within the past 14 days? two camps.
3. Was anyone in this household in close contact with a confirmed COVID-19 positive Although the original plan was to revisit non-
patient within at least 14 days? response households for inclusion in the survey,
4. Is anyone in this household currently in home or centre quarantine for isolation? this was not required as all three surveys had
achieved adequate samples despite the exclusion
of some households. The overall data quality for
Table 3 Proportion of households and children included in SMART surveys the three surveys was either “good” (Makeshift
Survey location Targeted5 Households Targeted Children Non-response camp) or “excellent” (the two registered camps)
households achieved children achieved rate (NRR) as per the SMART plausibility score. The overall
Makeshift camp 611 578 [94.6%] 492 488 [99.2%] 33 [5.4%]
quality of the survey for the Makeshift camp was
high but a penalty was given for a standard devi-
Nayapara registered camp 585 552 [94.4%] 362 305 [84.3%] 33 [5.6%] ation (SD) of weight-for-height Z-score (WHZ)
Kutupalong registered camp 709 650 [91.7%] 334 346[103.6%] 59 [8.3%] (SD value <=0.8; acceptable) which was due to
higher homogeneity in that camp.

Table 4 Distribution of non-response households by cause Although there was no standardisation test
used, most enumerators were highly experienced
Survey area Absent Refused Excluded due to Others* Total non-response and skilled and therefore a high level of stan-
children’s high fever rate (NRR)
dardisation was assumed which resulted in very
Makeshift camp 23 [3.8%] 0 [0%] 9 [1.5%] 1 [0.1%] 33[5.4%] few outliers in the data.
Nayapara 7 [1.2%] 1 [0.2%] 0 [0%] 25 [4.3%] 33 [5.6%]
5 The sample size was calculated using ENA for SMART
registered camp
software based on different parameters. A two-stage cluster
Kutupalong 26 [3.7%] 33 [4.6%] 0 [0%] 0 [0%] 59 [8.3%] sampling technique was applied in the Makeshift camp
registered camp whereas a simple random sampling technique was applied
in the two-registered camps.
*Wrong address/moved to another place
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62
 Field Articles

The data collection time of 15 minutes for each thorough series of discussions with Nutrition In terms of measures used during the con-
household, as recommended by the SMART op- and Health Sector partners and local health and ducting of surveys, several adaptations were
erational guidelines, was not feasible in this context. administration authorities and a constant review made to the interim guidance based on a series
A minimum of 20 to 25 minutes was required on of local epidemiological trends around COVID- of discussions and consultation with the Nutrition
average per household with the anthropometry 19. Gaining an understanding of the local context Sector, AIM-TWG, NNS, IPHN, the local Civil
and mortality components. Administration of the and community perceptions around COVID-19, Surgeon’s Office as well as ACF Canada and
health screening checklist, measuring of body including stigma, fear and misconceptions, was France headquarters advisors. Since the COVID-
temperature, asking/putting on masks for household also important prior to embarking on the survey 19 crisis was new for everyone and there was a
members and disinfecting equipment added to in this context. This understanding informed great deal of sensitivity around conducting
the time required. There was no refusal related to community sensitisation prior to the survey and surveys in this period, a large number of stake-
fear of COVID-19 and health and safety measures communications during the fieldwork which led holders were hesitant to embark on the process.
were well accepted by community members. Almost to a high level of community compliance with A lot of the additional recommendations therefore
all households already had facemasks and other came from multiple partners, organisations and
the survey. The selection of locally experienced,
PPE that they were willing to use. However, it was technical experts which were added to the global
skilled enumerators who could understand the
often very challenging to maintain a distance of at guidance particularly for the specific CXB context
context was also important.
least one metre especially in the Makeshift camp but which would not necessarily be needed in
due to the very limited space available in and There is a high risk that excluding children other settings.
around the households. and households due to high fever will pose a sys- The interim guidelines on SMART surveys
All survey team members tested negative for tematic bias by also excluding potentially mal- recommend the use of both hand gloves and
COVID-19 prior to the survey and no one devel- nourished children. This could impact the reported sanitiser for team members. However, using both
oped other signs/symptoms of COVID-19 or be- malnutrition prevalence and other relevant indi- items proved to be time consuming, resource-
came unwell during the survey implementation. cators since there is a general assumption that heavy and had the potential to create an extra
sick children are more likely to be malnourished. waste management burden at field level. It was
Reflections and key lessons This is unlikely to have affected the results of the therefore decided to only use hand sanitiser (aside
learned three surveys here, given that the exclusion rate from the use of gloves for those cleaning equipment)
Weighing up the risks and benefits of conducting was very low, but should be considered as a po- so as to reduce the resources needed. This appeared
surveys during the COVID-19 pandemic is im- tential source of bias in SMART surveys in other to have no negative impact on transmission rates
portant. That was aided in this experience by a contexts where COVID-19 rates are higher. in the context of these three surveys.
Experience from this survey showed that the
Box 1 Recommendations to implement SMART surveys in the context of COVID-19 standard facemask size was difficult to use with
children. The recommended 15 minutes allocated
Pre-survey preparation for each household was not adequate to complete
1. Critically review and monitor the COVID-19 situation in the context before embarking on a decision the anthropometry and mortality components
to conduct a SMART or other population level survey that requires household level data collection. of the survey and apply IPC measures. On the
2. Inform and consult with local authorities (e.g., local government, law enforcement authorities, camp basis of this experience, several recommendations
management committees and the Health and Nutrition Sectors) prior to conducting any survey are made to partners who would like to conduct
during the COVID-19 pandemic. This is particularly important during the pandemic as internal and SMART surveys in COVID-19 context, as de-
in-country rules and regulations may be imposed including movement restrictions due to the scribed in Box 1.
pandemic. Consultation with the relevant authorities is critical to gain the necessary approvals and
full cooperation to successfully conduct the survey. Conclusion
3. Use local in-country expertise in technical and management survey aspects wherever possible to Experience from conducting three SMART sur-
ensure both quality data collection and the community’s health and safety in the COVID-19 context. veys in the context of COVID-19 in CXB showed
4. Invest in community mobilisation and advocacy prior to the survey to address rumours and context-specific adaptations can enable the
misinformation around COVID-19 in the community. proper application of SMART survey guidelines.
5. Adequate funding and time should be planned for the proper adaptation of IPC health guidance, the In this context, community mobilisation that
procurement of necessary disinfectant and PPE items and any unforeseen contingency measures took into account prevailing community COVID-
required to make the survey as safe as possible in the COVID-19 context.
19 myths and concerns prior to the survey en-
6. Organisations and the Sector/Cluster should focus on the minimum key indicators required in the
abled a good response rate and IPC measures
survey questionnaire to enable sufficient nutrition situation monitoring and evaluation and decision-
prevented virus transmission among respondents
making in the context. All additional non-essential indicators should not be included in surveys
implemented in the COVID-19 context to reduce exposure time to the survey population and households.
and survey team members. This enabled the
7. Carefully adapt and contextualise the global guidance (e.g., interim global operational guidance on collection of information to inform the nutrition
population level surveys and household level data collection in the COVID-19 context) with a group response. It is recommended that surveys con-
of experts through a technical committee (e.g., AIM-TWG, Sector/Cluster) to ensure that the tinue to be conducted despite the extra efforts
guidelines suit the unique context in which they are being applied. and resources needed to minimise the risk of
8. The NRR should be carefully estimated during sample size calculations. Child fever prevalence based virus transmission.
on a two-week recall period should not be directly used for COVID-19 related NRR for sample size
calculations as it may unnecessarily inflate the NNR.
For more information, please contact
Md. Lalon Miah at
Survey implementation [email protected]
9. Review the allocated time per household based on field testing while taking into consideration extra
time for health screening and IPC measures during household visits.
10. Very close monitoring of daily survey field activities by the responsible survey manager is needed to
ensure adherence to IPC guidance, data quality, the health and wellbeing of the survey team
References
members and the number of non-responses either due to COVID-19 related rejection or exclusion. Government of Bangladesh, Ministry of Planning (2017)
Preliminary Report on Household Income and
11. Additional survey days (e.g., two to three days) should be planned for during the COVID-19 pandemic
Expenditure Survey 2016. Dhaka
to revisit all missed or excluded households either due to high fever or absenteeism. This will minimise
the possible high NRR that may happen if many children and/or mothers/caregivers are found with Government of Bangladesh and UNHCR (2021) Joint
Registration Exercise, 31 January 2021. Accessed at
fever on the designated days of data collection.
https://data2.unhcr.org/fr/documents/download/85034
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Field Exchange issue 65, May 2021, www.ennonline.net/fex
63
 Snapshots
Research .............................................................
The burden of malnutrition and fatal COVID-19: years lived with disability (YLD) attributed to
iron and vitamin A deficiencies and high body
A global burden of disease analysis mass index (BMI).
There was no correlation between the rate of
Research snapshot1
death for child growth failure and CFR for
COVID-19. A slightly higher CFR for COVID-

T
he role played by population-level nu- the countries where a high burden of malnutrition
19 was seen in countries with very high rates of
tritional status in the vulnerability of coincides with higher rates of fatal COVID-19 YLD for iron deficiencies. Countries’ vulnerability
countries to COVID-19 illness and disease, indicating a potential relationship be- to fatal COVID-19 was slightly higher with in-
death is unknown. Because childhood tween these burdens. Analyses were conducted creasing rates of vitamin A deficiency, with no
malnutrition is associated with high morbidity for 172 countries for which data were available further increases for countries with very high
and mortality, mainly due to infectious diseases, on both COVID-19 case fatality ratios (CFR) rates of vitamin A deficiency. Vulnerability to
it can be assumed that undernourished popula- and the country-level burden of malnutrition, fatal COVID-19 was slightly higher in countries
tions may be at greater risk of severe or fatal quantified using death rates for child growth with increased rates of high BMI compared to
COVID-19 illness. This study aims to identify failure (underweight, stunting and/or wasting), countries with low and median rates of high
BMI. No correlations were seen between the
rate of YLD for high BMI and CFR for COVID-
© WFP/Leni Kinzli

19. Increasing rates of high BMI were, however,

associated with a higher vulnerability to fatal
COVID-19 in low-income countries.
Countries ranking high on at least three mal-
nutrition indicators and with elevated CFR for
COVID-19 are sub-Saharan African countries,
namely, Angola, Burkina Faso, Chad, Liberia,
Mali, Niger, Sudan and Tanzania as well as
Yemen and Guyana. The authors conclude that
population-level malnutrition appears to be re-
lated to increased rates of fatal COVID-19 in
areas with an elevated burden of undernutrition
such as countries in the Sahel strip.
1
Mertens, E and Peñalvo, J L (2021) The burden of
A child being assessed for malnutrition at malnutrition and fatal COVID-19: A global burden of disease
a nutrition center in North Darfur, Sudan analysis. Front. Nutr. 7:619850. doi:
10.3389/fnut.2020.619850

Improving complementary feeding practices change compared to the control group in their
nutrition status: WHZ increased by +0.34 ± 0.26
(p <.05), WAZ increased by +0.35 ± 0.20 (p<.05)
through smartphone-based maternal and HAZ increased by +0.34 ± 0.21 (p<.05).
More children in the intervention group recovered
education in Iran Research snapshot 1
from wasting (WHZ <-2) and underweight (WAZ
<-2) than children in the control group (p<.05)
while no statistically significant change was ob-

M
others’ poor nutrition-related for-age z-score (HAZ) <-2) were recruited with served for stunting (HAZ<-2). At endline, 6% of
knowledge, attitudes and practices their mothers in a well-child clinic in Urmia, the children were wasted in the intervention
are considered to be major causes Iran. The children and mothers were randomly group compared with 32% in the control group.
of malnutrition in children, along assigned to either the intervention group (smart-
with socio-economic and environmental factors. phone-based maternal nutrition education covering The six-month smartphone-based maternal
The growing ownership of smartphones offers a principles based on child age, child feeding be- nutrition education programme on comple-
cost-effective platform to provide evidence- haviour, timing and appropriate introduction of mentary feeding was more effective than standard
based health information and behavioural change complementary feeding and mothers’ health) or routine nutrition information for correcting
interventions. Researchers assessed whether the control group (routine health service treatment wasting and underweight among children under
providing mothers with nutritional education as usual which included the provision of standard three years of age in middle-income food-secure
through a smartphone application would have nutrition information during regular check-ups). communities. Although HAZ status improved,
an effect on child undernutrition in a food- stunting rates did not which can be explained
Between baseline and endline, mothers in by the relatively short intervention period.
secure environment over a period of six months.
the intervention group showed greater and sta-
Children under three years of age with mod- tistically significant improvement in the three 1
Seyyedi, N, Rahimi, B, Eslamlou, H R F, Afshar, H L, Spreco, A
erate or severe malnutrition (“wasting”, defined indicators of nutrition literacy (critical knowledge, and Timpka, T (2020) Smartphone-Based Maternal
Education for the Complementary Feeding of
by weight-for-height z-score (WHZ) <-2) and/or feeding attitudes and nutritional practice) com- Undernourished Children Under 3 Years of Age in Food-
underweight (defined by weight-for-age z-score pared to the women in the control group. Children Secure Communities: Randomised Controlled Trial in Urmia,
(WAZ) <-2) and/or stunting (defined by height- in the intervention group showed greater positive Iran. Nutrients, 12(2), 587. doi:10.3390/nu12020587

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64
 Research Snapshots
.......................................................................................................................................

Misalignment of global COVID-19 breastfeeding and newborn care

guidelines with World Health Organization recommendations
Research snapshot1

I
nterruption of exclusive and continued which the policy supported or undermined viral epidemics of the WHO.
breastfeeding is responsible for nearly breastfeeding, namely (1) skin-to-skin contact,
700,000 maternal and child deaths annually. The authors recommend that those developing
(2) early initiation of breastfeeding, (3) room-
There are concerns that the separation of guidance need to appropriately consider the
ing-in, (4) direct breastfeeding, (5) provision of
mothers and newborns to reduce mother-to- importance of skin-to-skin contact, early initiation
expressed breastmilk, (6) provision of donor
infant transmission of SARS-CoV-2 in the of breastfeeding, rooming-in and breastfeeding
human milk, (7) wet nursing, (8) provision of
context of the COVID-19 pandemic is negatively to maternal and infant physical and psychological
breastmilk substitutes, (9) psychological support
affecting breastfeeding practices. A strategy for health. The implications of these acute changes
for separated mothers and (10) psychological
preventing the spread of the virus responsible in infant feeding practices, microbiomes, overall
support for separated infants.
for COVID-19 is to separate those who are in- infant morbidity and mortality, maternal health
fected from those who are not infected. In new- The findings showed that none of the guidance and other unforeseen changes will remain un-
borns, the risk posed by virus transmission from the 33 countries recommended all aspects known for a long time. Recommendations against
must be weighed against the protection that of the WHO guidance and most countries did maternal proximity and breastfeeding should
breastfeeding provides. The World Health Or- not recommend keeping mothers and infants therefore not be made without compelling evi-
ganization (WHO) issued guidance for mothers in close proximity or direct breastfeeding. Rec- dence that they are necessary and less harmful
suspected or confirmed as having COVID-19 ommendations against practices supportive of than maintaining dyad integrity.
and their newborns which supported maintaining breastfeeding were common, even in countries
mother and infants proximate to one another with high infant mortality rates. Decisions related
and early and exclusive breastfeeding. to maternal and newborn proximity and breast-
1
feeding have been based on other prominent Vu Hoang, D, Cashin, J, Gribble, K et al. (2020) Misalignment
of global COVID-19 breastfeeding and newborn care
This study reviewed guidance documents organisations whose early guidance was based guidelines with World Health Organization
from 33 countries to assess their alignment with on fear of the unknown (the virus) instead of recommendations. BMJ Nutrition, Prevention & Health 3(2):
the WHO recommendations and the extent to the standard practices and knowledge of past 339-350. doi:10.1136/bmjnph-2020-000184

highlights several direct nutrition interventions

The Lancet Series on Maternal and Child that are ready for scaling up in health systems.
However, it stresses the need for well-resourced
Undernutrition Progress Research snapshot 1
nutrition data and information systems to inform
approaches. The authors also note the need for
more evidence on cost-effectiveness to allow

T
hirteen years after the first Lancet Series ciency and anaemia remain high. The paper
on Maternal and Child Undernutrition, further highlights the role of social inequalities governments to plan sufficiently for implemen-
the latest series on Maternal and Child in undernutrition and that the modest improve- tation and scale-up. The paper concludes with a
Undernutrition Progress revisits the ments made since 2000 may be offset by the call to action for nutrition stakeholders to unite
global agenda for tackling undernutrition. It ex- COVID-19 pandemic. (Victora et al, 2021) around common priorities to tackle the so-
plores key advancements made on stunting, called ‘unfinished undernutrition agenda’. (Hei-
The second paper, by Keats et al, explores dkamp et al, 2021)
wasting and micronutrient deficiencies and lays
updated evidence on interventions to address
out an ‘agenda for action’ to accelerate progress In an accompanying commentary to the Lancet
maternal and child malnutrition, examining
towards global nutrition goals. The series serves Series, Shekar et al explore progress in light of the
both direct and indirect interventions and
as an important milestone and a key moment to COVID-19 pandemic and call for renewed efforts
offering a revised framework for nutrition actions.
reinvigorate the nutrition agenda in 2021 as part to support countries to prioritise interventions to
The evidence collected supports the continued
of the Nutrition for Growth Year of Action. be delivered at scale. (Shekar et al, 2021)
effectiveness of all the interventions outlined in
The first paper, by Victora et al, reviews the 2013 Lancet Series. Evidence has strengthened
1
progress on undernutrition in 50 low- and mid- for the effectiveness of antenatal multiple mi- https://www.thelancet.com/series/maternal-child-
undernutrition-progress
dle-income countries using data from 2000 to cronutrient supplementation in reducing the
2015. It found that the prevalence of childhood risks of stillbirths, LBW and babies born small-
References
stunting has fallen (from 32.5% in 2000 to 21.9% for-gestational age and there is emerging evidence
in 2017) but progress on wasting and low birth- for preventative small-quantity lipid-based nu- Heidkamp, R A et al (2021) "Mobilising evidence, data, and
resources to achieve global maternal and child
weight (LBW) has been slow. New evidence has trient supplementation (SQ-LNS) for reducing undernutrition targets and the Sustainable Development
shown that 4.7% of children are affected by childhood stunting, wasting and underweight. Goals: an agenda for action." The Lancet 397(10282):
both wasting and stunting, a condition associated However, evidence gaps remain on how to tackle 1400-1418.
with a 4.8 times increase in mortality and that malnutrition in school age children and adoles- Keats, E et al (2021) "Effective interventions to address
both wasting and stunting can exist at birth and cents. Overall, greater efforts are needed to im- maternal and child malnutrition: an update of the evidence."
The Lancet Child & Adolescent Health 5(5): 367-384.
peak in the first six months of life. prove intervention coverage. (Keats et al, 2021)
Shekar, M et al (2021) "Maternal and child undernutrition:
Among women of reproductive age, the preva- The third paper, by Heidkamp et al, outlines progress hinges on supporting women and more
lence of low body-mass index has reduced but steps that must be taken if the 2025 World implementation research." The Lancet 397(10282): 1329-
1331.
the prevalence of short stature remains high. Health Assembly targets and the 2030 Sustainable
Data on micronutrient status is limited, particularly Development Goals are to be met. It reaffirms Victora, C G et al (2021) "Revisiting maternal and child
undernutrition in low-income and middle-income
for women, but evidence has shown improvements the importance of multi-sector actions and the countries: variable progress towards an unfinished
in vitamin A status. The prevalence of zinc defi- emphasis on the first 1,000 days. The paper agenda." The Lancet 397(10282): 1388-1399.
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65
 Research Snapshots
.......................................................................................................................................

Sustainability evaluation of a national infant and young child feeding

programme in Bangladesh and Vietnam Research snapshot 1

N
umerous infant and young child the A&T programme in Bangladesh and Viet- In both countries, some A&T activities were
(IYCF) interventions have struggled nam, two years after the end of external pro- continued via institutionalisation following project
to show impact at-scale. A notable gramme funding. closure, particularly IYCF counselling. However,
exception is the Alive & Thrive declines in mass media campaigns, policy and
The study design included quantitative data
initiative (A&T) implemented in Bangladesh, advocacy activities and social mobilisation activities
(surveys completed by 668 health workers and
Ethiopia and Vietnam between 2009 and 2014. were noted. Certain core A&T activities, such as
269 service observations) collected from January
The A&T programme aimed to achieve at- monitoring and evaluation and IYCF training,
to May 2017 and comparative data analysis from
scale child nutrition and health improvements were reduced in both countries in frequency,
areas that received all A&T programme activities
via contextualised activities including nutrition quality and coverage. Time and budget constraints
and those that received no A&T-related activities.
were cited as barriers to implementing these core
counselling, policy change, social mobilisation Interviews and focus group discussions were held
A&T activities.
and mass media campaigns with studies showing with 218 stakeholders (policymakers, experts,
that IYCF behaviours and outcomes improved non-governmental organisations and donor rep- When exploring health worker capacity across
as a result. This study aimed to explore the resentatives and health partners) to explore their intervention and comparison areas, it was found
sustainability of activities implemented during impressions of A&T programme sustainability. that IYCF knowledge scores remained significantly
higher among health workers in intervention
areas compared to those in comparison settings
© WFP/Shehzad Noorani

(on average 11% and 14% higher respectively).

However, this did not translate into better quality
of counselling as determined by the proportion
of recommended activities performed. Health
workers in intervention areas in Bangladesh re-
ported significantly higher job satisfaction (86%)
and self-efficacy (93%) than those in comparison
areas (83% and 85% respectively). No significant
differences were noted in Vietnam. Stakeholders
highlighted the importance of government lead-
ership for sustainability and the need for future
programmes to plan for institutionalisation from
the beginning of implementation.

1
Moucheraud, C, Sarma, H, Ha, T T T et al. (2020) Can complex
programs be sustained? A mixed methods sustainability
evaluation of a national infant and young child feeding
program in Bangladesh and Vietnam. BMC Public Health 20,
IYCF messaging in Bangladesh
1361 (2020). https://doi.org/10.1186/s12889-020-09438-2

Respondents with a multi-country focus were

Nutrition data use and needs: Findings from an more likely to have accessed both the DHS and
the GNR in the last year (85% and 82% respec-
online survey of global nutrition stakeholders tively) compared to those with a single-country
focus (60% and 66% respectively) (P < 0.001; P =
Research snapshot1
0.014 respectively). The most commonly accessed
indicators overall were the prevalence of exclusive

I
nformation on population-level nutritional their work, which nutrition indicators and data breastfeeding (69%), child minimum dietary di-
status and nutritional determinants are sources they had accessed in the previous year versity (66%), stunting (65%) and wasting (65%).
typically collected through periodic na- and unmet data needs. The survey was completed
tional and sub-national surveys. However, by 235 respondents, the majority of whom were Identified gaps in data include diet quality
there is growing global demand for improved from non-governmental organisations and re- indicators, nutrition-sensitive intervention cov-
country-level nutritional data. To justify in- search entities. Few government officials re- erage and infant and young child feeding pro-
vestment for improved data collection, evidence sponded to the survey. motion coverage. Data challenges noted by the
of the demand for information is needed. To respondents were the lack of geographical dis-
Of those who accessed country-specific data aggregation of data (82%), the lack of data for
fill this gap, the authors conducted an online
in the last year, Demographic and Health Surveys demographic groups (77%) or data being out of
survey of nutrition professionals working in
(DHS) were the most common (74%) followed date (77%). Results point to the continued need
low- and middle- income countries to identify
by Multiple-Indicator Cluster Surveys (MICS). for timely, high-quality nutrition data and greater
the nutrition indicators and data sources widely
Most respondents had accessed at least one investment in surveys.
used and the current unmet nutrition infor-
source of consolidated data in the last 12 months
mation needs.
(75%) of which the most common was the 1
Buckland, A J, Thorne-Lyman, A L, Aung, T, King, S E,
The online survey was disseminated through Global Nutrition Report (GNR). Routine facility Manorat, R, Becker, L, Piwoz, E, Rawat, R and Heidkamp, R
professional networks and online nutrition-fo- data sources such as the Health Management (2020). Nutrition data use and needs: Findings from an
online survey of global nutrition stakeholders. Journal of
cused listservs. Respondents were asked their Information System (HMIS) were less accessed global health, 10(2), 020403.
professional background, how they use data in compared to household surveys. https://doi.org/10.7189/jogh.10.020403
.......................................................................................................................................
Field Exchange issue 65, May 2021, www.ennonline.net/fex
66
 Research Snapshots
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An exploration of district-based health

health agenda. The analysis of data templates
decision-making in West Bengal, India revealed no harmonisation or sharing of data
across departments. In observed district health
Research snapshot1 meetings, 21 issues were discussed and action
plans developed. Yet, despite data being available

S
ince 2005, health planning has been in- Data templates contributing to the Health Man- for all of these issues, decisions on only nine
creasingly decentralised in India, through agement Information System (HMIS) were also (such as institutional delivery and immunisation
the Health Sector Reform Programme collected to understand the types of data available services) were based on available data. Discussions
and the National Health Mission, leading and data-sharing mechanisms. Findings were about infrastructure and supplies were not sup-
to increased district-level health decision-making subsequently triangulated thematically based on ported by data and planning targets were not
and the integration of health plans into multiple the World Health Organization’s health system linked to health outcomes. Findings show that
sectors. This qualitative study aimed to assess building blocks. existing local data is underutilised for decision-
health decision-making processes in two districts making. This highlights the need for strengthening
Findings revealed that, despite decentralised
in West Bengal, exploring the extent to which the use of data for priority-setting and follow-
planning being one of the pillars of India’s Health
local data is used for decision-making, planning up at district-level in India.
Sector Reform Programme, health plans and re-
and resource allocation for maternal and child
source allocations have remained structured
health across health-related sectors.
around the State and Central Government’s core 1
Bhattacharyya, S, Issac, A, Girase, B, Guha, M, Schellenberg, J,
Direct observations of four key decision- agenda rather than district-level priorities. The Iqbal Avan, B (2020) "There Is No Link Between Resource
Allocation and Use of Local Data": A Qualitative Study of
making meetings and qualitative interviews with contribution to decision-making by other de- District-Based Health Decision-Making in West Bengal, India.
16 key informants from multiple departments partments is limited as programmes are already Int J Environ Res Public Health. 2020;17(21):8283. Published
were conducted between June and October 2015. planned according to the State Government’s 2020 Nov 9. doi:10.3390/ijerph17218283

Greater precision of interactions between community health workers

and household members to improve maternal and newborn health
outcomes in India Research snapshot 1

I
n low- and middle-income countries, com- (n=5,469), their husbands (n=3,064), mothers- haviour change messages, such as the danger of
munity health workers (CHWs) provide in-law (n=3,626) and CHWs (n=1,052). complications, were associated with more check-
basic but lifesaving support for those who ups and delivery in a health facility but were
have little access to formal healthcare. To Results show that pregnant women who were
only used by 50%–80% of CHWs. During delivery,
identify which CHW actions and messages enable visited earlier in pregnancy and who received
57% of women had the CHW present and their
good outcomes and respectful care, the authors multiple visits were more likely to perform rec-
presence was associated with respectful care,
used logistic regression to study the associations ommended health behaviours including attending
early initiation of breastfeeding and exclusive
between CHW actions and household behaviours multiple check-ups, consuming iron and folic
breastfeeding but not with delayed bathing or
during antenatal, delivery and postnatal periods acid tablets and delivering in a health facility,
clean cord care. Home visits after delivery were
in Uttar Pradesh, India. This large-scale survey compared to women visited later or receiving
associated with higher rates of clean cord care
was conducted in the context of a mature gov- fewer visits. Counselling the woman was associated
and exclusive breastfeeding. Counselling the
ernment programme which has operated at scale with the higher likelihood of attending three or
mother-in-law (but not the husband or woman)
nationally, using close to a million CHWs, for 15 more check-ups and consuming 100+ iron and
was associated with exclusive breastfeeding.
years. Data was collected on a uniquely linked folic acid tablets, whereas counselling the husband
set of questions on behaviours, beliefs and care and mother-in-law was associated with higher CHW presence, the number and the timing
pathways from recently delivered women rates of delivery in a health facility. Certain be- of visits, behaviour change messaging strategies
and a focus on specific household members for
different behaviours were associated with better
© Sudharak Olwe, 2018

maternal and newborn care practices in this con-

text. Understanding the perspectives of the house-
hold decision makers, emphasising the importance
of home visits and identifying what messages are
shared helped to identify ways to increase the
impact of CHW home visits.
Programme managers can use these insights
to adapt CHW training, incentives and tools to
achieve greater impact, understanding that it is
not just the skills of the CHW but the trust
between the CHW and the beneficiary built up
over time that is important.

1
Smittenaar, P, Ramesh, B M, Jain, M, Blanchard, J, Kemp, H,
Engl, E et al (2020) Bringing Greater Precision to Interactions
Between Community Health Workers and Households to
Measuring MUAC during a home-
visit to a pregnant woman identified Improve Maternal and Newborn Health Outcomes in India.
as at-nutritional risk in India Global health, science and practice, 8(3), 358–371.
https://doi.org/10.9745/GHSP-D-20-00027
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67
 Research Snapshots
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Effect of nutrition-sensitive agriculture interventions on maternal

and child nutritional outcomes in rural Odisha, India (UPAVAN trial)
Research snapshot1

A
lmost a quarter of the world's un- but not in the AGRI group. There was an increase India. Future efforts could consider integrating
dernourished people live in India. in the proportion of mothers consuming at least similar interventions within larger scale, multi-
The investigators tested the effects five of ten food groups in the AGRI (adjusted sector programme designs to increase impact.
of three nutrition-sensitive agriculture RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA However, child wasting continues to be a problem
(NSA) interventions on maternal and child nu- (1·30, 1·10 to 1·53) groups compared with the and innovation in the prevention of child wasting
trition in the Keonjhar district of Odisha State control group but not in AGRI-NUT. There is an urgent priority.
in India. Clusters of villages were randomised were no effects on child wasting or on mean
1
maternal Body Mass Index (BMI). Kadiyala, S, Harris-Fry, H, Pradhan, R, Mohanty, S et al (2021)
to one of four arms: Effect of nutrition-sensitive agriculture interventions with
1) Women's group meetings and household The authors conclude that women's groups participatory videos and women's group meetings on
visits occurring each fortnight over 32 using combinations of NSA videos, nutrition- maternal and child nutritional outcomes in rural Odisha, India
months using NSA videos (AGRI group) (UPAVAN trial): a four-arm, observer-blind, cluster-randomised
specific videos and PLA cycle meetings improved controlled trial. Lancet Planetary Health. 2021;in press.
2) As above but combining NSA and maternal and child diet quality in rural Odisha, Published 2021 Mar 31. doi: 10.1016/S2542-5196(21)00001-2
nutrition-specific videos (AGRI-NUT
group)

© Sudharak Olwe
3) Fortnightly women's group meetings using
NSA videos and nutrition-specific
participatory learning and action (PLA)
cycle meetings and videos (AGRI-
NUT+PLA group)
4) Control group (no intervention)
These components have been implemented
separately in several low-income settings but
this was the first trial to test different combinations
of these approaches. Anthropometry and dietary
diversity outcomes were assessed in children
aged 6-23 months and their mothers through
cross-sectional surveys at baseline (November
2016) and at endline (November 2019).
Compared with the control group, there was
an increase in the proportion of children con-
suming at least four of seven food groups in the
AGRI-NUT (adjusted relative risk [RR] 1·19, Home-based nutrition gardens
95% CI 1·03 to 1·37, p=0·02) and AGRI- and backyard poultry, India
NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups

Although the absolute reduction in mortality

Biannual azithromycin distribution and between arms appears larger in both underweight
groups, no statistically significant evidence of
child mortality among malnourished effect modification was demonstrated by the
WAZ subgroup on either the additive or multi-
children in Niger Research snapshot 1
plicative scale. Based on these results, the authors
conclude that the treatment of all children aged

B
iannual azithromycin distribution has by underweight status was examined on the ad- between one and 11 months would save five
been shown to reduce child mortality ditive and multiplicative scale and the absolute times as many lives as restricting treatments
as well as increase antimicrobial re- number of deaths averted with azithromycin in only to children with a WAZ < −3. In this
sistance. The authors assessed whether each subgroup was estimated. setting, the number of deaths averted would be
this effect differed according to underweight greatest if all children were treated with
status in a high-mortality setting in West Africa. The communities assigned to azithromycin
azithromycin, regardless of nutritional status.
Children received biannual distribution of had lower mortality rates than those assigned
azithromycin or a placebo over two years in a to the placebo (−12.6 deaths per 1,000 person- 1
O’Brien, K S, Arzika, A M, Maliki, R, Manzo, F, Mamkara, A K,
large, randomised control trial in Niger. In this years (95% CI −18.5 to −6.9, P < 0.001)). Re- Lebas, E, et al (2020) Biannual azithromycin distribution and
analysis, the effect of azithromycin distribution ductions were larger among children with lower child mortality among malnourished children: A subgroup
WAZ: −17.0 (95% CI −28.0 to −7.0, P = 0.001) analysis of the MORDOR cluster-randomized trial in Niger.
on child mortality was assessed for underweight PLoS Med 17(9): e1003285. https://doi.org/10.1371/
subgroups using weight-for-age z-score (WAZ) among children with WAZ < −2 and −25.6 (95% journal.pmed.1003285
thresholds of −2 and −3 in 27,222 children CI −42.6 to −9.6, P = 0.003) among children 2
An additive interaction contrast greater than 0 indicates the
between one and 11 months of age who had with WAZ < −3. The estimated number of deaths joint effect of receiving placebo and being underweight is
averted with azithromycin was 388 (95% CI 214 greater than the sum of the individual effects considered
their weight measured at their first study visit.
separately. A multiplicative interaction contrast greater than
Mortality was defined as the community mortality to 574) overall, 116 (95% CI 48 to 192) among 1 indicates the joint effect of receiving placebo and being
rate (deaths per 1,000 person-years at risk). Mod- children with WAZ < −2 and 76 (95% CI 27 to underweight is greater than the product of the individual
ification of the effect of azithromycin on mortality 127) among children with WAZ < −3. effects considered separately.

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68
 Research Snapshots
......................................................................................................................................
for each country in 2015. Year and country-level low levels of GWG in Africa, especially in sub-
Analysis of gestational covariates were used as predictors and variable Saharan Africa. The five countries with the lowest
selection was guided by the model fit. The final GWG estimates were Congo, Afghanistan, Rwanda,
weight gain using model included year, geographic area, mean adult Central African Republic and the Democratic
female body mass index, gross domestic product Republic of the Congo. Sixteen LMICs met the
nationally per capita and total fertility rate. minimum GWG recommendation for normal-
representative data Gestational weight data was available for 67
weight women and only one country (Brazil:
14.0kg (95% UR: 2.8, 25.1)) met the minimum
of the total 137 low- and middle-income countries recommendation for underweight women.
Research snapshot1 (LMICs) in the DHS programme. Latin America
and Caribbean (11.80 kg (95% UR: 6.18, 17.41)) Results reveal a large burden of inadequate

A
dequate gestational weight gain and Central Europe, Eastern Europe and Central GWG in most LMIC countries and regions. Ges-
(GWG) is an important measure of Asia (11.19 kg (95% UR: 6.16, 16.21)) were the tational weight gain is strongly dependent on
maternal health during pregnancy; regions with the highest GWG estimates. Sub- modifiable maternal factors including nutritional
inadequate GWG is associated with Saharan Africa (6.64 kg (95% UR: 3.39, 9.88)) status, dietary intake, physical activity and pre-
negative maternal and newborn outcomes. To and North Africa and the Middle East (6.80 kg existing health conditions. Interventions promoting
fill the gap in our understanding of GWG levels (95% UR: 3.17, 10.43)) were the regions with the adequate GWG have the potential to improve ma-
and the burdens of inadequate and excessive lowest estimates. With the exception of Latin ternal, foetal and child outcomes across the world.
GWG in resource-limited settings, the authors America and Caribbean, all regions were below
1
of this paper computed GWG estimates across the minimum GWG recommendation for nor- Wang, D, Wang M, Darling, A M, Perumal, N, Liu, E, Danaei, G
and Fawz,i W W (2020) Gestational weight gain in low-
time using Demographic and Health Survey mal-weight women with sub-Saharan Africa and income and middle-income countries: a modelling analysis
(DHS) data. A hierarchical model was developed North Africa and the Middle East estimated to usng nationally representative data. BMJ global health,
to estimate the mean total GWG and associated meet less than 60% of the minimum recommen- 5(11), e003423. https://doi.org/10.1136/bmjgh-2020-
uncertainty ranges (URs) for a full-term pregnancy dation. National estimates for each country show 003423

Rates and risk factors for preterm birth and low birthweight Research snapshot1

P
reterm birth2 continues to be a major Pakistan). Trained study staff enrolled all pregnant were similar across sites and included nulliparity
public health problem contributing to women in the study catchment area as early as [RR − 1.27 (95% CI 1.21–1.33)], maternal age
75% of neonatal mortality worldwide. possible during pregnancy and conducted fol- under 20 years [RR 1.41 (95% CI 1.32–1.49)],
Low birth weight (LBW) is an important low-up visits shortly after delivery and at 42 days severe antenatal haemorrhage [RR 5.18 95% CI
but imperfect surrogate for prematurity when the after delivery. The authors analysed the rates of 4.44–6.04)], hypertensive disorders [RR 2.74 (95%
accurate assessment of gestational age is not possible. preterm births, LBW and a combination of CI − 1.21–1.33] and one to three antenatal visits
While there is an overlap between preterm birth preterm birth and LBW from January 2014 to versus four or more [RR 1.68 (95% CI 1.55–1.83)].
and LBW newborns, those that are both premature December 2018 and LBW and the risk factors
and LBW are at the highest risk of adverse neonatal associated with these outcomes. The results show that younger, nulliparous
outcomes. Understanding the epidemiology of women with limited access to antenatal care serv-
preterm birth and LBW is important for the pre- A total of 272,192 live births were included in ices are at higher risk of preterm births and need
vention and improved care of at risk newborns. the analysis. The overall preterm birth rate was more attention to prevent prematurity and LBW.
12.6% (ranging from 8.6% in India/Belagavi site
The authors3 conducted data analyses using to 21.8% in Pakistan), the overall LBW rate was 1
Pusdekar, Y V, Patel, A B, Kurhe, K G, Bhargav, S R, Thorsten,
the Global Network’s population-based registry V, Garces, A and al (2020) Rates and risk factors for preterm
13.6% (ranging from 2.7% in Kenya to 21.4% in
birth and low birthweight in the global network sites in six
of pregnant women and their babies in rural Pakistan) and the overall rate of both preterm low- and low middle-income countries. Reproductive health,
communities in six low- and middle-income birth and LBW was 5.5% (ranging from 1.2% in 17(Suppl 3), 187. https://doi.org/10.1186/s12978-020-01029-z
countries (Democratic Republic of the Congo, Kenya to 11.0% in Pakistan). Risk factors associated 2
Birth before 37 weeks of pregnancy
Kenya, Zambia, Guatemala, India (two sites) and with preterm birth, LBW and the combination 3
Birth weight below 2500g

Relapse and post-discharge body composition thropometry, fat-free mass, fat mass, skinfold
thickness z-scores and frequency of common
of children treated for acute malnutrition using illnesses four months post-discharge compared
to the standard protocol. Mean subscapular
a simplified, combined protocol Research snapshot 1 skinfold z-scores were close to the global norm
and there was also no significant difference in
the odds of relapse between protocols.

S
evere and moderate acute malnutrition protocol for uncomplicated SAM and MAM in
(SAM and MAM) affect more than 50 children 6-59 months of age against standard These results add further evidence that a com-
million children worldwide. Despite gains treatment.2 The combined protocol used a sim- bined protocol is as effective as standard care.
in the treatment of SAM in the past plified dosage and provided two sachets of ready This is an important finding as a simplified, com-
decade, there is no current consensus on how to use therapeutic food (RUTF) per day for SAM3 bined approach could stretch existing resources
best to manage children with MAM. Furthermore, children and one sachet per day for MAM4 chil- further and treat more children.
treatment coverage for SAM and MAM remains dren. Results demonstrate non-inferior recovery
low, with 80% of children not accessing care. of the combined protocol compared to standard 1
Lelijveld N, Musyoki E, Adongo W S, Mayberry A, Jonathan
One option to overcome these challenges is to care. To further inform policy, this study assessed CW, Opondo C, Kerac M, Bailey J (2021) Relapse and post-
combine the treatment of SAM and MAM into the four months post-discharge outcomes of discharge body composition of children treated for acute
malnutrition using a simplified, combined protocol: A nested
one simplified protocol. SAM and MAM children treated in Kenya. cohort from the ComPAS RCT. PLOS ONE. 2021;16(2):
e0245477. https://doi.org/10.1371/journal.pone.0245477
The ComPAS trial (Combined Protocol for The study recruited 850 children from 12 2
Weight-based dose of RUTF for children with SAM and
Acute Malnutrition Study) was a single-blinded, clinics (six using combined and six using standard RUSF for children with MAM.
cluster randomised, controlled, non-inferiority protocol). The study found children treated 3
Defined as MUAC < 11.5cm and/or mild or moderate oedema.
trial to compare the recovery rates of a combined with the combined protocol had similar an- 4
Defined as MUAC between 11.5 and <12.5cm and no oedema.
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69
 Research Snapshots
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The importance of food systems and the Triple trouble: The

environment for nutrition Research snapshot 1 triple burden of child
undernutrition,

T micronutrient
here is considerable ongoing debate in humanitarian or development contexts. Given
around how food systems can better en- the global inter-and transdisciplinary nature of
sure the delivery of healthy, safe, nutritious these challenges, the traditional boundaries need deficiencies and
foods in a way that is environmentally to be broken down to ensure relevant public health
sustainable and resilient to climate change. Food interventions, research and policies.
overweight in East
systems are complex entities with many intercon-
necting drivers, stakeholders and outcomes. Fur- Current research gaps in this important area Asia and the Pacific
thermore, food systems and climate change have a include: Research snapshot1
cyclical relationship, as environmental change is • Scientific consensus on definitions and
metrics to assess the sustainability of dietary

Y
both a driver and an outcome of food systems. oung children in East Asia and
patterns and food environments the Pacific region are failing to
Climate change impacts the immediate, un- • Limited scope of research e.g., research needs thrive in large numbers as indicated
derlying and basic causes of undernutrition. As to be implemented across different stages of by stagnation in the reduction of
climate change progresses, optimal conditions the supply chain, a wider variety of food child undernutrition and micronutrient de-
for human health will continue to come under products and on a wider range of nutrition ficiencies and a growing prevalence of over-
threat introducing instability into our food systems outcomes weight and obesity. To address the lack of
and ultimately decreasing access to nutritionally • Limited topic base e.g., research is needed on data on the drivers of child malnutrition in
dense and healthy foods. While this is likely to food safety, food waste and loss and the role the region, the UNICEF regional office for
affect the nutritional status of all populations, it of consumer practices East Asia and the Pacific commissioned a
will have a disproportionate impact on poor and • Levers of change in the food system and how series of papers in 2017 to 2019. These papers
marginalised populations. to utilise these found that most of the 26 countries in the re-
• Accurate global and subnational data on topics gion have a double burden of stunting, over-
The bi-directional relationship between food
such as dietary patterns, food loss and waste weight or anaemia and six countries suffer
systems, environmental change and nutrition de-
• Applicability of current literature to more from all three (the ‘triple burden’). Poverty
mands that nutrition scientists engage in food sys-
localised contexts and inequality are the leading drivers of child
tems transformation. Nutrition is inherently a
1
Fanzo J, Bellows L A, Spiker L M, Thorne-Lyman L A, Bloem malnutrition, with children often exposed to
multidisciplinary science; however, within nutrition,
WM (2021) The importance of food systems and the multi-dimensional forms of poverty, and poor
scientists have been traditionally siloed into those environment for nutrition. Am J Clin Nutr. 2021; 113(1): 7-6. maternal nutrition is a consistent predictor
studying undernutrition and overweight and those doi:10.1093/ajcn/nqaa313.
of stunting and wasting in the region.
However, national policies and pro-
grammes do not always address these key
Monitoring systems for the management of drivers and there is often still a focus on un-
dernutrition alone rather than on the triple
severe acute malnutrition programmes in burden of malnutrition. Implications for fu-
ture advocacy, policy and programme actions
northern Nigeria Research snapshot 1
highlighted in the papers are as follows:
• Governments must address all forms of

E
ach year in Nigeria, more than two and ancies existed between recounted and paper malnutrition in an integrated manner
a half million children under five years records for admissions, total exits, defaults, deaths across the life cycle.
of age are affected by wasting. Since and ready to use therapeutic food consumption • Improving women's nutrition is central
2016, UNICEF has supported the gov- for the audited month. The large discrepancies to breaking the intergenerational triple
ernment in the introduction of a Short Message in some facilities indicate the loss or removal of burden of malnutrition.
Service (SMS) for data transmission to support OTP cards and the discrepancies in death or • Policies and programmes require an in-
the monitoring of community-based management default rates can be attributed to inconsistencies tegrated multi-sector approach across
of acute malnutrition (CMAM) programmes. between actual treatment practices and national food, health, water and sanitation,
The SMS system operates in parallel with the CMAM guidelines, possibly leading to underes- education and social protection systems
to address the multiple determinants of
traditional paper-based system and transmits timations that give a false impression of good
child malnutrition.
data directly from health facilities to federal programme performance.
• Nutrition-sensitive social protection
levels on a weekly basis. In comparison, the pa-
There are several advantages to the SMS re- programmes are needed to address the
per-based system uses monthly data summaries
porting system such as fewer intermediate data disparities and inequalities in child
that are passed through all levels of government.
transfers. However, mobile network coverage is growth during the first 1,000 days.
This study undertook contextualised research2
not sufficiently reliable for the SMS system to re- • Prioritisation is needed in all countries
to assess data quality and performance in both to collect, analyse and utilise data to
place the paper-based system in Nigeria. The
CMAM information systems. assess progress and to inform decisions.
study highlights the need for improvements in
The study adopted a mixed-method approach. the design of the CMAM monitoring system, To address the drivers of the triple burden of
Primary data, observations, interviews and the training in and supervision of data management maternal and child malnutrition, synergistic
recount of data from outpatient therapeutic pro- and the communication of results. and accelerated change is needed through
gramme (OTP) cards were collected in nine 1 broader and bolder multi-sector approaches.
Tuffrey V, Mezger C, Nanama S, Bulti A, Oilsenekwu G, Umar C,
health facilities in one northern state in Nigeria, Jones E, Namukasa E. Assessment of monitoring systems in
while secondary data was obtained from five the management of severe acute malnutrition in northern 1
Blankenship L.J, Rudert C, Aguayo M.V. Triple trouble:
states. The accuracy and reliability of CMAM Nigeria. BMC Nutr. 2021; 7(2). https://doi.org/10.1186/s40795- Understanding the burden of child undernutrition
020-00405-z. micronutrient deficiencies, and overweight in East
data were deficient to a similar extent in both 1
Contextualised research based on the PRISMA (Performance Asia and the Pacific. Maternal and Child Nutrition.
the paper-based and SMS systems and discrep- of Routine Information System Management) framework 2020; 16(S2). https://doi.org/10.1111/mcn.12950.
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Research Snapshots

COVID-19 pandemic and mitigation strategies: source of health and nutrition information while
the education system is not fully functioning.
implications for maternal and child health Additionally, several community-level COVID-
19 response measures such as contact tracing
and nutrition Research snapshot 1
and self-isolation could also be exploited for
nutrition protection. While government-led im-
provements in sanitation infrastructures might

T
he adverse global impact of COVID- include interventions to strengthen the food be on hold as a result of the pandemic, commu-
19 on poverty, the coverage of essential supply chain through investment and policy re- nity-led sanitation programmes can ensure
support services and access to nutritious forms and to reduce food insecurity by assisting healthy household environments and reduce un-
foods is likely to lead to an increase those at immediate risk of food shortages. For dernutrition, for example, the Community Led
not only in the incidence of child wasting but incomes, interventions include targeted social Total Sanitation programmes in Nepal, Ethiopia
also maternal and child undernutrition more safety net programmes, payment deferrals or tax and Senegal.
broadly. A number of sectors that are critical for breaks as well as suitable cash support programmes
the reduction of maternal and child undernutrition for the most vulnerable such as the national con- Successful interventions to alleviate the effects
are at risk of collapse or reduced efficiency. Specifi- ditional cash transfer programme in Peru. of COVID-19 on maternal and child undernu-
cally, disruption to food systems, incomes and trition will require governments, donors and de-
Community health workers (CHWs) and velopment partners to restrategise and reprioritise
services that provide healthcare, education, social
community groups, targeting the most margin- investments for the COVID-19 era and will ne-
protection and sanitation need to be mitigated
alised households, can be utilised to address cessitate data-driven decision making, political
during and in the aftermath of COVID-19 to
shortfalls in current healthcare, education, social will and international unity.
reduce the burden of undernutrition.
protection and sanitation services. Ethiopia's
The authors build on their previous ‘Global health extension workers and Nepal's female 1
Akseer, N, Kandru, G, Keats, E C and Bhutta, Z A (2020)
Health’s Stunting Reduction Exemplars’ project community health volunteers showcase successful COVID-19 pandemic and mitigation strategies: implications
to suggest priority actions within low- and mid- models of mobilising CHWs. CHWs and other for maternal and child health and nutrition. The American
dle- income countries. For food systems, these community groups can also be an important journal of clinical nutrition, 112(2), pp.251-256.

only), vitamin B12 and folate. The last two articles

Assessing nutrient gaps and affordability of (Ryckman et al, (2021a); Ryckman et al, (2021b))
identified the most affordable foods that could
complementary foods Research snapshot 1
close the nutrient gaps previously identified. They
found several nutrients with few affordable sources,
with zinc being universally unaffordable.

I
dentifying nutrition and dietary gaps along- moderate or high) implied by each data point.
side foods that are best matched to fill these The methodology then assigns weights to each While it is too early to say for sure whether
gaps is essential to inform nutrition-related data point based on evidence type, geographic these deductions are indeed valid, these papers
policies and programmes. The five research representation, recency of data collection, age provide a strong basis for the design of interventions
papers in this Nutrition Reviews supplement ad- and sex representation and sample size. For each to improve the nutrition of infants and young
nutrient, an overall nutrient gap rating is derived children in the poorest regions of the world.
dress these questions for young children in Eastern
and South Africa and South Asia. The first article as well as an evidence quality rating.
References
by Beal et al (2021a) introduces a novel method- The next two articles (White et al, (2021); Beal Beal, T, White, M J, Arsenault, E J, Okronipa, H, Hinnouho,
ology for identifying the public health significance et al, (2021b)) detail the application of CONGO G, Morris, S S (2021a) Comprehensive Nutrient Gap
of nutrient gaps in children’s diets. The method- for children 6-23 months of age. The studies Assessment (CONGA): A method for identifying the public
ology, called Comprehensive Nutrition Gap Analy- found clear differences in the availability of relevant health significance of nutrient gaps. Nutrition Reviews:
sis (CONGO), collates all relevant data points 2021; 79(S1): 4-15. https://doi.org/10.1093/
data by country and micronutrient. Furthermore, nutrit/nuaa140.
from a given region and provides clear criteria important nutrient gaps were identified in iron,
White, M J, Beal, T, Arsenault, E J, Okronipa, H, Hinnouho,
for rating the nutrient gap (as negligible, low, vitamin A, zinc, calcium, vitamin C (South Asia G, Chimanya, K, Matji, J, Garg, A (2021) Micronutrient gaps
during the complementary feeding period in 6 countries
in Eastern and Southern Africa: A Comprehensive Nutrient
© UNICEF / Karel Prinsloo

Children eat a food supplement at a clinic Gap Assessment. Nutrition Reviews: 2021; 79(S1): 16-25.
in Democratic Republic of Congo https://doi.org/10/1093/nutrit/nuaa142
Beal, T, White, M J, Arsenault, E J, Okronipa, H, Hinnouho,
G, Murira, Z, Torlesse, H, Garg, A (2021b) Micronutrient
gaps during the complementary feeding period in South
Asia: A Comprehensive Nutrient Gap Assessment.
Nutrition Review: 2021; 79(S1): 26-34.
https://doi.org/10.1093/nutrit/nuaa144.
Ryckman, T, Beal, T, Nordhagen, S, Chimanya, K, Matji, J
(2021a) Affordability of nutritious foods for
complementary feeding in Eastern and Southern Africa.
Nutrition Review: 2021; 79(S1): 31-51.
https://doi.org/10.1093/nutrit/nuaa137.
Ryckman, T, Beal, T, Nordhagen, S, Murira, Z, Torlesse, H
(2021b) Affordability if nutritious food for complementary
feeding in South Adia. Nutretion review. 2021; 79(S1): 52-
68. https://doi.org/10.1093/nutrit/nuaa139.

1
Morris, S S, Garg, A, Black, E R Assessing the nutrient gap
and the affordability of complementary foods in Eastern
and Southern Africa and South Asia. Nutrient Reviews. 2021;
79 (S1): 1-3. https://doi.org/10.1093/nutrit/nuaa149.
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.......................................................................................................................................

Post-discharge interventions for children rodevelopmental scores in one domain and meta-
analysis showed an associated reduction in post-
hospitalised with severe acute malnutrition discharge mortality (RR: 0.36; 95% CI: 0.15, 0.87).
Research snapshot1 Other interventions of potential relevance
that were not incorporated here as they were ap-

I
t is well-evidenced that children hospitalised Interventions identified in the papers included plied to outpatient SAM recoverees include cash
with severe acute malnutrition (SAM) have the provision of zinc, probiotics, antibiotics, pan- transfers, water treatment packages and consid-
poor long-term outcomes following discharge creatic enzymes and psychosocial stimulation. eration of optimal timing of antiretroviral therapy
including high rates of mortality, relapse to initiation in HIV-infected children.
There was no evidence that zinc reduced mor-
acute malnutrition, risk of infection and impaired
tality post-discharge in the single study reporting The authors summarise that there is currently
cognitive development. While this evidence has
deaths. The two studies that gave probiotics did limited evidence to inform post-discharge inter-
resulted in calls for better support for children
not find significant differences in post-discharge ventions in children recovered from complicated
following discharge from inpatient treatment,
mortality, however the meta-analysis of the com- SAM despite the urgent need for evidence. Only
there is currently minimal guidance and evidence
bined data suggested that prebiotics did reduce 10 trials from the past five decades met the in-
on how to achieve this.
mortality (relative risk (RR): 0.72; 95% CI: 0.51, clusion criteria. Several biomedical and psy-
This systematic review and meta-analysis ex- 1.00; P = 0.049). Antibiotics reduced post-discharge chosocial approaches show promise but further
amined the types and effectiveness of post- infectious morbidity but did not reduce mortality. exploration is required.
discharge interventions for improving outcomes Pancreatic enzyme supplementation reduced in-
in children 6-59 months of age recovered from patient mortality (37.8% compared with 18.6%, 1
Noble, C C, Sturgeon, J P, Bwakura-Dangarembizi, M, Kelly, P,
Amadi, B and Prendergast, A J (2021) Postdischarge
complicated SAM. Peer-reviewed and grey literature P < 0.05) but there was no evidence of benefit on
interventions for children hospitalized with severe acute
was searched in December 2019; 15 articles were post-discharge outcomes. All studies providing malnutrition: a systematic review and meta-analysis. The
found, representing 10 studies in seven countries. psychosocial stimulation found improved neu- American journal of clinical nutrition, 113(3), pp.574-585.

Conceptual framework of food systems for both access to information and as potential buyers
of healthy food products, and intra-household
children and adolescents Research snapshot 1 dynamics. The framework also conceptualises
the dynamic linkages between the determinants,
influencers and drivers of food systems. The

M
alnutrition in all its forms – un- as key stakeholders. Given the unique nutritional
structure of the framework is based on that of
dernutrition, micronutrient defi- needs of this group and their susceptibility to
the more general food systems conceptual frame-
ciencies and overweight/obesity – malnutrition, food system transformations need work developed by the ‘high level panel of experts
affects all age groups across the to explicitly incorporate this angle. on food security and nutrition’ committee. The
world and children and adolescents are especially
This paper proposes a new conceptual frame- framework highlights the diversity of actors that
vulnerable. In low- and middle-income countries,
work (the ‘Innocenti Framework’) to better ar- influence the diets of children and adolescents
only one quarter of young children receive a
ticulate how the diets of children and adolescents and calls for greater emphasis on the governance
diverse diet necessary for growth and development.
are shaped by food systems. The food system de- and accountability mechanisms of these actors
Access to healthy and nutritious food is important
terminants within the framework include food in order to ensure access to nutritious, safe and
throughout the life course and there is growing
supply chains, external food environments, per- affordable food.
recognition that the current ‘food system’ needs
radical transformation to ensure nutritious, safe, sonal food environments and the behaviours of 1
Raza, A, Fox, E L, Morris, S S, Kupka, R, Timmer, A, Dalmiya, N
affordable and sustainable diets for all. However, caregivers, children and adolescents. Examples and Fanzo, J (2020) Conceptual framework of food systems
much of the discussion on transforming food of diet determinants specific to children and for children and adolescents. Global Food Security, 27,
systems has not included children and adolescents adolescents include the influence of schools, on p.100436.

The proposed ‘Innocenti Framework’

which outlines how the diets of
adolescents and children are
shaped by food systems

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72
.......................................................................................................................................

Fortified blended flour supplements displace plain

cereals in feeding of young children Research snapshot 1

G
rowth faltering often occurs during To explore this issue, the authors reanalysed indicating that those who consumed SC+ con-
the period of complementary feeding, data from a trial comparing the cost-effectiveness sumed similar amounts of fruits and vegetables
from six to 20 months of age, when of three FBFs and one LNS in the prevention of as those in the other study arms, although of
the child is transitioning from ex- stunting and wasting among infants aged seven different types. Consumption of other foods,
clusive breastfeeding to a family diet. In the to 23 months in Burkina Faso. Using logistic dietary diversity and breastfeeding did not differ
Sahel, most complementary foods are composed regression, the differential effects of these sup- significantly.
of cereals that are often combined with sugar plementary foods on the displacement of breast-
Evidence from this study that FBFs displace
and water to make a porridge. This may provide feeding or household complementary foods household cereals but not other more nutrient-
sufficient dietary energy but lacks the protein, were explored and which specific food groups dense foods may assuage concerns that supple-
fats and micronutrients needed for optimum were displaced was investigated. mentary foods have limited effectiveness due to
child growth and development. Lipid-based nu-
Supplementation with FBFs displaced house- the displacement of household foods. Given the
tritional supplements (LNS) and fortified blended
hold cereal consumption significantly when small stomach size and limited feeding time of
flours (FBF) are widely used to increase the nu-
compared to supplementation with LNS. The infants, this displacement of unfortified household
trient density of children's diets in supplementary
relationship was strongest for two of the three cereals by fortified flours may be beneficial for
feeding programmes but their effectiveness can
FBFs tested (CSB+ w/oil and CSWB w/oil). infants in the meeting of their nutrient needs.
be modified by the displacement of other foods:
if supplements replace plain household cereals While there was some evidence that the third
but not more nutrient-dense family foods, the FBF tested (SC+) may also displace more vitamin
1
Cliffer, I R, Masters, W A, Rogers, B L (2020) Fortified
nutrient-density of the diet would improve; if, A-rich fruits and vegetables than the LNS product
blended flour supplements displace plain cereals in feeding
however, supplements displace nutrient-dense tested, children who consumed SC+ were also of young children. Matern Child Nutr. e13089.
foods, the diet quality could worsen. more likely to eat other fruits and vegetables https://doi.org/10.1111/mcn.13089

Effectiveness of breastfeeding support packages in low- and middle-

income countries for infants under six months Research snapshot 1

S
mall and nutritionally at-risk infants of these focused on the general infant population. ventions of interest were breastfeeding support
under six months of age, defined as This review aims to address the evidence gap packages. Studies reporting breastfeeding prac-
those with wasting, underweight or other on how to best support breastfeeding in a sub- tices and/or caregivers’/healthcare staffs’ knowl-
forms of growth failure, are at high risk population of small and nutritionally at-risk in- edge/ skills/practices for infants under six months
of mortality and morbidity. The World Health fants under six months of age in low- and mid- from LMICs were included. Of 15,256 studies
Organisation 2013 guidelines on severe acute dle-income countries (LMICs) by synthesising initially identified, 41 were eligible for inclusion,
malnutrition highlight the need to effectively evidence on existing breastfeeding support pack- representing 22 geographically diverse LMICs.
manage this vulnerable group but programmatic ages for all infants under six months of age. Interventions were mainly targeted at mother-
challenges are widely reported. At the core of infant pairs and only 7% (n = 3) studies included
these guidelines is support for breastfeeding. The authors searched PubMed, CINAHL, at-risk infants. Studies were rated to be of good
Previous systematic reviews have examined in- Cochrane Library, EMBASE and Global Health or adequate quality. Twenty studies focused on
terventions to promote breastfeeding but most databases from inception to 18 July 2018. Inter- hospital-based interventions, another 20 on
community-based and one study compared
both. Among all interventions, breastfeeding
counselling (n = 6) and education (n = 6) support
packages showed the most positive effect on
breastfeeding practices followed by breastfeeding
training (n = 4), promotion (n = 4) and peer
support (n = 3). Breastfeeding education support
(n = 3) also improved caregivers’ knowledge/
skills/practices.
The identified breastfeeding support packages
can serve as ‘primary prevention’ interventions
for all infants under six months in LMICs. For at-
risk infants, these packages need to be adapted
and formally tested in future studies. Future work
should also examine the impacts of breastfeeding
support on anthropometry and morbidity outcomes.
© WFP/Will Baxter

1
Rana, R, McGrath, M, Sharma, E, Gupta, P, Kerac, M (2021)
A mother breastfeeds her Effectiveness of Breastfeeding Support Packages in Low-
malnourished 14-day-old son and Middle-Income Countries for Infants under Six Months:
at a health centre in Somalia A Systematic Review. Nutrients. 2021; 13(2):681.
https://doi.org/10.3390/nu13020681
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73
 Summaries
Research .............................................................
Impact of maternal mental health on recovery
from severe acute malnutrition in Malawi
MSc summer project1
By Mphatso Nancy Chisala
Mphatso Chisala is a medic by profession with an interest in the prevention and treatment of
child malnutrition. She recently completed a Master’s degree in public health nutrition at the
London School of Hygiene and Tropical Medicine (LSHTM) which is where she carried out this
work. She is currently a research associate with the Malawi Liverpool-Wellcome Trust Research
Programme under the Paediatric and Child Health Research Group.

As previously mentioned, there has been

MALAWI little research to assess the relationship between
maternal mental health and child outcomes in
What we know: Women face the biggest burden of mental illness globally. Maternal low and middle-income countries despite evi-
mental illness affects childcare practices which is one of the underlying causes of dence that mental health problems are four
childhood malnutrition. times higher and more persistent in developing
countries compared to developed countries
What this article adds: This article is a follow up study of children in Malawi treated (Bennett et al, 2017). Even so, studies that have
for severe acute malnutrition seven years prior. It adds to the limited literature base on assessed this relationship are usually of short
the relationship between maternal mental health and child health and growth postpartum periods and do not further explore
outcomes in low and middle-income countries. The study shows the complex the effects of maternal mental health in later
relationship between maternal mental health and child health, as the study finds no childhood. Additionally, no studies have further
association between mothers at high risk of common mental disorders and children’s explored the relationship between mothers at
nutritional status. There are several possible contributing factors to this finding risk of a CMD and the recovery of children
including the study methodology, loss to follow-up, the age of the children, shared with severe acute malnutrition (SAM). Maternal
parenting and the socio-economic context. The study did find that mothers reporting mental health has been identified as one of the
intimate partner violence and low social support are at a high risk of reporting nutrition-sensitive interventions that has the
symptoms of depression and anxiety. The complexity of the interaction between potential to optimise child growth and devel-
maternal mental health and child nutritional status highlights the need for holistic opment. Despite the increasing attention to
approaches when addressing these issues. interventions on the immediate causes of mal-
nutrition, there are still gaps in addressing ma-
ternal mental illness as a risk factor for child
malnutrition in settings like Malawi.
Background of reproductive age (Rehm & Shield, 2019).
Maternal mental illness has severe negative The Chronic Diseases Outcome after Severe
Malnutrition is one of the leading causes of
long-term effects on both mothers and infants. Acute Malnutrition (ChroSAM) explores the
mortality and morbidity amongst children
Mothers with a mental illness are more likely hypothesis that maternal illness affects child
under the age of five years (under-5) in Malawi
to have poor mother-child interaction and growth beyond the early years of life. It also
(Ministry of Health et al, 2015). Over a third
poor parenting practices resulting in poor explores the potential impact of maternal de-
of children under-5 (36%) are stunted and 12%
childcare and feeding practices and unstimu- pression/anxiety on the recovery of children
are underweight (NSO Malawi and ICF, 2015).
lating environments, indirectly resulting in who had been treated for malnutrition after
Additionally, 33% of deaths in children un-
poor child growth. However, the effects of ma- discharge. This presents an opportunity for
der-5 are associated with malnutrition (UNICEF,
ternal illnesses, especially depressive symptoms, untapped potential for interventions that aim
2011). It is estimated that approximately 10%
on child growth have been given less attention at improving child outcomes in women at risk
of Malawi’s Gross Domestic Product (GDP) is
in developing countries, especially in sub-Sa- of CMDs. This is important as it contributes
lost due to childhood malnutrition (~MKW
haran Africa (SSA). The prevalence of a common to the existing literature since there is now in-
147 billion/USD597 million per year) of which
mental disorder (CMD) amongst Malawian creasing interest in addressing maternal mental
60% is from reduced potential productivity
women is up to 30%, two times higher than health as a platform for improving child growth
due to nutrition related mortality and morbidity
the weighted prevalence of maternal mental and health outcomes.
(Ministry of Health et al, 2015).
disorders in the SSA region (Stewart et al,
The ChroSAM study is a prospective cohort
Mental disorders are the fifth leading cause 2014). Depressive and anxiety disorders are
study that followed 320 children admitted for
of global disability-adjusted life years (DALYs) the fourth leading cause of morbidity in Malawi
the treatment of SAM seven years prior in
and account for 32% of years lived with disability with the majority affecting women (Stewart et
Malawi. The aim of the ChroSAM study was to
(Rehm & Shield, 2019). Over the past three al, 2014). Maternal mental illness and childhood
assess the long-term effects of malnutrition on
decades, mental health disorders have increased undernutrition share similar risk factors in-
significantly (by 36.7%) with the highest burden cluding poverty, increased disease burden, il- 1
Summary of full MSc summer project paper which is
of these mental disorders being among women literacy, unemployment and food insecurity. available on request from the author.
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 Research Summaries
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children previously exposed to SAM. A secondary (53%) were female. The overall HIV prevalence mental health as was seen in Bangladesh and
analysis was conducted of the ChroSAM findings amongst the children was 14% although 28% of Vietnam (Nguyen et al, 2018). Similarly, a com-
to explore the potential association between the participants had an unknown HIV status. munity based prospective study in Peru, India,
mothers at risk of a CMD and the recovery of Cases had the highest HIV prevalence of 27% Vietnam and Ethiopia found a strong and per-
children with SAM in this setting. compared to the sibling and community control sistent association between mothers at risk of
(4% and 3% respectively, p-value <0.001). CMD and child growth at one, five and eight
Methodology years in India and Vietnam unlike in Ethiopia
The ChroSAM study followed 320 children who Overall, there was a high prevalence of un-
or Peru (Bennett et al, 2017).
were admitted for treatment for SAM while derweight and stunting amongst the study pop-
under five years of age at Queen Elizabeth Hos- ulation (46% and 36% respectively). Additionally, When interpreting the absence of association
pital, Malawi, seven years prior to the analysis. cases had a significantly lower WAZ, HAZ and in the Ethiopian studies, the authors suggested
The study also included 219 siblings of these BAZ score compared to the sibling control and that the shared parenting in such a setting prob-
cases and 184 children within the community these were also much lower than for community ably dilutes the negative effects of a CMD on
as comparison groups. The community controls controls. child growth compared to other settings like
were randomly selected by spinning a bottle South Asia. Additionally, the timing when as-
There was no association between SRQ-20
close to the cases’ house and matched by sex sessing the effects of maternal mental illness on
and nutritional status even after adjusting for
and age (±12 months). Multiple data on risk child growth affects the association between a
parity, maternal age, maternal employment, in-
factors associated with malnutrition was collected CMD and child nutrition status. Studies assessing
timate partner violence and child’s sex and HIV
at this follow-up including information about the impact of maternal depression in children
status. However, mothers who had a high SRQ
maternal mental health status. Amongst this over 12 months are less likely to see an impact
score had a two-fold increase in the odds of re-
cohort, 450 main carers/mothers were assessed of a CMD on growth as, beyond this point in
porting intimate partner violence (OR 2.5 95%
for a CMD using the World Health Organization settings like Malawi, childcare is not entirely
CI 1.5-4.4, p-value <0.001) and a four-fold in-
(WHO) self-reported questionnaire (SRQ-20). dependent on the mother but also her family
crease in the odds of having low social support
members/communities (Stewart, 2007). Addi-
The SRQ-20 is a screening tool developed by (OR 4.7 95% CI 1.6-13.9 p-value<0.001). This
tionally, the socio-economic context plays a
WHO to assess the risk of a CMD, including strong association was seen amongst mothers
major role in the association between maternal
depression and anxiety/stress, in communities to cases for both intimate partner violence and
mental health and infant growth. In areas with
in developing countries. The SRQ-20 has 20 social support but was lost amongst the com-
high food insecurity and poverty rates, any as-
yes/no questions related to the recent wellbeing munity controls. There was also some association
sociation between maternal mental health and
of the respondent in the past four weeks. A between having a high SRQ-20 score and being
any measurable impact may be masked/diluted
Chichewa version of SRQ-20 has been translated HIV positive or having a female child.
by these factors that are associated with both
and validated for use in Malawi (Stewart et al, Discussion undernutrition and depression. Overall, the
2009). The questionnaire suggested cut-off points This study showed no association between moth- different findings in the different settings are
of ≤ 8/20 as low risk for a CMD and >9/20 ers at a high risk of a CMD and children’s nutri- attributed to different study methods such as
scores as increased risk of a CMD requiring tional status seven years after treatment for clinical vs population-based studies, different
further referral or assessments. Children’s nu- SAM. Results do, however, highlight that mothers CMD measurement scales and times and different
tritional status was assessed according to weight- reporting intimate partner violence and low sample sizes.
for-age z-score (WAZ), height-for-age z-score social support are at a high risk of reporting
(HAZ) and body mass index-for-age z-score It is also important to consider that only
symptoms of depression and anxiety.
(BAZ) using WHO growth standards. In addition 47% of the cases were identified in the ChroSAM
to basic child characteristics (including age, sex, In a cross-sectional study assessing mental study with the major reason for loss to follow-
birth order and HIV status), information was disorders amongst women with young infants up being death from nutrition-related illnesses.
also collected on the mothers’ general wellbeing in rural Malawi, Stewart et al found that infants Considering that a major loss/traumatic event
including HIV status, education levels and the of mothers with a CMD had significantly lower like the loss of a child is a strong risk factor for
mothers’ ability to read or write. nutritional indices compared to infants of a CMD, mothers of surviving children are less
mothers without a CMD (Stewart et al, 2014). likely to present with symptoms of a CMD com-
Findings Similarly, a meta-analysis undertaken to assess pared to those that were lost to follow-up. This
A total of 295 out of 450 women who were ad- the effect of maternal mental health on child could potentially dilute the association between
ministered the SRQ-20 questionnaire were moth- nutrition in developing countries found a mod- a CMD and the nutrition status of children.
ers of children previously exposed to SAM (cases) erate association with children of depressed
The lack of association in this study emphasises
and 155 were mothers of community control mothers having 1.5 times the odds of stunting
that the pathways and interactions for the asso-
children. A total of 83 out of 450 of mothers and underweight compared to children of moth-
ciation between malnutrition and mental illness
(18%) were at risk of having a CMD, of which ers who were not depressed (Surkan et al, 2011).
are complex and should therefore be addressed
56 (67%) were mothers of cases. About one in However, some studies in South Africa and
holistically. In settings like Malawi that have
four mothers (26%) reported having experienced Ethiopia, which are similar settings to Malawi,
high rates of poverty and food insecurity, which
intimate partner violence in the past. Additionally, found no association with maternal mental
are both important risk factors for undernutrition
two-thirds of mothers (63%) reported having health and child growth even after controlling
and maternal mental disorders, multi-sector in-
available social support and only 4% of mothers for all factors associated with both (Nguyen et
terventions are needed that approach these issues
reported having low social support. There was a al, 2014).
holistically. Context-specific, targeted interventions
high prevalence of HIV status among mothers
Interestingly, studies in Asia have consistently aimed at addressing intimate partner violence
(30%), of which the majority were mothers to
found a strong and significant association between have the potential to reduce the risk of a CMD
cases compared to mothers of community controls
maternal mental health and child growth (Nguyen and thus improve childcare practices among
(37% vs 16%, p-value <0.001). More mothers of
et al, 2018; Saeed et al, 2017; Surkan et al, 2011). mothers. As social support plays a major role in
community controls had experienced intimate
In a multicentre study assessing the impact of childcare, mothers’/carers' support should be as-
partner violence compared to mothers to cases
maternal mental health in Ethiopia, Bangladesh sessed in communities and primary health care
(34% vs 21%, p-value 0.019).
and Vietnam, despite the high rates of stunting settings. This would also require training primary
The mean age for the children in the study and undernutrition seen in Ethiopia, there was health care and community health workers to
was 11.2 years (+/- 7.8) and 410 of children no association between stunting and maternal identify mothers at risk of depression.
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Research Summaries
References
Bennett, I, Schott, W, Krutikova, S, Jere, R and Population, T Nguyen, P H, Saha, K K, Ali, D, Menon, P, Manohar, S, Mai, L Stewart, R C (2007) Maternal depression and infant growth -
(2017) Maternal mental health and child growth and T, Rawat, R and Ruel, M T (2014) Maternal mental health is a review of recent evidence. Maternal & Child Nutrition, 3(2),
developmental in four low and middle income countries. J associated with child undernutrition and illness in 94–107. https://doi.org/10.1111/j.1740-8709.2007.00088.x
Epidemiol Community Health, 70(2), 168–173. Bangladesh, Vietnam and Ethiopia. Public Health Nutrition,
Stewart R C, Kauye F, Umar E et al (2009) Validation of a
https://doi.org/10.1136/jech-2014-205311.Maternal 17(6), 1318–1327. https://doi.org/10.1017/ Chichewa version of the Self-Reporting Questionnaire (SRQ)
Black, M M, Baqui, A H, Zaman, K, ElArifeen, S and Black, R E S1368980013001043 as a brief screening measure for maternal depressive
(2009) Maternal depressive symptoms and infant growth in Nguyen, P H, Friedman, J, Kak, M, Menon, P and disorder in Malawi, Africa. J Affect Disord. 2009;112(1-3):126-
rural Bangladesh 1–4. American Journal of Clinical Nutrition, 89, Alderman, H (2018) Maternal depressive symptoms are 134. doi:10.1016/j.jad.2008.04.001
951–957. https://doi.org/10.3945/ajcn.2008.26692E.MATERNAL negatively associated with child growth and Stewart, R C, Umar, E, Tomenson, B and Creed, F (2014) A
Bunn, J, Harrington, R, Iqbal, Z, Rahman, A and Lovel, H development: Evidence from rural India. Maternal and cross-sectional study of antenatal depression and
(2004) Impact of Maternal Depression on Infant Nutritional Child Nutrition, 14(4), 1–9. https://doi.org/10.1111/ associated factors in Malawi. Archives of Women’s Mental
Status and Illness. Archives of General Psychiatry, 61(9), 946. mcn.12621 Health, 17(2), 145–154. https://doi.org/10.1007/s00737-013-
https://doi.org/10.1001/archpsyc.61.9.946 Rehm, J and Shield, K D (2019) Global Burden of Disease 0387-2
Ministry of Health, World Food Programme, United Nations: and the Impact of Mental and Addictive Disorders. Current Surkan, P J, Kennedy, C E, Hurley, K M and Black, M M (2011)
Economic Commission for Africa, Development, & The New Psychiatry Reports, 21(2), 10. https://doi.org/10.1007/ Maternal depression and early childhood growth in
Partnership for Africa’s Development (2015) The Cost of s11920-019-0997-0 developing countries: systematic review and meta-analysis.
Hunger in Malawi: The Social and Economic Impact of Child Saeed, Q, Shah, N, Inam, S and Shafique, K (2017) Maternal Bulletin of the World Health Organization, 89(8), 608-615E.
Undernutrition in Malawi. May. depressive symptoms and child nutritional status: A cross- https://doi.org/10.2471/BLT.11.088187
National Statistical Office (NSO) [Malawi] and ICF (2015) Malawi sectional study in socially disadvantaged Pakistani UNICEF (2011) Malawi Nutrition Report. UNICEF Data, 000,
2015-16 Demographic and Health Survey. In The DHS Program. community. Journal of Child Health Care, 21(3), 331–342. 18–19. https://www.unicef.org/innovation/stories/
https://dhsprogram.com/pubs/pdf/FR319/ FR319.pdf https://doi.org/10.1177/1367493517721063 nutritional-surveillance-malawi

© WFP/Will Baxter
A child eats a fortified food
to help tackle malnutrition

Response to malnutrition
treatment in low weight-for-age
children: secondary analyses of
ComPAS trial data Research summary1

wasted children. Exploration of practical anthro-

KENYA AND SOUTH SUDAN pometric criteria for identifying children with
WaSt has found that severely low weight-for-age
What we know: Children who are concurrently wasted and stunted (WaSt) have a very high z-score (WAZ) has the highest (>90%) sensitivity
mortality risk but current programmes tend to focus on addressing stunting or wasting, not both. and specificity for identifying these children across
multiple settings (Myatt et al, 2018) and that a
What this article adds: A secondary analysis of moderately and severely wasted children
combination of severely low MUAC (already well
treated in the ‘ComPAS’ trial was undertaken to assess the response to treatment according to
evidenced to identify those at high risk of mortality
weight-for-age z-score (WAZ) and mid-upper arm circumference (MUAC) and the type of
and easy to use) plus a severely low WAZ could
feeding protocol given. The analysis of 4,020 children confirms that WAZ<-3 identifies the
best identify those malnourished children at most
majority of children as WaSt. Those with moderately low MUAC (11.5-12.5 cm) and a severely
risk of dying including those with WaSt and those
low WAZ (<-3), not currently eligible for therapeutic care, respond similarly to treatment when
with a severely low WHZ (Myatt et al, 2019).
provided with a supplementary diet of either one sachet per day of ready-to-use therapeutic However, given that WAZ<-3 is not currently one
food (RUTF) or a standard dose of ready-to-use supplementary food. Their recovery rate of the criteria for admission to therapeutic feeding
(54%) was better than those with severe wasting (19.6%) who were provided with a therapeutic programmes, the intensity of treatment required
diet and slightly worse than others with moderate wasting (59.5%). Children with a severely by this additional group of children and the
low MUAC (<11.5 cm) had similar recovery rates whether they were provided with a standard impact of their inclusion on therapeutic programme
dose of RUTF or a simplified, reduced dosage of two sachets per day. A model that supports caseloads is yet to be evaluated. To help fill this
moderately wasted children with WAZ<-3 with a supplementary dose of lipid nutrients and evidence gap, a secondary analysis of data from a
those with severe wasting with a reduced therapeutic dosage should therefore be explored in recent trial in Kenya and South Sudan (‘ComPAS
order to efficiently reach the majority of children at high risk of mortality. trial’) was conducted.

Methods
both. Current therapeutic feeding programmes The ComPAS trial database includes children
Background with MUAC<125 mm who were treated with
Children who are concurrently wasted and stunted use mid-upper arm circumference (MUAC) <
either a simplified, combined protocol (two
(WaSt) are among the most vulnerable of all mal- 11.5 cm, weight for height z-score (WHZ) <-3
sachets of ready-to-use therapeutic food (RUTF)
nourished children with a higher mortality risk and/or the presence of oedema as independent
per day for severe wasting and one sachet (2092
than either wasting or stunting alone and about a admission criteria. Some children who are severely
12 times greater risk of mortality in the absence wasted and concurrently stunted are included ac- 1
Bailey, J, Lelijveld, N, Khara, T, Dolan, C, Stobaugh, H, Sadler,
of treatment than those with normal anthropometry cording to these criteria but moderately wasted K, Lino Lako, R, Briend, A, Opondo, C, Kerac, M and Myatt, M
(Myatt et al, 2018). Current conventions in policy children who are concurrently stunted will not (2021) Response to Malnutrition Treatment in Low Weight-
for-Age Children: Secondary Analyses of Children 6-59
and practice mean that programmes tend to focus be captured for therapeutic feeding despite having Months in the ComPAS Cluster Randomized Controlled Trial.
on addressing either stunting or wasting, not a similar near-term mortality risk to severely Nutrients, 13(4), p.1054.
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 Research Summaries
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kJ/500 kcal) of RUTF per day for moderate confirmed previous findings that WAZ<-3 iden- Conclusion
wasting) or those treated with standard care tifies the majority of WaSt children. In this In summary, this data argues that children with
(weight-based dosage of RUTF for severe wasting dataset, 1,150 (89.5%) of children with a WHZ a MUAC<125 mm and a WAZ<-3 given a sup-
and one sachet per day ready-to-use supplementary <-2.0 and HAZ <-2.0 (true definition of WaSt) plementary dose of either RUTF or RUSF achieve
food (RUSF) for moderate wasting) (Bailey et al, also had a WAZ <-3.0. The analysis also found a recovery rate comparable to the rate achieved
2020). These two treatment groups allowed for that children in Group 2 (those with moderately by other children with MUAC<125 mm treated
comparison of the response to different intensities low MUAC (11.5-12.5 cm) and a severely low with the ComPAS protocol. Following further
of treatment for children with WAZ<-3. WAZ (<-3)) respond similarly to treatment in research, it may therefore be optimal for wasting
terms of both weight and MUAC gain when programmes seeking to support the highest risk
Children in the dataset were categorised into provided with a supplementary diet of either children to provide a therapeutic product to
the following four groups: 2092 kJ (500 kcal)/day of RUTF or a standard children with MUAC<115 mm and a supple-
• Group 1: MUAC < 11.5 cm and WAZ ≥ -3, dose of RUSF. Their recovery rate (54%) was mentary product to children with WAZ<-3 not
i.e., severely wasted but not WaSt better than those with severe wasting (19.6%) captured by a severely low MUAC. The poor re-
• Group 2: MUAC between 11.5 cm and who received a therapeutic diet and slightly covery rates found in the group of children with
<12.5 cm and WAZ < -3, i.e., moderately worse than others with moderate wasting (59.5%). both severely low MUAC and WAZ suggests
wasted and WaSt that more research is needed into the adequacy
• Group 3: MUAC < 11.5 cm and WAZ < -3, This analysis also confirms the particularly
high vulnerability of Group 3 children (MUAC of current therapeutic protocols for this highly
i.e., severely wasted and WaSt vulnerable group.
• Group 4: MUAC between 11.5 cm and <115 and WAZ <-3) who had the lowest recovery
rate (16.7%) despite being five months older on
<12.5 cm and WAZ ≥ -3.0, i.e., moderately
average than children in Group 1. Children in References
wasted but not WaSt
Group 3 also had the highest proportion of de- Bailey, J, Opondo, C, Lelijveld, N, Marron, B, Onyo, P,
Groups 1 and 3 are already included in faulters (39.4%) and deaths (1.9%) despite re- Musyoki, E N, Adongo, S W, Manary, M, Briend, A and
current therapeutic feeding programmes based ceiving therapeutic food. Children with a severely Kerac, M (2020) A simplified, combined protocol versus
standard treatment for acute malnutrition in children 6–
on MUAC definitions of severe wasting However low MUAC (<11.5 cm) (Groups 1 and 3), 59 months (ComPAS trial): A cluster-randomized
Groups 2 and 4 would not usually qualify for with/without a severely low WAZ (<-3), received controlled non-inferiority trial in Kenya and South Sudan.
therapeutic care under current guidelines al- a reduced dosage of RUTF on average if they PLoS Med, 17(7): e1003192.
though they may be eligible to receive supple- were in the combined protocol arm compared Myatt, M, Khara, T, Schoenbuchner, S, Pietzsch, S, Dolan, C,
mentary feeding if available in their context. to the standard protocol arm. However, despite Lelijveld, N and Briend, A (2018) Children who are both
this, both trial arms had similar recovery rates, wasted and stunted are also underweight and have a high
risk of death: a descriptive epidemiology of multiple
Key Findings although WAZ gain was potentially slower in anthropometric deficits using data from 51 countries.
The analysis, which included 4,020 children, the combined protocol arm. Archives of Public Health, 76, 28.

Commentary on the implications of this analysis from the

perspective of the ENN wasting and stunting (WaSt) project
By Tanya Khara, ENN Technical Director and WaSt Technical Interest Group1 Coordinator

P
ublications from the Wasting and Stunting use supplementary food (RUSF) or ready-to-use verely low MUAC criteria but potentially identified
Technical Interest Group (Myatt et al, therapeutic food (RUTF) was given. via growth monitoring and promotion platforms.2
2018 and Myatt et al, 2019) have high-
The above analysis does not include the group The increased caseload of children if WAZ<-3
lighted the potential of weight-for-age z-
of children who have WAZ<-3 and MUAC greater were to be added to programme admission criteria
score (WAZ) <-3 in identifying children with WaSt
than 125 mm simply because this group was not and the subsequent effects on the health service
at high risk of dying and have suggested that this
included in the original trial and therefore results remain important factors to consider. This analysis
admission criteria be considered for treatment found that, in these settings, WAZ<-3 affected
cannot be extrapolated to all children with WAZ<-
services. What this additional target group would 29% of children in the cohort even though this
3. The analysis also does not allow for exploration
need in terms of intensity of treatment to bring was limited to children with a MUAC<125 mm.
of what happens to this group of interest if they
them out of their high-risk state (i.e., treat the This is an important consideration for any potential
receive other non-lipid supplementary foods,
wasting component of their condition) is highlighted future research into how treatment programmes
such as corn-soy blended flour, no nutrition
by the group as an area requiring further study. may accommodate this group.
counselling or no care, an area that may be the
The findings of the above analysis that members subject of further study. It is also important to For more information, please contact Tanya
of the WaSt TIG collaborated on are promising. note that this dataset was not powered for these Khara at [email protected]
They suggest that the group of children with sub-group analyses specifically so a further analysis
1
https://www.ennonline.net/ourwork/reviews/wastingstunting
WAZ<-3 who also have a mid-upper arm circum- with a larger dataset is warranted. An initiative 2
https://www.ennonline.net/resource/newevidenceintopractice
ference (MUAC) of between 115 mm and 125 to do this, pooling a number of different datasets,
mm (i.e., who would not be included in therapeutic is already underway as a collaboration between References
feeding where MUAC was the only admission cri- Action Against Hunger and the WaSt TIG. Myatt, M, Khara, T, Schoenbuchner, S, Pietzsch, S, Dolan, C,
teria) did respond well to a supplementary dose Lelijveld, N and Briend, A (2018) Children who are both
wasted and stunted are also underweight and have a high
(500kcal/d) of a lipid nutrient supplement delivered The findings also support plans by the WaSt risk of death: a descriptive epidemiology of multiple
as part of the ComPAS protocol. This response, in TIG to test a programme model that seeks to anthropometric deficits using data from 51 countries.
terms of weight and MUAC gain, was comparable support children at highest risk by providing a Archives of Public Health, 76(1), pp.1-11.
to the rate achieved by other children with standard therapeutic protocol to children with Myatt, M, Khara, T, Dolan, C, Garenne, M and Briend, A
(2019) Improving screening for malnourished children at
MUAC<125 mm treated with a ComPAS protocol MUAC<115 mm and trialling a less intense protocol high risk of death: a study of children aged 6–59 months
and was similar irrespective of whether ready-to- to children with WAZ<-3 not captured by the se- in rural Senegal. Public health nutrition, 22(5), pp.862-871.
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 Research Summaries
A market garden for improved
nutrition, source of income and
social cohesion in Burkina Faso
© WFP/Evelyn Fey

Transforming
BURKINA FASO
food systems What we know: A multi-sector approach is essential to ensure nutrition security
for all.
to improve diet What this article adds: A Fill the Nutrient Gap (FNG) analysis was conducted in

affordability: Fill Burkina Faso to identify barriers to adequate nutrition intake and to propose
solutions to improve the availability of nutritious food, as well as its physical access
and its affordability, particularly by the most vulnerable populations. The results
the Nutrient showed that a nutritious diet is not affordable for half of the population. The cost
of an energy sufficient diet is USD1.22 per day for a household of six. The cost of a

Gap analysis in nutritious diet is USD2.59 which represents a proportion of 50% to 110% of the
minimum daily wage (USD2.20) in Burkina Faso. To improve access to nutritious
food and prevent malnutrition in a sustainable manner, the FNG analysis

Burkina Faso identified and modelled the potential impact of activities in several sectors that
target vulnerable households and individuals and are tailored to geographic and
seasonal specificities. Improved homestead gardens could cover 20% of the cost of
Research summary1
household food, milk and fish production could cover 40% while food baskets and
By Sumra Kureishy, Natalie West, combinations of interventions could cover more than 75% of the cost of household
Saidou Magagi and Katrien Ghoos food during the lean season and for displaced persons.

Sumra Kureishy is a Nutrition Officer

at the World Food Programme’s
Introduction study under the direction of the Prime
regional office for West and Central
Burkina Faso has made progress in recent Minister with technical and financial sup-
Africa.
years in improving the health and nutrition port from the World Food Programme
of children under five years of age. The (WFP) and the International Fund for
Natalie West is a Nutrition Officer at national trend in the prevalence of stunting Agricultural Development (IFAD).
the World Food Programme’s and wasting has decreased over the past
Regional Office for West and Central decade (World Bank, 2021). However, Methods
Africa. the country still faces challenges in re- The FNG analysis is a multi-sector food
ducing malnutrition, including micronu- system analysis approach to nutrition.
trient deficiencies. The analytical framework combines a
Saidou Magagi is a monitoring, Cost of the Diet (CoD) analysis with a
evaluation and knowledge With the recurrence of conflict, climate review of secondary data with the aim
management officer for nutrition at shocks and the COVID-19 pandemic, of identifying barriers to adequate nu-
the World Food Programme’s regional communities are experiencing a loss of trition intake and entry points for im-
office for West and Central Africa.
livelihoods resulting in increased food proving the availability of, and physical
Katrien Ghoos is Senior Regional insecurity and malnutrition (OCHA, and financial access to, nutritious foods,
Nutrition Adviser at the World Food 2020). Markets are poorly supplied with particularly by the most vulnerable pop-
Programme’s regional office for West high quality nutritious food, the infra- ulations (Deptford et al, 2017). The ef-
and Central Africa. structure to produce fortified food is in- fective engagement of stakeholders from
adequate and diets remain undiversified. multiple sectors plays a central role in
A multi-sector approach, using a range the analytical process and ensures that
The World Food Programme (WFP) Regional Bureau for the results of the analysis are followed
West and Central Africa (RBD) would like to thank the of policies, strategies and actions, is essential
Government of Burkina Faso for its leadership, to ensure nutritional security for all. To
1
collaboration and commitment to the Fill the Nutrient this end, the Government of Burkina Faso Gouvernement du Burkina Faso, WFP, FIDA (2020)
Fill the nutrient gap, Burkina Faso. Rapport Résumé.
Gap Analysis. WFP RBD would also like to acknowledge conducted a Fill the Nutrient Gap (FNG) Juillet 2020. https://docs.wfp.org/api/ documents/
the collaboration and support provided by the WFP HQ analysis in 2020. The Nutrition Directorate WFP0000122033/download/?_ga=2.31114303.1827
(Pierre Momcilovic, Zuzanna Turowska and Nora Hobbs) of the Ministry of Health conducted this 09335-8. 1617034052-2028320644.1583855001
and WFP Burkina Faso (Kouhin-Néa Doré and Olga Ninon). ...................................................................................
Field Exchange issue 65, May 2021, www.ennonline.net/fex
78
 Research Summaries
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by nutrition-specific and nutrition-sensitive

programmatic and policy decision-making Figure 1 Key interventions to transform food systems and improve affordability
(Bose et al, 2019).

Findings and key interventions

The analysis in Burkina Faso was carried out in
close partnership with IFAD which allowed for
a particular focus on food systems, including
food production. The results showed that a nu-
tritious diet is not currently financially accessible
(affordable) for half of the population. The cost
of an energy sufficient diet is USD1.22 per day
for a household of six people and the cost of a
nutritious diet is USD2.59 which represents
50% to 110% of the minimum daily wage
(USD2.20) in Burkina Faso (IFC, 2019). Within
the household, adolescent girls and pregnant
and lactating women have greater nutritional
needs and thus higher individual costs.
Structural bottlenecks in nutritious food
value chains have been exacerbated by recent
insecurity and conflict resulting in high prices,
especially for nutrient-rich animal source foods.
The impact is felt most acutely in the north of
the country which is supplied by the agricultural
breadbasket of the south. Food prices, the cost
of a nutritious diet and lack of affordability are
highest in the pastoral north and in areas hosting
internally displaced persons (IDPs). Displaced
populations also suffer higher rates of malnu-
trition than host populations and are more food
insecure due to the loss of their agricultural
livelihoods and the frequent sale of assets (in-
cluding livestock). In agricultural areas, cereals
are the dominant production. Investment in
and diversification of production are essential
to improve nutritional status not only in these
areas but in the rest of the country that depends
on these crops. such as the Société nationale de gestion des This project focuses on reorienting food systems
stocks de sécurité alimentaire (SONAGESS), toward the production, processing, distribution
Improving access to nutritious food and
IFAD and FAO. A key lesson learnt from the and consumption of nutritious, physically and
preventing malnutrition in a sustainable manner
FNG analysis in Burkina Faso is that it is im- financially accessible food, including for the
requires a reorientation of interventions toward
portant to strengthen knowledge about the role most vulnerable, in crisis-affected areas. This
food systems and multi-sector collaboration.
of supply chains and the multi-sector nature of includes improving resilience by strengthening
The FNG analysis identified and modelled the
interventions in order to improve availability small-scale farmers and food processing units,
potential impact of activities in several sectors
and access to nutritious food. access to markets and finance. The project will
that target vulnerable households and individuals
also implement social and behaviour change
and are tailored to geographic and seasonal Similar FNG analyses have been conducted
communication activities aimed at increasing
specificities. These interventions include agri- in other Sahelian countries and have led gov-
access to and affordability of locally available
cultural and pastoral production enhancement, ernments, in collaboration with the WFP, to
nutritious foods to improve feeding practices
food assistance, cash transfers and nutritional launch the CRIALCES project – Food Crisis
and prevent malnutrition.
supplementation (Figure 1). The activities mod- Response in the Central Sahel: Nutritional Sup-
elled can contribute directly to nutritious food port and Recovery for Burkina Faso, Niger and For more information, please contact Katrien
intake or through food purchases with the in- Mali (2020-2024) (European Commission, 2021). Ghoos at [email protected].
come generated, thereby reducing the remaining
cost of a nutritious diet and reducing non-
References https://eutf.akvoapp.org/en/project/9213/#summary
affordability. Improved vegetable gardens could
Bose, I, Baldi, G, Kiess, L, de Pee, S (2019) The “Fill the International Finance Corporation (2019) Créer des
cover 20% of the cost of household food and marches au Burkina Faso. Retrieved from:
Nutrient Gap” analysis: An approach to strengthen
milk and fish production could cover 40% while nutrition situation analysis and decision making towards https://www.ifc.org/wps/wcm/connect/f559446a-73de-
food baskets and combinations of interventions multisectoral policies and systems change. Matern Child 423e-9b22-39160d023ed1/201907-CPSD-Burkina-Faso-FR.
Nutr. 2019;15:e12793. https://doi.org/10.1111/mcn.12793 pdf?MOD=AJPERES&CVID=mNf5Hss
could cover more than 75% of the cost of house-
hold food during the lean season and for dis- Deptford, A, Allieri, T, Childs, R, et al (2017) Cost of the OCHA (2020) Central Sahel: Revised Needs and
Diet: a method and software to calculate the lowest cost Requirement Overview. Retrieved from:
placed people. https://www.unocha.org/sites/unocha/files/RNRO%20Cen
of meeting recommended intakes of energy and nutrients
from local foods. BMC Nutr 3, 26. tralSahel%20Oct%202020_EN%20Web.pdf
Conclusion https://doi.org/10.1186/s40795-017-0136-4 World Bank (2021) DataBank: Health, Nutrition and
This analysis created several opportunities in- Population Statistics. Retrieved from:
European Commission (2021) CRIALCES - Réponse à la
cluding strengthening partnerships between CRIse ALimentaire au CEntre Sahel : support nutritionnel https://databank.worldbank.org/source/health-nutrition-
government structures and technical partners et relèvement. Retrieved from: and-population-statistics

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The No Wasted Lives
Research Agenda - tification and management, as well as to inform
and drive the development of policy and program-

Revisited ming. To achieve this, coordinated formal and op-

erational research from diverse contexts including
This article is a summary of the Research Agenda Revisited South Asia is required. Also key is active engagement
published by the No Wasted Lives Secretariat and the Council in the World Health Organization (WHO) guideline
of Research Technical Advice on Acute Malnutrition. development process, engagement across sectors
including health, early childhood development,
maternal mental health and neonatal health and
Background While research on the simplified approaches the dissemination of evidence through global and
April 2021 marked the end of the CMAM 2.0: is encouraging, more evidence is needed. The con- regional networks. These actions are being pursued
Reinventing Community Management of Acute sequences of using MUAC and oedema only for by the MAMI Global Network https://www.en-
Malnutrition grant supported by the Children’s admission and discharge require further evaluation nonline.net/ourwork/research/mami
Investment Fund Foundation that financed the and additional approaches to identify at-risk
children should be explored. More evidence is Alternative formulations
No Wasted Lives initiative. Over the last five years, In recent years, several studies have investigated
the initiative has been recognised for its influence needed on the impact of reduced treatment dosage
on height, body composition and non-anthropo- the effectiveness of alternative formulations of
in moving research forward and addressing knowl- RUTF. These include aims to replace or reduce
edge gaps in the treatment of child wasting, with metric outcomes, as well as on the effects among
different age groups and vulnerable populations. milk and/or peanut content and to change fatty
the Council of Research & Technical Advice on acid profiles. A new guideline on the dairy protein
Acute Malnutrition (CORTASAM) playing a key The Research Agenda Revisited identifies a need
for research from contexts outside of sub-Saharan content of RUTF is underway. Future studies
role in the identification of knowledge gaps. should include an evaluation of the costs and the
Africa, in particular from South Asia which has
In January 2018, CORTASAM and the No the highest global burden of wasting. Promising acceptability of alternative RUTF formulations,
Wasted Lives Coalition published a global Research interventions and modifications to treatment pro- the growth, body composition and neurocognitive
Agenda for Wasting (CORTASAM, 2018). This tocols also require testing at scale and the integration outcomes and whether one product can be used
was based on the results of a research prioritisation of community-based approaches to wasting man- for managing both moderate and severe wasting.
exercise (Angood, Kerac, Black et al, 2021) and agement need to be strengthened. Future research The role of emulsifiers in RUTF should also be
outlined seven priority research areas with high should recognise the continuums between moderate investigated. In addition, the effectiveness of new
potential for improving the effectiveness of, and and severe wasting, as well as between the prevention formulations should be tested in home-based set-
access to, wasting treatment (Box 1). and treatment of wasting, and should also explore tings at operational scale. Lastly, economic, health
effective interventions for wasting prevention. system and environmental implications as well as
In 2019, a Research Landscape Review was the role of the private sector in the development
conducted to evaluate the progress made towards Fluid management in severely wasted and delivery of RUTF should be examined.
the Research Agenda outcomes (CORTASAM, children
2020a). Based on these results, the members of Recent reviews have highlighted the need to Conclusions
CORTASAM identified outstanding gaps and update global guidelines on fluid management Significant progress has been made towards the
published the Research Agenda Revisited in early in children with severe wasting. Further research CORTASAM’s original research priority areas.
2021 (CORTASAM, 2021). The key findings are is needed on which fluids to use and in what cir- However, gaps remain and continued evidence
summarised below. cumstances, as well as on adequate volumes and generation and exploration into innovative ap-
the routes of administering these. proaches are needed. These should prioritise un-
Progress in priority areas of der-researched populations to improve the effec-
research Post-treatment relapse tiveness and scalability of programmes.
Simplified approaches The burden of, and risk factors for, post-treatment
Significant progress has been made in the first relapse across contexts is poorly understood. In More details can be found in the Research
three research areas which are now generally order to generate evidence on relapse, a standardised Landscape Analyses and the Research Agenda
grouped together under the term ‘simplified ap- definition is needed. In 2020, CORTASAM pro- Revisited on the No Wasted Lives Website
proaches’. These encompass expanded admission posed interim guidance for the standard definitions (www.nowastedlives.org).
and discharge criteria to include moderate wasting, of relapse, regression and reoccurrence of wasting
the use of mid-upper arm circumference (MUAC) and called for feedback from researchers and prac- References
and oedema only for admission and discharge, titioners on these (CORTASAM, 2020b). A con- Angood C, Kerac M, Black R et al (2021) Treatment of child
reduced dosage of ready-to-use therapeutic food ceptual framework was also generated to support wasting: results of a child health and nutrition research
the development and testing of effective interven- initiative (CHNRI) prioritisation exercise [version 1; peer
(RUTF), the treatment of moderate and severe review: awaiting peer review]. F1000Research 2021, 10:126
wasting with one product and the involvement of tions to reduce post-treatment relapse (Schaefer
(https://doi.org/10.12688/f1000research.46544.1)
community health workers in wasting management. et al, 2020). There is a large body of ongoing and
CORTASAM (2018) A Research Agenda for Acute
planned research on relapse that should consider
Malnutrition. No Wasted Lives; 2018. (https://www.
Priority research areas according the latest guidance on definitions and measurement. nowastedlives.org/documents-research-agenda)
Box 1 to the 2018 Research Agenda
Management of nutritionally at-risk CORTASAM (2020a) (https://www.nowastedlives.org/
documents-landscape-reviews).
1. Effective approaches to detect, diagnose and mothers and infants
treat wasting in the community CORTASAM (2020b) Guidance to improve the collecting
There has been significant progress in managing
2. Appropriate entry and discharge criteria for and reporting of data on relapse in children following
wasting treatment to ensure optimal outcomes at risk mothers and infants under six months of treatment in wasting programmes. 2020. (https://www.
3. Reduced dosage of ready-to-use therapeutic food age through the piloting and implementation of nowastedlives.org/documents-relapse-statement)
for the treatment of wasting the C-MAMI tool in several contexts and, more
4. Effective treatment of diarrhoea in children with CORTASAM (2021) The Research Agenda- Revisited. 2021
recently, remodelling of the tool as the MAMI (https://www.nowastedlives.org/documents-research-
severe wasting
5. Rates and causal factors of post-treatment care pathway. A body of evidence is also being agenda-revisited)
wasting relapse across contexts built on criteria to identify at risk infants using Emergency Nutrition Network https://www.ennonline.net/
6. Identification and management of small and weight-for-age (WAZ) and MUAC, as well as ourwork/research/mami
nutritionally at-risk infants under six months of feeding, clinical and maternal indicators.
age and their mothers Schaefer R, Mayberry A, Briend A, Manary M, Walker P, Stobaugh
7. Alternative formulations of ready-to-use foods for H, Hanson K, McGrath M, Black R (2020) Relapse and regression
However, there is a need for coordinated, evi- to severe wasting in children under 5 years: A theoretical
wasting
dence-based global guidance to advance case iden- framework. Maternal and Child Nutrition 2020;e13107.
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Seasonality of
acute malnutrition
and its drivers:
A case study from
eastern Chad
By Anastasia Marshak, Gwenaëlle Luc,
Anne Radday and Helen Young

©Gwenaelle Luc
Anastasia Marshak is a Senior
Researcher at the Feinstein
International Center at Tufts
Women getting water in Sila, Chad 2019
University. She has over 10 years of
experience working in humanitarian
contexts with a focus on study
design and methods, evaluating impact on nutrition
and food security outcomes.

Gwenaëlle Luc is a social

SILA PROVINCE, CHAD
anthropologist who currently works What we know: The existing evidence base on acute malnutrition seasonality is
for the global Food Security Cluster,
limited and fraught with methodological constraints resulting in the
led by the Food and Agriculture
Organization and World Food
predominance of the assumption that acute malnutrition peaks during the ‘lean
Programme, steering efforts to season’ or ‘hunger gap’.
address food crisis amongst humanitarian,
development and peace actors.
What this article adds: This article summarises findings from a 23-month
study following approximately 200 children age 6-59 months across 89
Anne Radday is the focal point for households in eastern Chad. Results indicate that there are two peaks of acute
research communications and malnutrition. The primary and larger peak occurs at the start of the rains
knowledge management at the corresponding to the first weeks of intermittent rain. Acute malnutrition
Feinstein International Center, Tufts
prevalence declines during the rainy season as food insecurity increases and
University. She has more than 15
years of experience in marketing and
peaks again, but only slightly, immediately before the harvest. The results
communications, knowledge management, highlight the need to reconsider programme focus, design, timing and
knowledge product development, organisational evaluation in light of the possible multiple seasonal peaks of acute
strategy and external relations. malnutrition, likely corresponding to a set of different drivers.
Helen Young is a Professor at the
Friedman School of Nutrition
Science and Policy, Tufts University, Background one peak or frequently aggregating and/or
where she directs Feinstein’s Previous evidence has highlighted the comparing prevalence data across a small
Research Program on Nutrition, role of seasonality in acute malnutrition number of seasons (Marshak et al, 2020).
Livelihoods and Conflict. Over the where changes in environmental conditions Recently, there have been renewed efforts
past 35 years her research has contributed to
trigger the underlying and immediate to better understand the seasonality of
practical guidelines, policy changes, minimum nutrition outcomes (FAO & Tufts, 2019;
drivers of acute malnutrition and lead to
standards, institutional learning and capacity Young, 2020). This article summarises a
development. increases in prevalence. In contexts with
one main rainy season and a population research study that aimed to describe sea-
The authors would like to express thanks for the that partially depends on farming for sonal patterns of and relationships between
support of their partner, Concern Worldwide, their livelihood, as is in Chad and much acute malnutrition and some of the po-
especially Chris Pain, Franck Flachenberg, Amanda of the Sahel, there is a predominant nar- tential drivers including water contami-
Yourchuck, Kate Golden, Isaac Gahungu, Laurent
rative that acute malnutrition peaks once nation and livestock management among
DeRuyt, Baba Lassou, Abdoulaye Danni and Bella communities in eastern Chad in order to
during the rainy season (the so-called
Hodgkinson. In addition, the authors thank the inform and influence programmes and
quantitative and qualitative data collection team
‘hunger gap’ or ‘lean season’) as a result
of a combination of increasing food inse- policies that address persistent acute mal-
and the coliform analyst. This research would not nutrition in the region.
have been possible without the respondents who, curity and disease burden, particularly
month in and month out, continued to share malaria (Chambers et al, 1981; Devereux,
valuable information about their lives and 2012). This prevailing assumption is so 1
Marshak, A., Luc, G., Radday, A., and H. Young (2021)
communities and to donate their precious time to strong in literature that seasonality is “Seasonality of Acute Malnutrition and its Drivers in
the research. Finally, we would like to thank Irish Aid more often assumed than documented. Sila, Province Chad: a mixed methods analysis”.
for their generous funding. Feinstein International Center, February 2021
However, the evidence base is relatively https://fic.tufts.edu/research-item/seasonality-of-
limited, only testing for the possibility of malnutrition-in-eastern-chad/

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 Research Summaries
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Predicted prevalence and confidence intervals for wasting by month and season Methodology
Figure 1 in Sila Province, Chad Concern Worldwide and Tufts University col-
laborated to conduct a two-year mixed-methods
study in the Sila Region of eastern Chad based
on a panel survey and qualitative interviews.
Eight villages were purposely selected for the
study based on Concern Worldwide’s ability to
access these throughout the year. Eighty-nine
households with at least one child under 59
months of age were then randomly selected. The
study followed the same households and their
children monthly from May 2018 through to
March 2020. As children aged out of the study
(i.e., became over 59 months of age) they were
removed from the study, while children who
aged into the age criteria (i.e., turned six months
of age) were added. By March 2020, the study
included 212 individual children. In addition,
data was collected on coliform contamination
(a measure of the amount of fecal matter in the
water) across the water chain for the 89 house-
holds. We used mixed-effects harmonic regression
to analyse the seasonality of child wasting (weight-
for-height z-score <-2 standard deviations). Qual-
itative data collection including focus groups,
key informant interviews and semi-structured
individual interviews was carried out in August
2018 and May/June 2019 – times that correspond
to the two hypothesised peaks of wasting.

Table 1 Basic, immediate and underlying drivers of acute malnutrition, by season in

Sila Province, Chad
Key findings
Seasonal peaks in wasting
Season We identified two peaks of acute malnutrition
Intermittent Rainy Harvest Cool Hot and within a calendar year (Figure 1). The highest
rain and dry dry peak was in May, corresponding to the locally
Basic Environment Rainfall identified season of rushash, characterised by
Drivers intermittent rainfall that lasts for approximately
Temperature
three weeks prior to the start of the rainy
Vegetation
season. We then saw a decline in the prevalence
Livelihoods Livestock close to of acute malnutrition during the rainy season
communities
itself followed by a smaller secondary peak in
Farmer-herder conflict October, immediately prior to the harvest.
Women’s workload These findings highlight that the previously
Move to temporary commonly held assumption around seasonality
settlements is not always accurate and, while the secondary
Underlying Food Food insecurity acute malnutrition peak corresponds to the
drivers insecurity timing of high food insecurity and malaria
risk, both the presence of the first peak and
Inadequate Less time with children
social and the improvement in wasting that occurs during
care Poor hygiene the rainy season indicates that food security
environment behaviours and malaria cannot be the main drivers of the
Insufficient Poor health seeking first peak during rushash. This seasonal pattern
health behaviour may be generalisable to the greater Sahel region
services and more broadly as the presence of two peaks in
Poor water access
unhealth wasting is consistent with findings from a
environment Sharing water with recent analysis of half a million child observa-
animals
tions over 15 years of SMART surveys across
Animal disease the Sahel (Venkat, 2021).
Immediate Food intake Poor milk access
Drivers When exploring the basic, immediate and un-
Reduced breastfeeding derlying drivers of acute malnutrition, clear
Morbidity Malaria seasonal patterns emerge. As Table 1 depicts,
Respiratory illness all the drivers identified through both the qual-
itative and quantitative data collection appear
Diarrhoea
to be seasonal. Findings suggest that the main
Acute Malnutrition peak of acute malnutrition prior to the start of
Note: darker colors indicate that a driver is a greater problem during the season compared to lighter the rains corresponds to limited water access,
colors. Blank cells indicate the driver was not identified by either qualitative or quantitative data. an increased concentration of animals at water
sources and hence increased sharing of water
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foster greater efficiency across programmes as

it would allow organisations to focus on specific
drivers at specific times of the year, tailoring
programmes and messaging accordingly.
Monitor and evaluate key outcomes
by season
The seasonality of acute malnutrition and its
drivers also has implications for data collection,
be it the annual timing of SMART surveys,
routine programme monitoring or general eval-
uations of programme impact on child nutrition.
Mistiming data collection could result in either
an under or over-estimation of nutrition outcomes
as well as the programme impact on those out-
©Gwenaelle Luc

comes. For example, in Chad, an evaluation of

food security programmes on nutrition outcomes
Cattle herd in Sila, Chad, 2019 should occur at the end of the rainy season
when that driver is likely to be most critical,
while an evaluation of a programme on hygiene
resources by animals and humans resulting in programmes and policies could be targeting the and sanitation is likely to show the greatest
the consumption of contaminated water and wrong driver, or the right driver at the wrong impact on nutrition at the end of the dry season.
decreased absorption of nutrients in children. time, resulting in significantly lower impact on Furthermore, just as with seasonal programme
The secondary and smaller wasting peak, im- acute malnutrition as well as wasting resources. implementation, focusing on monitoring and
mediately before the harvest, corresponds to A first step in this process is to document the evaluations activities around the timing of when
the period of lowest food security and a greater local seasons and engage the community to different drivers are at their seasonal worst could
burden of malaria. The encouraging news is identify drivers during each season. Similarly, further increase efficiency and simplify planning
that, during the cool dry season, wasting preva- quantitative data collection would require multiple and data collection.
lence drops significantly. within-year observations to correspond to the
local seasons to identify how nutrition outcomes Conclusion
Programme implications and and their drivers might vary. Future programming and research must better
broader recommendations understand and incorporate the seasonal nature
The results of the study reveal a far more complex Promote a multi-temporal approach of both acute malnutrition and all its drivers in
and nuanced pattern of the seasonality of child There is a general agreement that we need to order to be effective. This process starts with
acute malnutrition than previously assumed or take a multi-sector approach to successfully more formative mixed-methods longitudinal
documented indicating that all monitored drivers prevent acute malnutrition. However, we must research, the design of and investment in evi-
are seasonal and thus need to be addressed sea- also take a multi-temporal approach – i.e., ad- dence-driven multi-sector and multi-temporal
sonally. These findings have direct implications dressing the different drivers of acute malnutrition programming and monitoring and evaluation
for research, policy and programming as follows. at relevant times and seasons. This is already a that reflects the complex and nuanced seasonality
focus within the agricultural and food security of acute malnutrition and its drivers.
Invest in formative research on sectors which have long since timed appropriate
seasonality supplies and messaging according to the agri- For more information please contact Anastasia
When programmes aim to have a longer-term cultural cycle. However, a seasonal mindset is Marshak at [email protected]
sustainable impact, formative research to identify far less common in other sectors, with a few ex-
seasonal patterns of acute malnutrition and the ceptions, including the CMAM Surge Approach References
associated drivers is essential. Without a clear, (Concern Worldwide, 2021). Grounding pro- Chambers, R, Longhurst, R and Pacey, A (1981) Seasonal
evidence-driven understanding of seasonality, gramme timing in a seasonal perspective would dimensions of poverty. 1981, London: Frances Pinter.
Concern Worldwide (2021) The CMAM Surge Approach
https://www.concern.net/insights/cmam-surge-approach
Devereux, S, Sabates-Wheeler, R and Longhurst, R (2012)
Seasonality, rural livelihoods and development. 2012, New
York: Earthscan.
Marshak, A et al (2020) Sensitivity of Nutrition Indicators to
Measure the Impact of a Multi-Sectoral Intervention: Cross-
Sectional, Household, and Individual Level Analysis. Int J
Environ Res Public Health, 2020. 17(9).
Marshak, A, Luc, G, Radday, A and Young, H (2021)
“Seasonality of Acute Malnutrition and its Drivers in Sila,
Province Chad: a mixed methods analysis”. Feinstein
International Center, February 2021
https://fic.tufts.edu/research-item/seasonality-of-
malnutrition-in-eastern-chad/
FAO and Tufts (2019) Twin peaks: the seasonality of acute
malnutrition, conflict, and environmental factors in Chad,
South Sudan, and the Sudan. 2019, Food and Agricultural
Organization: Rome and Boston.
Venkat, A et al (2021) Seasonality of acute malnutrition in
African drylands: a review of 15 years of nutrition surveys. in
©Gwenaelle Luc

progress, 2021.
Young, H (2020) Nutrition in Africa's drylands: A conceptual
Seasonal river in Sila, Chad, 2019 framework for addressing acute malnutrition. 2020,
Feinstein International Center, Tufts University.
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© UNICEF / Christine Nesbitt

A health worker gives women
therapeutic food for their
malnourished children

Scale-up of severe wasting management within

the health system: A stakeholder perspective
on current progress Research summary1
This summary was prepared by Brenda Akwanyi who undertook the review together with Philip James,
Natascha Lelijveld and Emily Mates on behalf of ENN

Helene Sandbu Ryeng

© UNICEF / South Sudan;
GLOBAL Scale-up of severe
management with wasting
health system in the

A stakeholder perspective
on current progress

What we know: Slow progress is being made towards scaling up the integration of severe wasting management
into national health systems.

What this article adds: A qualitative synthesis of key informants’ perspectives on the barriers and enablers to scaling up
wasting treatment through routine health services was conducted by the Emergency Nutrition Network (ENN) between
September 2020 and February 2021. Key informants shared examples of scale-up from pilot studies and case studies,
emphasising the need to achieve best practice at scale. Programme coverage remains low and enablers proposed to improve
this included an understanding of context-specific bottlenecks and the use of coverage as an indicator of programme success.
Participants identified a need to remove the silos between nutrition and health workforce teams and to prioritise the
community component of health systems, for example through investment in community health workers. Key informants also
identified the need to adapt and simplify nutrition protocols to reduce the requirements and costs of ready-to-use therapeutic
food and the need for more local production to shorten supply chains. Other important aspects identified for successful scale
up were to minimise parallel reporting systems, ensure adequate technical expertise for data interpretation and translation, the
integration of treatment service into existing community platforms and sustained advocacy, funding and political will from
governments, donors and implementing agencies.

Background World Health Organisation (WHO) health in some countries. Maximising the core entry
There has been considerable progress towards system strengthening framework. points for child health service delivery at facility
integrating severe wasting management into na- and community level was identified as a key en-
tional health systems in countries with high
Service delivery abler to ensuring that severe wasting is included
While there has been progress towards scale up in investments into routine community outreach
burdens of wasting. However, scale-up remains
of severe wasting services, programme coverage services. The role of community health workers
slow. This report offers a qualitative synthesis
remains low. Key enablers to improve coverage (CHWs) and family members in the early de-
of key informants’ perspectives on the barriers
include understanding the importance of coverage tection of severe wasting is also central to
and enablers to scaling up wasting treatment
as an indicator of treatment success and con- reaching children at risk. Various adaptations
through routine health services, conducted be-
text-specific bottlenecks. for case detection such as the ‘Family mid-up-
tween September 2020 and February 2021. A
total of 25 in-depth interviews were conducted Several initiatives have aimed to identify the per-arm circumference (MUAC)’ approach have
with key informants from a range of national drivers of wasting to inform responsive pro- been developed to facilitate this and innovation,
and regional government institutions, non-gov- gramming over the last decade. While successful experience sharing and the scale-up of pro-
ernmental organisations (NGOs), United Nations activities, including community outreach for gramme adaptations by health systems are
(UN) agencies and academic institutions. In- severe wasting management and building demand needed. Key informants also felt that successful
terviews were guided by a semi-structured ques- for services, should now be implemented at
tionnaire based around the six pillars of the scale, severe wasting has dropped off the agenda 1
http://www.ennonline.net/scaleupseverewastinghealthsystem
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 Research Summaries
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examples of using surge capacity to manage in- supply chain efficiencies and/or developing new, Financing
fectious diseases such as cholera, Ebola and cheaper formulations. As these protocols undergo Full and accurate budgeting is required to im-
COVID-19 could be utilised to improve the further piloting and review, the existing supply plement severe wasting treatment at scale, yet
scale-up of severe wasting services. This would chains of national health systems need to be the allocations for severe wasting treatment in
require recognising severe wasting as an urgent further reinforced. To date, 43 country govern- some national and subnational budgets is in-
health condition. ments have included RUTF in their essential sufficient. The ongoing costing exercise for coun-
medicine lists and are moving towards a more try action plans that target wasting (Global
Health workforce secure national supply chain. However, the Action Plan for wasting outcome 4) offer an
The integration of severe wasting treatment COVID-19 pandemic added further strain on
within the health workforce was felt to require opportunity to ensure realistic national and sub-
the global supply chain and highlighted the need national costing and budgeting for severe wasting.
a dual approach of training health staff and en- for more local production of RUTF to shorten
suring their accountability to severe wasting Involving health systems specialists in these
and potentially simplify the supply chain. budgeting activities could further improve fi-
outcomes and training nutrition staff in the
nancial projections.
principles of health system strengthening. This Health information systems
would diminish siloed teams and better empower Key enablers to effective health information sys- Currently, most severe wasting treatment
primary health teams to plan and implement tems include minimising parallel reporting sys- services are largely funded through international
severe wasting treatment. tems and ensuring the availability of technical humanitarian or emergency financing mecha-
The community component of health systems expertise to interpret data on severe wasting so nisms which can be unpredictable and inefficient.
was identified by key informants as the most that this can be translated into programmatic They also tend to use parallel systems that do
neglected in terms of funding and institution- action. Identified bottlenecks also need to be not build national capacity. Securing adequate
alisation. Lobbying is needed to increase in- tackled within the District Health Information and sustainable longer-term funding streams
vestment for CHWs at subnational and national System 2 (DHIS2) which is already used in 73 for wasting costs requires innovative funding
levels and to put in place appropriate legal reg- countries so as to maximise its potential to sup- mechanisms and the informants proposed many
ulation, certification and remuneration and port health workers to better anticipate and possible opportunities. These included expanding
simplified referral systems to support the work manage fluctuations in demand for severe wasting innovative regional multilateral development
of CHWs. services. The intentional embedding of technical finance initiatives, such as the Global Financing
expertise in nutrition information systems within Facility, and exploring regional government
Supplies maternal and child health information and/or procurement services to reduce the costs of es-
The costs of ready-to-use therapeutic food (RUTF) monitoring and evaluation departments could sential supplies.
remain a stubborn barrier to the scale-up of also improve the analysis and use of nutrition
severe wasting management and challenges to data. For example, key informants described Leadership and governance
sustainable supplies of RUTF hamper the conti- how governments with established e-health plat- The ongoing national and global discussions on
nuity of care and quality of services. Product forms could feasibly integrate nutrition data universal health coverage (UHC) offer a huge
adaptations and simplified nutrition protocols into existing infrastructure at scale and pilot opportunity to ensure the health consequences
offer promising opportunities to decrease the programmes have been successful in using digital of severe wasting are prioritised, especially for
amount of RUTF required, for example through platforms to integrate severe wasting data. En- high burden countries. The Tokyo Nutrition for
adapted dosage regimes for severe wasting treat- gaging with scalable e-health platforms and Growth (N4G) working group on nutrition has
ment, reducing logistics costs through local pro- leveraging them to scale up e-nutrition digital laid down some priority commitments that can
duction, controlling misuse or ‘leakage’, improving investment is now needed. be leveraged for these discussions. There are
many examples of health services that achieve
impressive coverage, such as the community
© UNICEF / Roger LeMoyne

integrated management of childhood illnesses

(C-IMCI) and the expanded programme on im-
munisation (EPI). These provide platforms into
which severe wasting services should be integrated
to maximise coverage. Key informants also sug-
gested that support infrastructure from agencies
needs to be maintained alongside government
prioritisation of wasting and that this should
involve consistent messaging on the importance
of scaling up severe wasting management from
all stakeholders who influence government policy
and funding.

Conclusion
Many successful examples of scaling up severe
wasting management from pilot studies and
case studies exist but the need to achieve best
practice at scale remains. During this qualitative
synthesis, key informants highlighted the need
for sustained advocacy and funding and political
will from governments, donors and implementing
agencies to continue progress and to maximise
opportunities including the current efforts to-
wards achieving UHC.
A nurse measures the height of
a malnourished child at a For more information, please contact Brenda
health clinic in DRC
Akwanyi at [email protected]
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 Research .............................................................
Link NCA offers a new
opportunity to study drivers
of concurrent wasting and
© UNICEF / Christine Nesbitt

stunting (WaSt)
Community discussion on causal mechanisms of
stunting, Grand Cape Mount, Liberia, 2019 By Lenka Blanárová and Grace Heymsfield

Lenka Blanárová is Senior Grace Heymsfield is a Registered The authors would like to acknowledge the
Nutrition Assessment Dietitian Nutritionist with five years following agencies for their engagement during
Coordinator at Action of nutrition assessment and nutrition the Link NCA exercise in Liberia, namely, the
Against Hunger UK. As a programming experience. She led a Liberia Wash Consortium, including Action
member of Link NCA Link NCA study across five counties Against Hunger, Concern Worldwide, Water Aid
Technical Unit she provides of Liberia and contributed at various and Tearfund in Liberia with the technical
technical support to organisations degrees to Link NCA studies in Bangladesh, Haiti, support of their respective headquarters and the
implementing Link NCA studies worldwide. Myanmar, Uganda and South Sudan. financial support of Irish Aid.

idence was used to develop a Theory of Change

Liberia with actionable multisector recommendations to
address identified risk factors, targeting most
What we know: Link NCA (Nutrition Causal Analysis) is an established methodology for analysing vulnerable communities, households, and children,
the multi-causality of undernutrition to inform context-specific nutrition-sensitive programming. to feed into programme design. A secondary re-
What this article adds: This article summarises a recent Link NCA study covering five search question emerged during the study’s qual-
itative inquiry, inspired by community members’
counties grouped into three regions in Liberia that extended its original research
perception of malnutrition as wasting and not
questions revolving around stunting to include analyses of concurrent wasting and
stunting. Therefore, the quantitative analyses con-
stunting (WaSt). Logistic regression revealed significant associations between WaSt and
ducted during the Link NCA were extended to
younger age (<24 months) across all three regions. Further associations were apparent in
wasting and concurrent wasting and stunting, to
one of three regions including episode(s) of diarrhoea during two weeks preceding the
explore potential interactions of risk factors
survey; child being taken care of by a non-immediate family member; medium to high
among multiple nutrition outcomes. In this article
score on reduced coping strategy index and/or caregivers’ perceived low level of social
we focus on the extended WaSt analyses.
support. A child’s measles vaccination and caregiver’s perceived breastmilk sufficiency
were protective factors in one region. Broader results revealed limited access to markets as Methodology
the key root cause of stunting in this context. The authors conclude that analyses focusing The Link NCA is a mixed methods study, as de-
purely on stunting would not allow for the design of interventions that address risk scribed in Box 1. During the preparatory phase
factors for WaSt for those who are at the highest risk of mortality. Shared risk factors for an in-depth literature review was undertaken
both stunting and WaSt should therefore be examined using Link NCAs in contexts with to identify hypothesised risk factors for field
high burdens of wasting and stunting to better inform programme design. testing during the qualitative inquiry and a
quantitative survey. The second stage of this
study, the qualitative inquiry, covered 10 sampled
Context encouraging the routine reporting of the prevalence locations (two per county) across various liveli-
Wasting and stunting tend to be addressed as of WaSt from nutritional anthropometry surveys, hood zones and included 131 focus group dis-
separate issues despite evidence of common broader surveys (e.g. Multiple Indicator Cluster cussions, 52 semi-structured interviews and 29
causality and the fact that children may suffer si- Surveys and Demographic and Health Surveys), observations with over 1,300 participants. All
multaneously from both conditions (WaSt). Chil- surveillance systems and other nutrition infor- qualitative data was recorded manually in a
dren with concurrent wasting and stunting may mation systems that collect and report on an- notebook and reproduced electronically at the
have comparable mortality risk to children with thropometric data (Myatt et al, 2018). end of each data collection period. The data
severe wasting only and they also tend to be As a part of extensive formative research to was grouped by themes and analysed using
more severely wasted than children who are only better understand context-specific causes of stunt- qualitative content analysis methods.
wasted (Wells et al, 2019). The heightened risk of ing and related behaviours in five counties in
1
mortality associated with WaSt means that further Liberia (Grand Bassa, Grand Cape Mount, Rural Region 1 covered Grand Cape Mount Country, Region 2
Rural Montserrado and Grand Bassa Counties and Region 3
understanding of the aetiology, prevention, case- Montserrado, Rivercess and Sinoe), a Link NCA Rivercess and Sinoe Counties.
finding and treatment of children with WaSt, as was carried out to identify and categorise risk 2
Indicators for assessing infant and young child feeding
practices Part 2 Measurement. Available at:
well as the extent to which current interventions factors for stunting across the study area. Specifi- http://www.unicef.org/nutrition/files/IYCF_Indicators_part_
are reaching these children, is urgently required. cally, the Link NCA aimed to describe interactions II_measurement.pdf
Work on the mechanisms of the association be- between identified risk factors, their seasonality 3
Maxwell, Daniel, Jennifer Coates, and Bapu Vaitla (2013).
How Do Different Indicators of Household Food Security
tween wasting and stunting on mortality may and historical variations as well as most vulnerable Compare? Empirical Evidence from Tigray. Feinstein
prove useful. Consideration should be given to groups among the population. The compiled ev- International Center, Tufts University: Medford, USA.
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Research
Local terms used to describe
Box 1 About Link NCA ‘Tightness’ is differentiated from shortness if a Table 1 stunting and wasting
child progressively falls further behind his/her
Link NCA (Nutrition Causal Analysis) is an peer’s growth. On the other hand, a wasted Stunting
established participatory and results-orientated child was described as ‘dry’, meaning that his/her Local term Meaning
methodology for analysing the multi-causality ribs protrude and his/her legs are ‘too skinny to Tight Short for age
of undernutrition to inform context-specific
carry him/her.’ Other nicknames for wasting Short butt Short for age
nutrition-sensitive programming. The Link NCA
methodology was developed to help tease at a child’s physical appearance, including AK-47
researchers discover the prevalence and severity dry and scaly like a ‘chameleon’ or ‘Mister Bone NGO – “Never Unable to grow to potential
of undernutrition in a study population; Chairman.’ Causes of wasting were directly or grow old”
statistical associations with a variety of indirectly linked to perceived negligence of the
Small in the Short for age
individual and household indicators that depict child’s mother. A child is perceived at risk of body
the broader environment; causal pathways of becoming wasted if s/he ‘does not get food on
undernutrition; changes in patterns of Forever young Looks younger than he should
time’, if s/he is not washed frequently enough
undernutrition over time and seasonally; risk
and/or has frequent diarrhoea. Unlike general Cornerstone Never changing, never growing up5
factors and pathways likely to be the most
morbidities, a ‘dry’ child is more likely to be Little man Small for age, with a face like an
modifiable by stakeholders; and old man
recommendations for programming. perceived to have been a victim of witchcraft.
Small man in Very tight in the body Increased
To answer these questions Link NCAs employ a Community aetiology of stunting roughly the iron jacket severity
mixed-methods approach, combining both fell into three categories: hereditary, environ- Lazy child The baby is too weak to grow
qualitative and quantitative research methods, and mental and spiritual. The dominant belief is
draw conclusions from a synthesis of results. The Iron rock A child who looks older than his age,
that a ‘tight’ child is short because his/her parents but stooped like an elderly person
Link NCA is carried out in the following five steps: are short. A child could become stunted if s/he
preparatory phase; identification of hypothesised Wasting
was not well taken care of in the home - this re-
risk factors and pathways; community-level data Dry Dry skin, no fat in the body, child
collection; synthesis of results and building ferred to both nutrition and household hygiene.
who is very sickly
technical consensus; and communicating results A few community members identified pregnancy
and planning for a response. and lactation as influential times that could in- Witch child Child is a witch the child is flying at
night
fluence a child becoming or not becoming stunt-
For more information see https://www.linknca.org/ Chameleon Appearance like a lizard
ed, but this was typically recorded in areas that
had been sensitised to the health benefits of Boney boney Appearance like a dry boney fish
The quantitative survey included the collection breastmilk for child health. As was true for any Malnourished The child is very dry, weak, pure,
of anthropometric measurements of children other protracted undesirable situation (health, dirty, dry and small in size
under five years of age and 45 household indi- economic, etc.), a ‘very very tight’ child could Win child Poor birth spacing6
cators in 1,094 households across all five counties have been vexed by witchcraft. Dirty child The child is not cared for by his or
of the study zone, grouped into three regions, her parent nor caregivers
The overwhelming consensus was that boys
based on the 2016 Malaria Indicator Survey Weaky weaky Child who is sicker than other
were more vulnerable to stunting than girls.
precedent.1 Household indicators included a children
Boys were said to be greedy when breastfeeding.
range of standard and/or adapted indicators Mr. Bone or The child’s ribs and others bones
If their nutritional needs or preferences were
used in sectoral cross-sectional surveys, for ex- Bone of his/her body can be seen and
not satisfied from infancy (meaning insufficient
ample, Individual Dietary Diversity Score Chairman counted
food, undesirable food, or both), they were be-
(IDDS),2 reduced Coping Strategy Index (rCSI)3 Skinny-winnie The child’s legs and arms are very
lieved to be frustrated and unable to grow.
and others. The quantitative data was collected dry and his stomach is big
via an electronic questionnaire downloaded A summary of terms used to refer to stunting
onto mobile devices. Paper anthropometry and and wasting are included in Table 1. It is important Logistic regressions, by region, revealed sig-
mortality forms were maintained for verification to note that terms used to refer to wasting implied nificant associations between concurrent wasting
before nightly upload of data onto the online a medical condition, while stunting was regarded and stunting and the indicators presented in
platform KoBoToolbox. After final compilation, as growth failure. No special terms were reported Table 2. Indicators are highlighted in orange if
all data was exported in the form of an Excel for a child who was concurrently wasted and exposure is a risk factor significantly associated
spreadsheet and analysed with STATA software. stunted - the child could be called ‘tight and dry,’ with higher odds of WaSt and green if exposure
The anthropometric data was analysed using or some combination of the below terms. A child is a protective factor significantly associated with
ENA for SMART software (2011 version).4 The who is ‘dry’ was identified as needing urgent lower odds of WaSt (p <0.05). A child who is less
analyses included bivariate logistic and linear treatment in the health facility, but no therapeutic than 24 months of age was more likely to be
regressions (WaSt children vs. children with no treatment was implied for stunting. WaSt. This was true across all three regions of
anthropometric deficits). The final stage involved the study. Regional variations in other risk factors
The quantitative survey revealed a prevalence
the synthesis and triangulation of data, which should be interpreted with caution, as correlations
of global chronic malnutrition (GCM) on the
included design of causal pathways based on were limited by the small percentage of children
basis of height-for-age less than -2 z-scores
community perceptions, available scientific ev- with WaSt and should not be considered relevant
(HAZ <-2) as above 30% in all three regions of
idence and generated evidence. to only one region without further investigation.
the study, all classified as ‘very high’ according
Results to WHO prevalence thresholds. Prevalence of Such risk factors include the child having episode(s)
Communities visited during the qualitative in- global acute malnutrition (GAM) on the basis of diarrhoea during the two weeks preceding the
quiry did not perceive stunting as a medical of weight-for-height z-score (WHZ <-2) ranged survey, the child being taken care of by a non-
condition and therefore discussions around its from 5.4% to 8.7%, classified as ‘medium’ ac- immediate family member, medium to high re-
causal pathways were challenging. Despite a cording to the WHO thresholds. WaSt prevalence duced coping strategy index (rCSI) and/or care-
discrepancy of perceived severity of this form ranged from 3.4% to 4.1%. All children who giver’s perceived low level of social support. A
of malnutrition, there was a consensus that were wasted and stunted were also underweight 4
Children with missing or flagged WHZ and HAZ information
stunting differed from natural and normal short- (30), as depicted in Figure 1. A majority of chil- were dropped; WHO 2016 flags applied.
5
ness. A stunted child was described as being dren who were stunted were not also underweight The child is the oldest of all the children in the community
but he/she is very short and small.
‘tight’ in the body, meaning that he/she could or wasted (150). Few children (17) were wasted, 6
The child was ‘won’ by parents by having sex too soon after
not grow into his or her full height for age. underweight, and not stunted. the preceding baby.
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Table 2 Select indicators’ association with WaSt

Risk factor Region I – Grand Cape Region II-Grand Bassa/ Region III- Rivercess/
Logistics regression Mount County Rural Montserrado Sinoe
Children age 6-59 months Children age 6-59 months Children age 6-59 months
Indicator N n Prevalence Design P- Odds Ratio P- Odds Ratio P- Odds Ratio
effect value [95% CI] value [95% CI] value [95% CI]
Age group <24 months 356 128 36.0[31.5-40.7] 0.8 0.002 11.22[2.37-53.07] 0.008 6.30[1.63-24.40] 0.029 5.90[1.20-29.09]
Age group <36 months 356 198 55.6[51.0-60.2] 0.8 0.033 9.52[1.20-75.33] 0.115 3.48[0.74-16.44] 0.114 5.41[0.67-44.03]
Measles vaccine (confirmed by card) 286 194 67.8[62.1-73.1] 1.0 0.508 1.70[0.35-8.20] 0.596 0.65[0.13-3.20] 0.033 0.15[0.03-0.86]
Diarrhoea [during 2 previous weeks] 350 91 26.0[21.4-31.2] 1.1 0.925 0.94[0.24-3.62] 0.557 1.44[0.43-4.84] 0.024 6.26[1.27-30.84]
Child watched by an auntie 270 50 18.2[12.6-25.6] 2.0 0.569 0.54[0.07-4.42] 0.621 1.53[0.29-8.14] 0.045 5.40[1.04-28.03]
Perceived breastmilk sufficiency 170 156 91.8[86.0-95.3] 1.2 0.864 0.83[0.10-7.19] 0.282 0.45[0.11-1.92] 0.023 0.14[0.03-0.77]
Individual Dietary Diversity (IDDS) 159 16 10.0[6.1-16.1] 1.0 0.983 1.02[0.12-8.69] Perfect collinearity 0.001 24.20[3.87-
Score zero 151.36]
Mother perceived external support: 275 52 18.9[13.5-25.8] 1.7 0.973 0.97[0.20-4.74] 0.009 9.20[1.73-49.06] 0.593 0.55[0.06-4.85]
Lowest
Reduced coping strategies index: 350 111 31.7[25.0-39.3] 2.2 0.129 0.20[0.03-1.59] 0.607 0.58[0.07-4.65] 0.004 7.54[1.88-30.27]
Medium or high
Borrowing of food (3 of 7 days) 351 70 19.9[14.4-27.0] 2.2 Perfect collinearity 0.049 4.30[1.01-18.38]
Reducing number of meals in the 351 83 23.7[17.8-30.7] 2.1 Perfect collinearity 0.017 6.00[1.38-26.14]
day (3 to 7 days)
A family member died during the 356 14 3.9[1.9-8.0] 1.9 0.004 15.64[2.44-
recall period 100.16]

child’s measles vaccination and caregiver’s perceived being of their child. The nutritional status of to the specificities of the intervention zone.
breastmilk sufficiency came out as protective women, assessed using mid-upper arm circum-
It must be acknowledged that this Link NCA
factors in Region III. The analyses showed almost ference (MUAC), was significantly linked with
study did not substantiate evidence to suggest
no overlap of risk factors for stunting and WaSt a child’s HAZ score. In agricultural livelihoods
effects on linear growth slowing as a child’s
apart from the mining/concession livelihood zones, where access to resources is intrinsically
wasting progresses, or vice versa. The current
zone being a risk factor for wasting and stunting linked with the availability of external support,
research design is limited to a snapshot of a
and potentially for WaSt. Some risk factors, in- children of mothers with perceived low levels
child’s nutritional status at the time of the data
cluding age group <24 months, measles vaccination of such support and who were not part of
collection as opposed to longitudinal studies,
and rCSI were associated with both wasting and external support groups, were potentially at a
which collect the relevant data points over an
WaSt but not stunting. greater risk of stunting.
extended period of time. In addition, while stunt-
Broader results revealed that the dominant Discussion and conclusion ing is less influenced by seasonality than wasting,
overarching pathway to stunting in this context The Link NCA study in Liberia was completed available cross-sectional data did not substantiate
took roots in limited access to markets, which as part of a three-assessment package of formative potential seasonal stresses that influence growth
appear to exacerbate a variety of household fac- research, which informed a project design process faltering, whether that be wasting or stunting.
tors, including personal and environmental hy- for the Liberia WASH Consortium (LWC), in- Therefore, it is important to consider an integration
giene, as well as consumption of a diverse and cluding Action Against Hunger, Concern World- of longitudinal evidence in the structuring of
nutritious diet. The study also substantiated ev- wide and Water Aid. The Link NCA study causal pathways, especially regarding the influence
idence regarding the role of women’s nutritional yielded meaningful evidence regarding stunting of wasting on stunting and vice versa.
status and social support in the health and well- and WaSt that informed the design of a holistic
More details on the methodology and findings
intervention targeting both forms of undernu-
Number of cases by
can be found in the full report which is available
trition. Analyses focusing purely on stunting
Figure 1 anthropometric deficiency
would not necessarily allow for a design of in-
from https://linknca.org/etude/grand_bassa_
(excluding children with no great_cape_mount_rural_montserrado_riverces
anthropometric deficiencies) terventions encompassing concurrent forms of
s_and_sinoe_counties.htm
undernutrition, for example by addressing moth-
ers’ breastmilk production, which the analyses For more information, please contact Link
N=307
found to be solely associated with WaSt. NCA Technical Unit at Action Against Hunger
Stunted UK/ Action Against Hunger France at
Due to the multifaceted nature of findings,
150 [email protected]
and facilitation of the proposal development by
an external partner, consortium partners were References
led to design a novel project and not repeat Wells J.C.K., Briend A., Boyd E., Berkley J.A., Hall A., Isanaka
0 94
status quo programming, putting children at the S., et al. Beyond wasted and stunted – a major shift to
30 highest risk of mortality (WaSt) at the heart of fight child undernutrition. Lancet Child & Adolescent
9 programme design. On the basis of this experience, Health, Online, September 11, 2019
7
Wasted 17 Underweight we recommend that contexts with high stunting Myatt, M. et al. Children who are both wasted and
and wasting burdens use Link NCA studies to stunted are also underweight and have a high risk of
death: a descriptive epidemiology of multiple
explore risk factors for WaSt to ensure that pro- anthropometric deficits using data from 51 countries.
grammatic recommendations are tailored to ad- Archives of Public Health (2018) 76:28,
dress the needs of children at most risk, according https://doi.org/10.1186/s13690-018-0277-1
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 Research
© WFP/Evelyn Fey

A community garden provides livelihoods and asset

support to people who are food insecure in Chad

Estimating the
BURKINA FASO, MALI, MAURITANIA,
burden of NIGER, CHAD & SENEGAL
wasting during What we know: An incidence correction factor (K) of 1.6 is generally used to estimate the
burden of wasting; some countries report that this leads to underestimates.
COVID-19 based What this article adds: A revised mathematical model was developed to address a

on empirical perceived risk of underestimation of the burden of wasting in the six Sahelian
countries. Drawing on previous work, a mathematical model was devised to improve
estimates and account for food insecurity, seasonal variation and the impact of
experiences in COVID-19. It drew upon existing national and regional admissions data from
community-based management of acute malnutrition programmes (2014-2019),

the Sahel prevalence data from nutrition surveys, population data from national censuses and
food and nutrition insecurity data from the Cadre Harmonisé. Programme coverage
was assumed to be 100% to estimate the total burden for the period covering April to
By Saidou Magagi, Sumra Kureishy, December 2020. Estimations for 2020 found a burden of 5.35 million wasted children,
Jessica Bourdaire and Katrien Ghoos higher than the 4.54 million originally projected. The mathematical model allowed for
the estimation of region-specific incidence correction factors per quarter accounting
Saidou Magagi is a
for food insecurity, seasonal variations and COVID-19.
monitoring, evaluation and
knowledge management
officer for nutrition at the
World Food Programme’s
Introduction prevalence is estimated as a product of inci-
regional office for West and Central Africa.
Wasting is a global public health problem dence and the average duration of disease.
Sumra Kureishy is a nutrition that results in increased child morbidity and Hence, through simple substitutions, the bur-
officer at the World Food mortality. It was estimated in 2019 that the den simplifies to the population size, preva-
Programme’s regional office global prevalence of wasting in children under lence and incidence correction factor (K).
for West and Central Africa. Box 1 provides details on the current formula
five years of age was 47 million, with a preva-
lence of 7.9 million wasted children in West used to estimate the burden of wasting in
Jessica Bourdaire is a and Central Africa (UNICEF, WHO & World this way (Bulti et al, 2017).
Nutrition Research Officer at Bank, 2020). Prevalence is estimated through Research shows that governments, United
the Nutrition Division of the cross-sectional surveys. However, as prevalence Nations (UN) agencies and community-based
World Food Programme’s data is based on a snapshot in time, some management of acute malnutrition (CMAM)
Headquarters. cases will be missed and the number of chil- implementing partners around the world use
dren affected by wasting underestimated. In- 7.5 months as the average duration of an un-
Katrien Ghoos is a senior
cidence estimates, captured through longi- treated severe acute malnutrition episode for
regional nutrition adviser at
tudinal cohort studies, capture new cases a one-year planning period which provides
the World Food Programme’s
regional office for West and
over time and are therefore a more accurate an incidence correction factor (K) of 1.6
Central Africa. estimate of the burden (Insanaka et al, 2016). (Garenne et al, 2009). However, some countries
When longitudinal studies are unavailable, have recently reported that the use of this
World Food Programme RBD would like to burden can be estimated using the context- single K has led to burden underestimation
acknowledge the collaborating partners of the specific relationship between prevalence and (Bulti et al, 2017).
model presented in this article, including incidence (Bulti et al, 2017). The average du-
UNICEF and European Civil Protection and ration of disease reflects when a prevalent An urgent request was made to the World
Humanitarian Aid Operations (ECHO), as well as case has recovered or dies or has moved out Food Programme (WFP) regional office for West
the donors, the governments and the food of the population of interest. When the inci- and Central Africa by the regional (West Africa)
security and nutrition working groups/clusters. dence is stable for the duration of the disease, Food Security and Nutrition Working Group
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Research
assumed to be 100% as the model aimed to es-
Box 1 Current formula used to estimate burden of wasting timate the total burden for the period covering
April to December 2020. The model was reviewed
Prevalence = Number of wasted children 6-59 months during a specific time period for technical validity and endorsed by the re-
Total population during the same time period gional FSNWG.

Incidence = Number of new cases of wasted children 6-59 months in a given time period With the rise in the number of wasted children
aged 6 to 59 months during the lean season
Number of children 6-59 months at risk of wasting in the same period (April-September) and regional experiences dic-
Prevalence = Incidence x Average duration of disease episode tating a wide variation in the average duration
of an episode of wasting, the regional FSNWG,
Incidence = Prevalence x (Duration of planning period ÷ Average duration of a disease episode)
along with national nutrition and food security
Burden = Population 6-59 months x [Prevalence + Incidence] clusters, agreed that the proposed pattern of
Burden = Population 6-59 months x [Prevalence x (1+ Incidence correction factor (K))] wasting and the average duration of an episode
should be based on standard calendar quarters.3
Where: K = Duration of planning period ÷ Average duration of a disease episode
Moreover, since the pandemic was only declared
after March 2020, the incidence correction factor
of K=1.6 was used to estimate the burden of
(FSNWG)1 in 2020 to address any risk of under- Methods wasting in quarter one.
estimating the burden of wasting for the G5+1 Sources of data and assumptions
Sahel countries (Burkina Faso, Mali, Mauritania, The model was generated based on the experi- Steps to adjust for food insecurity,
Niger, Chad and Senegal) as a result of the COVID- ences and lessons learned from previous burden seasonal variation and COVID-19
19 pandemic and accounting for food insecurity analyses carried out and existing national and The average duration of a wasting episode was
and seasonal variation. In response, we developed regional CMAM admissions data from the pre- estimated as the product of the planning period
a mathematical model, based on the burden model vious five years (2014-2019), prevalence data per quarter (Qn) and the quotient of the global
developed by Mark Myatt (Myatt, 2012) and from nutrition surveys in the G5+1 countries, average duration of an untreated episode (7.5
regional experiences. This article outlines the steps population data from national censuses and months) for a one-year planning period (Box 2,
taken and the equations used to obtain this food and nutrition insecurity data from the equation 1). Mean smoothing of the three months
revised model for burden estimation. Cadre Harmonisé.2 Programme coverage was of each quarter was applied to the average du-
ration of an untreated episode to reduce and
Revised formula for the calculation of the burden of wasting based on the
control for random variation (STE) (Box 2,
adjusted incidence correction factor for food insecurity, seasonal variation equation 2). The incidence correction factor per
Box 2 and COVID-19 per quarter quarter adjusted for food insecurity was calculated
as the quotient of the planning period per
Average duration of an Average duration of an untreated episode quarter (Qn) and the smoothed average duration
(1) untreated episode by standard = of an untreated episode (STE) (Box 2, equation
calendar quarters (ATE) Duration of planning period
3). The burden of wasting was then adjusted
based on the incidence correction factor for
Smoothing of the average duration of an food insecurity per quarter (FSQn), as detailed
(2) = (Qn + 1) – ATE in Box 2 (equation 4). To adjust for seasonal
untreated episode between quarters (STE)
variation, admissions data from the previous
(3) K = Qn ÷ STE five years was analysed and the mean was
smoothed to determine the burden averaged
across the previously mentioned quarters (Qn)
(4) Burden adjusted for food insecurity per quarter (FSQn) = N x P [1 + K] (Box 2, equation 5).
To determine the impact of the COVID-19
Average observed number of programme pandemic on the burden of wasting, experiences
Adjusted correction factor
(5) for seasonal variation per = admissions per year over the past 5 years and CMAM, admissions data from the Ebola
quarter (SVQn) crisis (2014-2016) and World Health Organization
Total number of quarters (Qn)
data (WHO, 2016) were used to forecast an in-
crease in the expected number of new cases for
Burden adjusted for food Burden adjusted Quarterly Quarterly each quarter (Box 2, equation 6). The approach
insecurity, seasonal variation & for food insecurity x incidence factor for x impact factor of was then used to estimate the burden of wasting
(6) =
COVID-19 per quarter per quarter seasonal variation COVID-19 adjusted for food insecurity, seasonal variation
(FSQn + SVQn + COVIDQn ) (FSQn ) (SVQn) (IFCOVIDQn)
1
The regional Food Security and Nutrition Working Group
Q1 Burden Q2 Burden Q3 Burden Q4 Burden (FSNWG) is based in Dakar, Senegal. Under the coordination
Burden of adjusted adjusted adjusted adjusted of the Office for the Coordination of Humanitarian Affairs, it
Wasting for = for FSQ1 + + for FSQ2 + + for FSQ3 + + for FSQ4 + consists of the regional representation of UN agencies,
(7)
donors, and international non-government organisations
Apr-Dec 2020 SVQ1 + SVQ2 + SVQ3 + SVQ4 +
who have interventions in West and Central Africa.
COVIDQ1 COVIDQ2 COVIDQ3 COVIDQ4 2
The Cadre Harmonisé is West Africa’s equivalent to the
Integrated Phase Classification (IPC) which provides a
where ; meta-analysis of data from existing information systems on
Qn = Planning period per quarter; Q1, Q2, Q3 and Q4 agriculture, household economy, food consumption
Average duration of an untreated wasting episode = 7.5 months patterns, health and nutrition to classify the severity of
Duration of planning period = 12 months acute food and nutrition insecurity.
3
The standard calendar quarters were defined as January –
N = Population size
March (quarter 1), April – June (quarter 2), July – September
P = Prevalence (quarter 3) and October – December (quarter 4); the
K = Adjusted incidence correction factor for food insecurity per quarter planning periods per quarter were defined as 3 months for
IFCOVIDQn = Impact factor of COVID-19 per quarter (Q1, Q2, Q3 and Q4) quarter 1, 6 months for quarter 2, 9 months for quarter 3
and 12 months for the last quarter.
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Research
and COVID-19 for the period of April to De- Estimates of the adjusted incidence correction factor for
cember 2020 (Box 2, equation 7). Table 1 food insecurity per quarter

Results Planning Average Duration Smoothing of the Average Incidence

In the first step, estimating the smoothed du- Quarters Months Period of Episode (ATE) Duration of Episode (STE) Correction
ration of an episode for food insecurity per (months) by Quarters between Quarters Factor
quarter, the incidence correction factors were Q1 Jan - Mar 3 N/Aa N/Ab 1.6
found to be 1.6, 1.85, 2.06 and 2.18, respectively.
Q2 Apr - Jun 6 3.75 3.25 1.85
Table 1 shows the resulting adjusted incidence
correction factors for food insecurity per quarter. Q3 Jul - Sept 9 5.63 4.38 2.06
These correction factors were found to increase Q4 Oct - Dec 12 7.50 5.50 2.18
substantially per quarter; the correction factor a,b
K increased more than 30% by the fourth The region continued to use the global 1.6 incidence correction factor since COVID-19 was only
declared a pandemic after March 2020
quarter. The second estimation step found an
attribution of 20-25% from seasonal variation
on the burden of wasting. Wasting burden estimates for 2020 adjusted for food insecurity, seasonal
Table 2 variation and the impact of COVID-19 in G5+1 Sahel countriesa
For the impact of COVID-19 on wasting,
the third estimation step found an increase in GAM TOTAL Change
the initial expected number of new cases by 0% Initial Burden 2020 b
4,537,948 NA
in Quarter 1, 10% in Quarter 2, 15% in Quarter
3 and 20% in Quarter 4. This step accounts for Revised Burden (with FS + SV) 4,865,712 7%
the negative impact of the restrictive measures Revised Burden (with FS + SV + C19) 5,347,833 18%
on access to healthcare, delays in the diagnosis
and treatment of wasting, access to food supplies SAM TOTAL Change
and other socio-economic aspects (WFP, 2020). c
Initial Burden 2020 1,318,660 NA
Table 2 shows the initial burden of wasting,
Revised Burden (with FS + SV) 1,434,787 9%
calculated using an incidence correction factor
of 1.6 and the revised burden adjusted for food Revised Burden (with FS + SV + C19) 1,578,129 20%
insecurity, seasonal variation and COVID-19
for 2020. The burden of wasting calculated with MAM TOTAL Change
a K=1.6 was found to have vastly underestimated Initial Burden 2020 d
3,219,287 NA
the annual burden of wasting by about 0.8
million children. This corresponds to an un- Revised Burden (with FS + SV) 3,430,925 7%
derestimation of 18% of the burden initially Revised Burden (with FS + SV + C19) 3,769,705 17%
forecasted for April to December 2020. a
The improved burden estimates were calculated for Burkina Faso, Mali, Mauritania, Niger, Chad and Senegal.
b,c,d
Discussion The initial burden for 2020 was calculated using the Harmonised Framework for March 2020 which
The improved burden estimates were used to relies on the global incidence correction factor of 1.6.
identify priority geographical areas in need of
urgent assistance. Overall, the revised burden
estimates enabled the region to adjust and orient region to produce adequate burden estimates. References
planned activities and resources to address wast- By applying standard calendar quarters, the Bulti, A, Briend, A, Dale, N M, De Wagt, A, Chiwile, F, Chitekwe,
ing in the hardest hit areas. model was able to account for the seasonal S, Isokpunwu, C, Myatt, M (2017) Improving estimates of the
variation observed in the burden of wasting burden of severe acute malnutrition and predictions of
caseload for programs treating severe acute malnutrition:
Similarly, the G5+1 countries were able to across the Sahel region. experiences from Nigeria. Archives of Public Health 75:66
use the revised burden estimates to inform na-
tional hotspot analyses which led to the early Conclusion Garenne, M, Willie, D, Maire, B, Fontaine, O, Eeckels, R, Briend, A,
Van den Broeck, J (2009) Incidence and duration of severe
identification of priority areas and to the adap- The revised mathematical model presented wasting in two African populations. Public Health Nutr.
tation of the WFP's wasting prevention and in this article allowed for the estimation of 2009;12(11):1974–82.
treatment response. These adaptations led WFP region-specific incidence correction factors Isanaka, S, Boundy, E, Grais, R F, Myatt, M and Briend, A (2016)
to increase its reach to beneficiaries by an addi- per quarter accounting for food insecurity, Improving Estimates of Numbers of Children With Severe
seasonal variations and COVID-19. The Acute Malnutrition Using Cohort and Survey Data. Am J
tional 15 to 30% across the six countries. More-
Epidemiol. 2016;184(12):861–869
over, the revised burden estimates have been quarterly values of correction factors esti-
Myatt, M (2012) How do we estimate caseload for SAM and / or
used to guide regional research, such as the on- mated for 2020 based on population, preva-
MAM in children 6 – 59 months in a given time period?
going Fill the Nutrient Gap analysis which iden- lence and coverage data from 2014 to 2019 Retrieved from: https://www.humanitarianresponse.
tifies and models multi-sector approaches to found a burden of 5.35 million wasted chil- info/sites/www.humanitarianresponse.info/files/documents/fil
prevent malnutrition in the Sahel. dren which appears to be a more accurate es/caseload_cmam-june-2012.pdf
estimate of the burden than the 4.54 million UNICEF, World Health Organization and the World Bank (2020)
Through clear and organised consultations originally estimated. In the absence of up UNICEF-WHO-World Bank Joint Child Malnutrition Estimates.
and consensus building with countries (gov- to date health and nutrition data during
UNICEF, New York; WHO, Geneva; The World Bank, Washington,
ernments, non-governmental organisations and DC.
COVID-19, this approach using incidence
UN agencies), the revised model was able to World Food Programme (2020) Update on the impact of Covid-
correction factors adjusted for food insecurity, 19 on food and nutrition security in West and Central Africa.
generate estimates in a coordinated manner
seasonal variation and COVID-19 may be World Food Programme. Retrieved from: http://www.food-
and ensure buy-in, a key lesson learned during security.net/en/document/update-on-the-impact-of-covid-19-
considered for improving burden estimates
this experience. on-food-and-nutrition-security-in-west-and-central-africa/
of wasting in G5+1 Sahel countries.
World Health Organization (2016) Ebola data and statistics -
Evidence-based decision-making is essential situation summary. World Health Organization. Retrieved from:
to creating sustainable change and, given the For more information, please contact Ka- https://apps.who.int/gho/data/view.ebola-sitrep.ebola-
COVID-19 pandemic, the model enabled the trien Ghoos at [email protected] summary-latest.%20Accessed%20on%20December%2030
.......................................................................................................................................
Field Exchange issue 65, May 2021, www.ennonline.net/fex
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© GOAL, Ethiopia
A mother with a
counsellor in Gambella
. . . . . . . . . . . . . . . . . . . . . . . . . .refugee
. . . . . . .camp,
. . . . . .Ethiopia
Research
................................................................................................

ETHIOPIA
What we know: The use of educational videos is emerging as an effective mode of
health education including to support optimal infant and young child feeding.

What this article adds: GOAL has begun using breastfeeding educational
videos within its Maternal, Infant and Young Child Feeding (MIYCF) and
Management of ‘at risk’ Mothers and Infants (MAMI) programme in Gambella
refugee camps in Ethiopia. Eight Global Health Media Project (GHMP)
Use of educational breastfeeding education videos were translated into the local language and
shown to mothers with infants under six months of age attending
MIYCF/MAMI clinics over the course of eight weeks between August and
videos to improve December 2020. Changes in maternal breastfeeding knowledge and practice
were assessed to determine the feasibility of the approach through semi-

maternal structured interviews at baseline and endline and, at endline, through focus
group discussions with mothers and key informant interviews with health
workers. A total of 93 mothers were included in the study. At baseline, 100%
breastfeeding of the mothers practiced breastfeeding and 92.5% practiced early initiation of
breastfeeding (EIBF). At endline, analysis of primary outcomes demonstrated

knowledge and a statistically significant difference in knowledge about introduction to

complementary feeding (increased by 8.7 percentage points) but no significant
differences in other primary breastfeeding practice and knowledge outcomes.
practices in Analysis of secondary outcomes showed a substantial change in knowledge,
including improvement in knowledge about the advantages of EIBF,

Ethiopia attachment and positions during breastfeeding and signs to identify that the
baby is hungry. Qualitative results showed that mothers and health workers
found the videos acceptable, useful and effective. GOAL now plan to
implement this video-assisted counselling in both MIYCF and MAMI
By Ritu Rana, Hatty Barthorp, Liya Assefa,
programmes in the Gambella programme with increased frequency and on
Alemayhu Beri and Mary T Murphy
bigger screens. In addition, community health workers will show the videos on
tablets to family members and key influencers to address wider barriers to
Ritu Rana is a GOAL Nutrition Research
Advisor (Management of At-risk
optimal breastfeeding practices.
Mothers and Infants under six months
(MAMI)). She has a PhD in nutrition
(India), a second Master’s Degree in
Nutrition for Global Health (UK) and using counselling cards while the MAMI
nine years’ experience working in nutrition research.
Background
Optimal breastfeeding practices are asso- service is focused on one-on-one coun-
Hatty Barthorp is a GOAL Global ciated with reduced morbidity and mor- selling, predominantly using MAMI coun-
Nutrition Advisor. She has worked on tality in young children (Sankar et al., selling cards.
emergency, transitional and 2015). For infants under six months, ex-
development programmes for 18 years. The use of educational videos is emerging
clusive breastfeeding (EBF) is recommend- as an effective mode of health education
ed by the World Health Organization (Tuong, Larsen & Armstrong, 2014). Studies
Liya Assefa is a Senior Nutrition (WHO) as the optimum diet. However, from Uganda, Rwanda and Malaysia have
Research Officer (MAMI). She has a breastfeeding women may experience chal- shown that educational videos are effective
Bachelor's Degree in Public Health, a lenges to maintaining EBF for the first six in improving knowledge and practices
Master's Degree in Project Management months. A review documented various around breastfeeding (Monoto & Alwi,
and is currently pursuing a Master’s barriers to EBF in low- and middle-income 2018; Mukarubayiza & Gowan, 2019; Mu-
Degree in Reproductive Health. She has countries (LMICs), including maternal tanda, Waiswa & Namutamba, 2016). Thus,
around five years’ experience in nutrition and research. perceptions of insufficient breastmilk, to address the barriers faced by breastfeeding
Alemayhu Beri is a supervisor for MAMI breastfeeding problems and lack of coun- women during the first six months of a
and Senior Community Management of selling (Kavle et al., 2017). These barriers child’s life, GOAL has started using breast-
Acute Malnutrition (CMAM) Programme are often not adequately addressed through feeding educational videos within its MIYCF
Officer at GOAL Ethiopia. He has around infant and young child feeding (IYCF) and MAMI programme. To pilot the ap-
nine years’ experience in humanitarian counselling programmes. proach, GOAL translated eight Global
programming. Health Media Project (GHMP)1 breast-
GOAL has been implementing nutrition
Mary T Murphy is a Refugee Programme feeding educational videos to Nuer language,
programmes, including maternal infant
Manager at GOAL Ethiopia. She has the local language of the South Sudanese
and young child feeding (MIYCF) and
over 20 years’ experience in nutrition refugees in Kule and Tierkidi camps. To
management of at-risk mothers and infants
and humanitarian programming. document the learnings, this study was
under six months (MAMI) in Kule and
designed to assess the changes in maternal
Tierkidi refugee camps in Gambella since breastfeeding knowledge and practice and
The authors would like to thank the Global Health Media 2014. As part of these support services, to determine the feasibility (acceptability
Project (GHMP) for supporting the translation and counselling on infant feeding is provided and utility) of the videos.
narration of selected GHMP videos in Nuer language to mothers or caregivers. Currently, MIYCF
and Nächstenliebe Weltweit for supporting the counselling services are mainly didactic
implementation. and include group education sessions 1
https://globalhealthmedia.org/
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Methods your milk supply, v) how to express breastmilk, istics, breastfeeding knowledge and practices was
Design and setting vi) storing breastmilk safely, vii) what to do about administered to mothers at baseline and endline
We used an adequacy design with pre (baseline) nipple pain, and viii) what to do about breast (WHO, 2010). Additionally, we also conducted
and post (endline) assessments. From August to pain. Based on the mothers’ breastfeeding challenges focus group discussions (FGDs) with mothers
December 2020, GOAL piloted the GHMP breast- or preference, counsellors decided on the sequence (two FGDs/site, total eight) and key informant
feeding educational video intervention in all four of the videos (most pertinent followed by others) interviews (KIIs) with health workers –
refugee camp sites – Kule 1, Kule 2, Tierkidi 1 and and, if needed, the videos were repeated as required. MIYCF/MAMI counsellors (two staff/site, total
Tierkidi 2, Gambella, Ethiopia (Figure 1). Each participant was shown at least two videos at eight) at endline. Topics included in the FGD/KII
one contact point (weekly visit at MAMI/MIYCF guides are shown in Box 1.
Study population and intervention programme clinic) and, over a period of eight
delivery The health workers (counsellors, Diploma in
weeks, the participants were shown all eight videos,
The study population included mothers of infants General Nursing and Midwifery (DGNM)) in-
repeated at least twice. Exposure to the intervention
under six months. At pre assessment, i.e., baseline, terviewed the mothers while the research staff
for participants was also recorded.
mothers with infants under four months residing (Master of Public Health) conducted FGDs with
in Kule and Tierkidi refugee camps who attended Sample size and data collection the mothers and KIIs with the health workers.
the MIYCF and/or MAMI programme and re- Sample size was determined to assess the effect of All data was collected using pen and paper.
ceived breastfeeding counselling (based on MAMI the intervention over time using a comparison of
paired proportions. We considered the following
Intervention delivery and data
and UNICEF IYCF counselling cards) were invited collection adaptation in the context of
to participate in the study. Mothers were shown assumptions: 2% success-failure proportion, 45%
failure-success proportion, 5% level of significance, COVID-19
breastfeeding videos over a period of two months The tablets used for showing videos were sanitised
(eight weeks) (ENN et al., 2018; UNICEF, 2012). 80% power and 20% non-response rate. We esti-
mated that a total sample size of 96 (24 per camp with disinfectant after each use. For interviews, a
Thereafter, the same mothers were followed up minimum distance of one metre was maintained
for post assessment. site) was sufficient to compare paired proportions
from baseline to endline. Data was collected at between the data collector and study participant.
Using a multimedia platform (tablet), a total two time points – pre (baseline) and post (endline) For FGDs, a maximum number of five participants
of eight videos of average length of seven to eight assessments between August and December 2020. was decided and the discussions were conducted
minutes were shown on a one-to-one basis. Subjects We used both quantitative and qualitative tools. in an open space, maintaining at least one metre
of the videos included i) attaching your baby at A semi-structured tool, adapted from the WHO distance between individuals (Figure 2).
the breast, ii) positions for breastfeeding, iii) is indicators for assessing IYCF practices (measure- Data analysis and presentation
your baby getting enough milk? iv) increasing ments), with questions on participant character- Data was first entered and cleaned in Microsoft
Excel spreadsheets (pre-post sheet, FGD sheet
and KII sheet). The sheet with pre-post data was
Figure 1 Study flow diagram imported in STATA and this data was analysed to
calculate frequencies of participant characteristics
Programme Pre assessment Intervention Post assessment and changes in proportions of breastfeeding
MAMI and MIYCF Mothers with infants Educational videos Follow-up after two knowledge and practice outcomes.
aged 0-4 months + standard care months [Oct-Dec 2020]
[Aug-Oct 2020] Five primary outcomes were defined: i) exclusive
breastfeeding, ii) bottle feeding, iii) cup feeding,
iv) knowledge of early initiation and v) knowledge
of complementary feeding. Three secondary out-
Box 1 Topics for FGD/KII guides comes were also defined related to knowledge
about: i) advantages of early initiation of breast-
• What do you think of the breastfeeding videos? feeding (EIBF) (1: healthy start to the baby, 2:
• What have you learnt from these videos/how do you find them as an educational tool?
skin-to-skin contact, 3: colostrum, 4: suckling
• What do you like about the videos/what do you like about using the videos?
will speed up contraction of uterus and delivery
• Anything you did not like about the videos?
• How did you find this new method of IYCF support compared to how you were being supported of placenta and 5: help bond with the baby), ii)
before (mothers)/how did you find this new method of IYCF support compared to how you were attachment and positions (1: hold baby close, to-
upporting before (health workers)? wards mother, 2: head and body inline/straight,
• After watching the videos, have you made any changes in the way you breastfeed the child (mothers)/ 3: nipple opposite nose, 4: fingers away from
after showing the videos, have you observed any changes in the mothers’ breastfeeding knowledge nipple, 5: mouth wide open, 6: chin against breast
and practices (health workers)? and 7: lip turned out) and iii) signs that baby is
• What other support do you think would help you to maintain good breastfeeding practice (mothers)/ hungry (1: moving lips/tongue, 2: hand to mouth,
what other support do you think would help you to provide adequate IYCF services (health workers)? 3: opening mouth; 4: turning head side to side
• Who influences feeding practices for babies and young children at home or in your community? and 5: crying/irritable/restless). Qualitative data
• Is there anyone else you think should be watching these videos in your community? was coded in Excel and themes identified. Results
are presented according to themes.

Figure 2 Data collection adaptations to prevent COVID-19 infection Ethical considerations

We followed the ‘ethical standards for research
during public health emergencies’ guidelines by
WHO (WHO, 2020). We ensured that the research
work did not impede the emergency response ef-
forts and all participants were treated with equal
respect. All data was collected after obtaining in-
formed consent from the participants.

Results
Of the 96 participants, three did not complete
the study (moved to host community) and hence
Left, FGD and right, KII
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Characteristics of study
Table 1 population at baseline Table 2 Change in primary outcomes related to knowledge and practice

Characteristics Frequency Percentage Knowledge and practice Pre (%) Post (%) Difference (%) P value*
Nutrition Programme Practised exclusive breastfeeding 100 98.9 1.1 0.31
MAMI 22 23.7 Practiced bottle feeding† 3.2 4.3 1.1 0.70
IYCF 71 76.3 †
Practiced cup feeding 3.2 1.1 2.1 0.31
Infant sex
Correct knowledge about EIBF‡ 95.7 96.8 1.1 0.65
Male 40 43.0
Female 53 57.0 Correct knowledge about introduction to 89.1 97.8 8.7 0.02
complementary feedingI
Parity
Primiparous 26 28.0 †used to feed expressed milk, ‡Mothers who understood breastfeeding should be initiated immediately
or within an hour of birth, ‖Mothers who understood the correct timing of introduction of
Multiparous 67 72.0 complementary feeding at six months, *McNemar's test
Infant age (months)
<1 24 25.8
1 39 41.9 Figure 3 Change in secondary outcomes related to breastfeeding knowledge
2 16 17.2
3 12 12.9
4 2 2.2
Practiced ever breastfeeding
Yes 93 100.0
Practiced EIBF
Immediately 72 77.4
after birth
<1 hour 14 15.1
1-24 hour 6 6.5 Numbers on x axis represent number of knowledge items
Do not know 1 1.1
Experienced breast pain while breastfeeding primary outcomes demonstrated a statistically Utility
Yes 21 22.6 significant difference in the knowledge about in- All mothers found the videos useful. Health
No 72 77.4 troduction to complementary feeding – increased workers also found them useful – they mentioned
by 8.7 percentage points (Table 2). However, no that mothers like watching the videos. One of
Experienced nipple pain while breastfeeding
significant differences were observed in other pri- the health workers highlighted that using only
Yes 38 40.9
mary breastfeeding practice and knowledge out- counselling it is difficult to demonstrate [“we
No 55 59.1 comes. It is important to note that, at baseline, all don’t demonstrate everything because it’s hard to
Worried infant not getting enough breastmilk mothers were already practicing EBF and only a show our private body parts”]. Another health
Yes 21 22.6 small proportion were practicing bottle or cup worker mentioned it could reduce their workload
No 72 77.4 feeding using expressed breastmilk. Similarly, the [“The counselling used to take us around 40
Practiced expressing breastmilk vast majority of mothers at baseline already had minutes. Now we can undertake other activities
Yes 21 22.6
correct knowledge about EIBF. while they are watching the video”].
No 71 76.3 Figure 3 presents the changes in secondary Appropriateness
Do not know 1 1.1 outcomes related to mothers’ breastfeeding knowl- Mothers stated they learnt about attachment and
Practiced storing breastmilk edge. Unlike the primary outcomes, these illustrate positioning, expressing and storing breastmilk,
Yes 21 22.6 a substantial change in knowledge. Overall, there managing breast pain and identifying signs of
was an improvement in knowledge about the baby getting enough milk. Health workers said
No 71 76.3
advantages of EIBF, attachment and positions they liked the length and pace of the videos.
Do not know 1 1.1 during breastfeeding and signs to identify that They also highlighted that the videos are com-
baby is hungry. Before watching the videos, most prehensive and self-explanatory and appreciated
the final analysis is based on 93 participants. mothers only knew about ‘a healthy start to the the local language translation.
Characteristics of participants at baseline are pre- baby’ and ‘colostrum’ as advantages of EIBF.
sented in Table 1. More than three-quarters of However, after watching the videos, they also Acceptability
the mothers were attending the MIYCF pro- knew about ‘skin-to-skin contact’ and ‘bonding When asked about likes or dislikes, both mothers
gramme. The majority (67.7%) had infants ≤1 with the baby’. Similarly, regarding attachment and health workers said there was nothing that
month of age. All mothers practiced breastfeeding and positions, most mothers only knew about they did not like about the videos. Mothers shared
and the vast majority (92.5%) also practiced EIBF ‘holding baby close’ and ‘mouth wide open’ while, various examples of what they liked about the
(immediately after birth to less than an hour). after watching the videos, they also knew about videos such as – they can practice while watching
Just under a quarter of mothers practiced expressing ‘head and body in line/straight’. Mothers’ knowl- the videos, they liked how real the videos are [“I
and storing breastmilk and 22.6% of mothers edge about identifying signs that baby is hungry came from rural area in South Sudan I did not
were worried about their infant not getting enough also improved – initially they could only identify know breastfeeding had to follow a certain way.
milk. The proportion of mothers who experienced ‘moving tongue/lips’ and ‘crying/irritable/restless’. The video elaborates that one by one. The mothers
nipple pain specifically was 40.9% while 22.6% After exposure to the intervention, they were do not get humiliated when they show their breast,
reported more generalised breast pain. also looking for signs such as ‘opening mouth’ I like how real the videos are”], appreciated the
and the baby putting ‘hand to mouth’. videos are in their local language [“I like how it
Effect of videos on maternal was done in our language”] and found them easy
breastfeeding knowledge and Feasibility of the videos to follow and remember [“the videos are not
practices Five themes emerged from the qualitative findings: playing fast, so, we can attentively follow”]. Similar
Each mother watched the eight videos at least utility, appropriateness, acceptability, effectiveness, to the mothers’ responses, health workers also
twice. After watching the videos, analysis of the challenges and suggestions. mentioned that mothers can practice side by side
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while watching. One of the health workers said Suggestions taining healthcare behaviors (Kellams et al., 2016;
“The videos give time for the mothers to practice Mothers suggested these videos should also be Aditya, Tiwari & Mishra, 2020). Baseline EBF
while watching the video. The mothers can follow shown to young girls, pregnant women and one rates were not assessed in these studies however.
the flow of the video and practice side by side. additional caregiver (husband). Mothers men-
Due to the COVID-19 pandemic, we used an
And the animators are humans which make the tioned similar videos can be prepared for pregnant
adequacy evaluation design with longitudinal
videos more acceptable”. women while health workers suggested continuing
data collection. As there was no control group, it
such videos beyond the first six months of life.
Effectiveness Other suggestions included a request for in-
may be difficult to infer any observed changes
Comparing the digital version of IYCF support were due to the intervention and that these
creasing the frequency and a bigger screen for
with standard counselling support, mothers men- changes would not have happened anyway. The
watching the videos.
tioned the advantages of the videos over standard observed changes may have been caused by other
support. Mothers said the videos were compre- Discussion factors such as women can become more knowl-
hensive and the practices are demonstrated while This study found that the majority of the mothers edgeable about breastfeeding as they continue
with standard counselling they only received were already practicing exclusive breastfeeding their breastfeeding journey – i.e., as their infant
messages thus must translate these into practical before exposure to the intervention, however, their grows and they overcome various challenges.
actions. They also highlighted that, when they knowledge about the various advantages of early
The data we collected was brief and investi-
watch the videos, it is easier to remember messages initiation of breastfeeding, attachment and posi-
gations were not as detailed as would have been
while with standard counselling they sometimes tioning, and identifying signs that baby is hungry
planned under normal circumstances. To save
forget. On the other side of the fence, health was limited. Post exposure, after watching the
health workers’ time, who were overburdened,
workers said that convincing mothers to participate videos, exclusive breastfeeding was sustained and
there were considerable improvements in more
we only collected post-assessment information
in counselling requires effort. However, with
detailed breastfeeding knowledge. Both mothers on selected indicators. The FGDs and KIIs were
videos, they are happy to focus on behaviour
and health workers found the videos acceptable, also minimised to be completed under 20-30
change. One of the health workers said – “coun-
useful and effective. Other benefits recorded were minutes and 10-15 minutes, respectively. The
selling takes more time and sometimes beneficiaries
improved ability of the videos to convey ideas and study results should be interpreted in line with
get bored, however, with videos they are happy to
physically demonstrate specific practices that not these limitations. Since our study population at
learn”. Mothers said after watching the videos,
usually achieved through didactic counselling, al- baseline was already practicing EBF, it would be
they had started practicing expressing and storing
lowing mothers to trial various practices whilst interesting to conduct a similar study in a popu-
breastmilk, observing signs that baby is getting
being shown them, improving engagement and lation where breastfeeding practices are not as
enough milk and observing attachment to nipple.
memory retention by mothers/carers and providing optimal at baseline and compare the results.
Health workers confirmed these changes in prac-
tices. The most commonly cited reasons for prac- a marked reduction in workload for health workers. We plan to implement this video-assisted
tising expressing and storing breastmilk were Although EIBF and EBF are two core IYCF in- counselling in both MIYCF and MAMI pro-
mothers’ other household responsibilities, such dicators and are most commonly measured to assess grammes in Gambella, Ethiopia. However, as sug-
as going to market and fetching firewood. One the IYCF practices for infants under six months, gested by mothers and health workers, we would
of the mothers said – “I learnt how to express the other qualitative indicators, such as attachment and consider increasing the frequency and introducing
milk from my breast. This is a new thing. We have positioning, are also important. Effective breastfeeding bigger screens – displaying videos on a television
so many responsibilities as a woman. Knowing is a function of both the correct positioning of so that the mothers can watch them together,
this method has helped me reducing my burden”. mother and baby and the correct attachment of practice side by side and discuss with or support
the child to the mother's breast. It is essential to each other. Through video-assisted counselling,
Challenges we would also be addressing the challenges faced
Acceptance of expressing and storing breastmilk support early growth and development as it is as-
sociated with long-term health. by the mothers due to local traditions, elaborating
was found to be a challenge by the community.
on when these practices can be used to maximise
Some mothers said their family members do not The GHMP breastfeeding videos have also positive outcomes for the infant. In addition to
support them as they find these practices to be been tested in other settings. A study from displaying breastfeeding videos on bigger screens
against their culture and religion. Mothers said Malaysia found these videos to be a suitable ed- as part of clinic-based counselling services, we
that elderly people in the family influence their ucational and training tool in helping breastfeeding also plan for the community health workers to
feeding practices; a mother shared, “the influence mothers (Monoto & Alwi, 2018). Another study use tablets to show the videos to family members
is high from our fathers and mothers. They want from Rwanda found the GHMP videos were or key influencers to address any challenges faced
to raise our children the way we grew up. They effective in improving parental knowledge in by the mothers due to cultural or religious belief.
refuse us to practice some of the practices we learn caring for their pre-term infant (Mukarubayiza
here. For example: removing the milk from the & Gowan, 2019). Other studies have also found For more information, please contact Hatty
breast is not accepted well by the community”. that video-assisted counselling is effective in sus- Barthorp at [email protected]

References stay in a low-income population, Journal of Human breastfeeding practices and infant and child mortality: a
Lactation, 32: pp. 152-59. systematic review and meta-analysis, Acta paediatrica,
Aditya, V, Tiwari H C and Mishra R (2020) A study on 104: pp. 3-13.
effectiveness of video assisted counselling in establishing Monoto, E M M and Alwi, N K M (2018) Breastfeeding
and sustaining appropriate breast feeding practices, videos as a new training tool for Malaysian breastfeeding Tuong, W, Larsen E R and Armstrong A W (2014) Videos to
Journal of Family Medicine and Primary Care, 9: 4680. peer counsellor program in empowering breastfeeding influence: a systematic review of effectiveness of video-
communities, IIUM Medical Journal Malaysia, 17. based education in modifying health behaviors, Journal of
ENN, GOAL, LSHTM and Save the Children (2018) C-MAMI behavioral medicine, 37: pp. 218-33.
Tool, Version 2 (2018)', Emergency Nutrition Network Mukarubayiza, M R and Gowan, M (2019) Educational
(ENN), Accessed 27 February 2021. intervention to increase parental care of preterm neonates UNICEF (2012) Infant and Young Child Feeding:
https://www.ennonline.net/c-mami. at district hospital in Kigali, Rwanda Journal of Medicine and Counselling Cards for Community Workers, Accessed 27
Health Sciences, 2: pp. 105-11. February 2021.
Kavle, J A, LaCroix E, Dau H and Engmann, C (2017) Addressing https://sites.unicef.org/nutrition/files/counseling_cards_O
barriers to exclusive breast-feeding in low-and middle- Mutanda, J N, Waiswa, P and Namutamba, S (2016)
ct._2012small.pdf.
income countries: a systematic review and programmatic Community-made mobile videos as a mechanism for
implications, Public Health Nutrition, 20: pp. 3120-34. maternal, newborn and child health education in rural WHO (2010) Indicators for assessing infant and young
Uganda; a qualitative evaluation, African health sciences, child feeding practices: part 2: measurement.
Kellams, A L, Kelly, K G, Hornsby, P P, Drake, E, Riffon, M,
16: pp. 923-28.
Gellerson, D, Gulati, G and Coleman V (2016) The impact WHO (2020) Ethical standards for research during public
of a prenatal education video on rates of breastfeeding Sankar, M J, Bireshwar, S, Chowdhury, R, Bhandari, N, health emergencies: Distilling existing guidance to
initiation and exclusivity during the newborn hospital Taneja, S, Martines, J and Bahl, R (2015) Optimal support COVID-19 R&D Geneva: WHO, 2020.

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 Research
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Pastoral Community Development Programme

A systematic review of – Human and Animal Health Post

nutrition interventions
for mobile pastoralists
By Natasha Lelijveld and Emily Mates
Emily Mates is a Technical Director at ENN with
over 20 years of experience in international public
health and nutrition programming. At ENN, she
leads several technical areas including adolescent
nutrition and acts as the Technical Team
Coordinator.
Natasha Lelijveld is a Senior Nutritionist at
Emergency Nutrition Network (ENN). She
previously worked at the University of
Southampton, the Hospital for Sick Kids in

© FAO/IFAD/WFP/Michael Tewelde
Toronto, University College London, the London
School of Hygiene and Tropical Medicine and the
No Wasted Lives initiative at Action Against Hunger.
The authors would like to thank the Irish Department of Foreign
Affairs for generously funding ENN to undertake this review, among
other work. Also thanks to Kate Sadler for her expertise and input.

best to reach and improve nutrition in children

GLOBAL among mobile pastoralist communities is an
important global health priority.
What we know: Pastoralist communities are vulnerable to seasonally-driven and shock-
related high rates of acute malnutrition. A recent systematic review of health inter-
ventions among mobile pastoralists found 140
What this article adds: A systematic review was undertaken of studies describing studies, seven of which included child nutrition
interventions within mobile pastoralist communities to improve child nutrition status. A outcomes (Wild et al, 2020). Their description
total of 16 studies were included, drawn from a previous systematic review of health of the results focuses largely on the facilitators
interventions in pastoralist communities and previous Emergency Nutrition Network and barriers to intervention success and, since
Field Exchange articles. The results reveal that low levels of education, poverty, poor they include all health interventions, the mention
infant and young child feeding practices and poor health-seeking and hygiene practices of nutritional interventions is very limited. Given
are key determinants of child malnutrition in mobile pastoralist communities. Food the high rates of malnutrition among children
security is also a contributing factor, especially during drought and conflict, and in this community and the limited knowledge
pastoralists who settle, particularly in regions unsuitable for agronomist lifestyles, have a synthesis on this topic, in this report we revisit
greater risk of food insecurity. During stable periods, however, there is evidence that the seven nutrition intervention studies found
children in mobile pastoralist communities can access quality diets. Evidence from that search and summarise these alongside a re-
intervention studies shows that targeting livestock health can add nutritive value and view of all the articles on this topic that have
stability to the milk supply chain, food aid during periods of shock can reduce the levels been published in Emergency Nutrition Network
of child wasting and anaemia and culturally-targeted, community-directed nutrition (ENN)’s Field Exchange. The purpose of this re-
education may improve child nutrition. More research in this area is needed across a view was to answer the questions – what types
range of contexts. of interventions have been described and what
aspects of these interventions have succeeded or
failed in improving the nutritional status of chil-
dren living in mobile pastoralist communities?
Introduction alone (Carr-Hill, 2013). Children who live in
Pastoralists, defined as populations that practise pastoralist areas are increasingly regarded as Methodology
animal husbandry as their primary economic some of the most nutritionally vulnerable in We reviewed and described the seven studies
activity and typically practise some degree of the world. Nutrition surveys in Eastern Ethiopia identified by a recent search of PubMed/MED-
seasonal mobility, inhabit some of the harshest, and other pastoralist areas of Africa have long LINE, Scopus, Embase, the Cumulative Index
most remote terrain on earth. These communities identified seasonally high rates of acute malnu- to Nursing and Allied Health Literature (CINAL),
migrate with herds of livestock to follow seasonal trition (Chotard et al, 2010). Pastoralist popu- Web of Science, the World Health Organization
grazing grounds and water sources. Often not lations are vulnerable to shocks that result in (WHO) Catalog, Agricultural Online Access
included in routine demographic surveys, their nutrition risks such as drought, animal disease, (AGRICOLA), the Centre for Agriculture and
numbers are unknown, however estimates range market disruption and the closure of borders Bioscience International (CABI), the Scientific
from 50 to over 300 million individuals globally. and many pastoralists’ nomadic livelihoods pre- Electronic Library Online (ScIELO) as well as
The African Union estimates there are 268 vent them from accessing health services designed Google Scholar and structured Google searches
million pastoralists on the African continent for sedentary populations. Understanding how to query grey literature such as humanitarian
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Research

Table 1 Summary of papers included

Author Country Population Objectives Study design Findings

and year
Peer reviewed publications
(Chege et Kenya 60 mothers of To investigate the influence of Qualitative focus Nomadism results in animal products being inaccessible to
al, 2015) Maasai children <5 culture on dietary practices groups (descriptive) most children since men are away with animals. Animals
years among Maasai children are rarely slaughtered or sold. Children mainly consume
cereals and legumes. (descriptive) (descriptive)
(Gizaw et Ethiopia 367 children <2 To assess the prevalence of Cross-sectional Prevalence of diarrhoea was high at 31%. It was associated
al, 2016) years in a nomadic diarrhoea and its association survey (descriptive) with sub-optimal breastfeeding practices and eating
population with feeding practices uncooked foods.
(Vossenaa Kenya 882 breastfed To formulate age- and context- Combination of Optimising current diets to improve complementary
r et al, children aged -23 specific complementary feeding nutrient gap analysis feeding could ensure adequate levels of most nutrients
2017) months recommendations, based on and ethnographic among settled and pastoralist infants/children, but less so
current diets and assess barriers techniques among agro-pastoralist communities where use of
to uptake of recommendations. (descriptive) nutrient-dense foods was limited.
(Seid et al, Ethiopia 420 children aged To assess the determinants of Facility-based, Rural residence, illiterate father, monthly income of less
2017) 6-59 months with acute malnutrition unmatched case than 1000 birr and food served together with family were
their caregivers control study statistically associated with acute malnutrition.
(descriptive)
(Le Port et Senegal 204 children age To assess whether a dairy value Cluster randomised Anaemia prevalence was very high at baseline (80%) and
al, 2017) 2-5 years chain could be used to distribute controlled trial (RCT) dropped to 60% at endline with no differences between
a micronutrient-fortified yoghurt (intervention) study groups. Hb increased by 0.55 g/dL, (95%CI 0.27 0.84)
to improve haemoglobin (Hb) more in the intervention compared to the control group
and reduce anaemia after one year.
(Bernard Senegal 320 household To reduce variability in milk RCT (intervention) This intervention increased the regularity of milk deliveries
et al, 2019) groups deliveries and improve children’s and may have improved child Hb status.
nutritional status by providing
fortified yogurt to milk suppliers
(Salehi et Iran 811 families with To assess the impact of a RCT (intervention) After 12 months, intervention, children had significantly
al, 2004) children aged <5 community-based education greater gains in weight-for-age (WAZ), height-for-age (HAZ)
years intervention on child growth and weight-for-length (WLZ) than controls.
(Stefanak Chad 641 malnourished To assess the impact of centre- Unmatched case Children receiving supplementary food in a two-week take-
and children based vs take-home control study home programme had similar weight gain to those
Jarjoura, (WLZ<80% supplementary feeding on child (intervention) enrolled in a supervised daily rehabilitative feeding
1989) median) <5 years weight gain programme.
(Bush, Kenya 1,000 households To evaluate the role of food Cross sectional There was a decline in rates of childhood malnutrition as a
1995) in drought- assistance in the context of long- surveys and result of food assistance.
affected Turkana term drought qualitative case
district studies (intervention)
Other literature
(CDC, Mongolia 937 children 6-59 To assess the nutritional effects Cross-sectional There was no difference in nutritional status (wasting,
2002) months of severe winters on pastoralist survey (descriptive) stunting underweight) between affected and unaffected
children areas. Wasting was approx. 2% and stunting 30%
(Sadler Ethiopia 40 men and To examine pastoralists’ views on Qualitative Milk contributes the majority of children’s diets when it is
and women sampled the causes of child malnutrition, participatory focus available. During the dry season and during periods of
Catley, from two areas of links between child nutritional groups (descriptive) drought, milk is not available and this is perceived to be
2010) the Somali region status and milk supply and directly associated with child weight loss.
interventions for addressing
malnutrition
(Mayer et Mali Representative To field test a novel survey Novel prevalence The method is practical for use in pastoral populations it is
al, 2009) sample of whole method, better designed to survey (descriptive) valid and is simple to apply. The method used local
population of assess prevalence of knowledge to sample whole ‘troupes’ (groups of
30,000 people malnutrition among pastoralist pastoralists who move together). There are significant
children differences in wasting prevalence when using MUAC vs
WLZ in this community.
(Reese- Kenya 227 children aged To investigate the socio- Secondary data Stunting prevalence was 28%, wasting by WLZ 8.8% and
Masterson 6-23 months economic and health-related risk analysis of survey MUAC<11.5cm 1.3%. Hand-washing, fever and older age
et al, 2016) factors associated with stunting, data (descriptive) were associated with stunting. Not owning livestock was
wasting and both combined associated with concurrent wasting and stunting.
(Buchanan Kenya All households in To evaluate the Oxfam Wajir Project evaluation Rates of malnutrition decreased during the provision of
-Smith the affected district Relief Programme 1996–98 report food aid and supplementary feeding.
and malnutrition
Barton, assessed in
1999) children < 5 years
(Sadler Ethiopia 940 children 6-59 To evaluate the impact of Case control study Targeted livestock support to milking animals that stay
and months livestock support on child (intervention) close to women and children during the dry season
Mitchard, nutritional status during the dry increases milk production and consumption among
2012) season children and improves nutritional status.
Cont’d next page
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Author and Country Population Objectives Study design Findings
year
Other literature
(Sesay et al, Somalia Community members To determine the viability of a Feasibility study Interventions should aim to enhance milk production
2018) from three livelihood livestock intervention and (cross-sectional and processing during the wet season and should
groups: pastoralists, identify areas to improve the survey and focus on improving milk handling, production and
agro-pastoralists and nutritional status of children 6- qualitative methods) preservation. Behaviour change related to IYCF
urban populations 23 months (intervention) should also be implemented.
*Abbreviations: IYCF=infant and young child feeding; RCT= randomised controlled trial. WLZ=weight for length z-score; WAZ= weight for age z-score; HAZ= height for age z-score; MUAC= mid-
upper arm circumference

agency reports (i.e., the International Organi- et al, 2017). Misinformation and cultural beliefs by community elders that educated children
zation for Migration (IOM), the United Nations detrimental to nutrition are common among during periods of migration. This resulted in
High Commission for Refugees (UNHCR) and pastoralist communities, such as the early intro- greater uptake of messages compared to when
Medecins Sans Frontieres (MSF)). duction of herbal teas before the age of six months messages were conveyed by ‘outsiders’ and led
Additionally, we searched the Field Exchange and the consumption of raw meat and blood to greater consumption of eggs, legumes and
database to identify any further studies not already which has infection risks (Chege et al, 2015). vegetables in children in the intervention group.
captured. We used similar search terms to those Positive nutritional cultural beliefs in this Animal milk is a nutrient dense food and
used in the above review, including ‘pastoralis*’ population include the perceived benefit of has long been recognised as an important com-
OR ‘nomad*’ AND ‘malnutrition’ or ‘nutrition’. animal milk for young children; when fresh ponent of pastoralist diets across the world. In-
Inclusion criteria was any descriptive or inter- milk is available, it is frequently given to children terventions that can increase milk production,
ventional child nutrition research targeted at no- and added to complementary foods (Sadler & sustain milk production through the dry season
madic or semi-nomadic pastoralist populations. Catley, 2010). While milk from animals is a and include milk consumption alongside the
major part of children’s diets when the animals promotion of optimal IYCF practices are likely
Results are accessible and productive, the animals are to positively impact child nutrition. While many
Seven studies already identified by Wild et al
often not accessible to women and children as livestock interventions have taken place in these
(2020) were included. Our search of the Field
they are away with the men seeking pasture communities, we only found four examples that
Exchange database identified 213 titles and ab-
(Chege et al, 2015). In a normal year, the dry demonstrated a positive impact on child nutrition
stracts of which 10 full texts were reviewed with
season can result in a 70% reduction in children’s (Sadler, 2012; Sesay, 2018; Le Port, 2017; Bernard,
six reports ultimately included. Two of these
consumption of milk and, in a drought year, 2019). A feasibility study found that the timing
studies were interventions and four were de-
children’s milk consumption can drop to negli- of these interventions is important. To maximise
scriptive. We excluded three studies targeting
gible amounts (Sadler & Catley, 2010). One impact, interventions should focus on enhancing
sedentarised pastoralist populations only. We
study suggests that, during a normal year, pas- milk production, processing and consumption
identified one study that was a systematic literature
toralist communities have access to adequate during the season when milk is most scarce
review of food assistance for pastoralist popula-
diets that could be optimised for adequate com- (Sesay et al, 2018). There is also a need to build
tions and we used the reference list of that review
plementary feeding with improved diet knowledge the capacity of communities in milk handling
to identify a further three studies with child nu-
by caregivers (Vossenaar et al, 2017). However, and preservation. An intervention that gave
trition outcomes (Czuba et al, 2017). In total,
agro-pastoralists (pastoralists who have largely milking animals a daily ration of supplementary
we included 16 papers in this review, details of
settled and practice crop production) had more feed plus a package of vaccinations and de-
which are summarised in Table 1.
limited access to diverse diets and sedentarisation worming medications during the four months
Descriptive studies can lead to further impoverishment and mal- of the dry season resulted in significantly in-
Descriptive studies of pastoralist communities nutrition as the context is often too unpredictable creased milk consumption among young children
have found child malnutrition rates to be high, for crop production and the families are inex- and had positive implications for nutritional
especially in the lowest income families and those perienced in this way of life (Vossenaar et al, status (Sadler & Mitchard, 2012). While a study
with illiterate parents (Reese-Masterson et al, 2017). The decreased mobility of pastoralists in this review found that biweekly outpatient
2016; Seid et al, 2017). The difference in 7natural globally has been caused by climate change, po- visits were effective at treating children with
body proportions of many pastoralist populations litical instability and programmes that encourage severe wasting (Stefanak & Jarjoura, 1989), a
means that estimates of wasting prevalence differ settled status (Bush, 1995). preventative intervention such as livestock
significantly when using weight-for-length/height support is likely to be more cost-effective and
z-score (WLZ/WHZ) versus mid-upper arm cir-
Interventions reduce the risk of severe wasting happening in
Education interventions, food assistance, the the first place.
cumference (MUAC); which method to use and
provision of fortified yogurts as part of the milk
how to address this is an ongoing challenge.
value chain and livestock support have all been Besides livestock support, two other studies
Poor infant and young child feeding (IYCF), effective in improving children’s diets and nu- improved children’s milk product consumption
health-seeking and hygiene practices are common tritional status. These successful interventions and nutritional status through a milk value
among pastoralists with high rates of child un- were all highly tailored to their context, based chain incentive intervention (Le Port et al, 2017;
dernutrition (Sesay et al, 2018). The nomadic on discussions with communities and aimed to Bernard et al, 2019). Farmers were offered
lifestyle and the temporary nature of many set- support the communities’ semi-nomadic way fortified yoghurt for their children when they
tlements mean that many families do not have of life and optimise child survival in these arid came to sell their milk to a processing factory
access to health, education and sanitation services. contexts. For example, in Iran, a successful ed- during both the wet and dry seasons despite the
This is likely to contribute to high rates of diar- ucation and behaviour change intervention milk production level falling in the dry season.
rhoeal disease which leads to and exacerbates aimed at tackling harmful cultural beliefs such The yoghurt was fortified with iron due to high
undernutrition (Gizaw et al, 2016). A study of as the discarding of colostrum and the delayed rates of anaemia in the region. Additionally, the
water hygiene practices in communities with introduction of complementary feeding was im- practice of milk fermentation improves the
large concentrations of cattle also found that plemented by building on positive cultural beliefs bioavailability of micronutrients in milk and
child malnutrition rates were lower in families and utilising known community influencers improves food safety. This public-private part-
that cleaned their water containers or did not (Salehi et al, 2004). The intervention was em- nership also had the benefit of improving the
share their water source with livestock (Marshak bedded within existing mobile schools formed regularity of milk deliveries to the factory,
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98
Research
................................................

making the business viable which, in turn, could

improve investment and employment in the
area (Le Port et al, 2017; Bernard et al, 2019).
Contexts with nomadic pastoralist commu-
nities are vulnerable to shocks as well as the
impact of seasonality, often as a result of warming
climates, irregular rainfalls and political insecurity.
During crises, food aid interventions have fre-
quently been used to protect children from severe
wasting. The effectiveness of food aid interventions
has been evaluated by a number of studies in-
cluding a systematic review in 2017 (Czuba et

© FAO/IFAD/WFP/Michael Tewelde
al, 2017) which included three studies that
focused on child nutrition outcomes (Buchanan-
Smith & Barton, 1999; Bush, 1995; CDC, 2002).
These studies all argue that the rates of malnu-
trition in children decreased because of access
Pastoral Community
to food assistance. For example, following the Development Programme –
loss of many livestock due to drought in Wajir Human and Animal Health Post
district in Kenya, a food relief programme was
set up that provided 80% of households’ calorific
requirements. This saw acute malnutrition rates been assessed, those that have, have been suc-
fall from 25% to 9% in just four months
Conclusion
In conclusion, there is evidence from descriptive cessful. Interventions that target livestock health
(Buchanan-Smith & Barton, 1999). There was and add nutritive value and stability to the
also a tangible drop in child mortality and other studies that low levels of education, poverty,
poor IYCF practices and poor health-seeking milk supply chain or that provide sufficient
secondary benefits including a reduction in food aid during periods of shock have seen re-
household debt and a reduction in the price of and hygiene practices are important determi-
nants of child malnutrition in mobile pastoralist ductions in the levels of child wasting and
maize which allowed more families to purchase anaemia. Given the identified risk factors, nu-
it. These economic benefits of food aid are often communities. While studies show that food
insecurity is a significant contributing factor trition education interventions are also im-
not assessed but are important for the sustainability portant for this community and those that
of the intervention. For example, a generous to child malnutrition, especially during times
provide culturally tailored and community-di-
ration of food relief following a drought in of drought and conflict, there is evidence from
rected interventions show promise for improving
Turkana district in Kenya helped prevent further one study that, during stable periods, children
child nutrition. More research into these in-
livestock depletion and enabled cash generation of nomadic pastoralists can access quality diets.
terventions across a range of pastoralist contexts
through the selling of surplus food (Bush, 1995). Pastoralists who have settled, often in regions
is needed, given the high rates of child malnu-
This evidence suggests that, despite the notion that are unsuitable for an agronomist lifestyle,
trition in these vulnerable communities.
that food aid is an unstainable intervention, it have greater food insecurity than nomadic pas-
can have longer term benefits for child nutrition toralists. While few interventions for improving For more information, please contact Natasha
when used during periods of drought. child nutrition in pastoralist communities have Lelijveld at [email protected]

References Gizaw, S, Abera, M, Muluye, M, Hoekstra, D, Gebremedhin, Salehi, M, Kimiagar, S, Shahbazi, M, Mehrabi, Y and Kolahi,
B and Tegegne, A (2016) Smallholder dairy farming A (2004) Assessing the impact of nutrition education on
Bernard, T, Hidrobo, M, Le Port, A and Rawat, R (2019) systems in the highlands of Ethiopia: System-specific growth indices of Iranian nomadic children: an
Nutrition-based incentives in dairy contract farming in constraints and intervention options. application of a modified beliefs, attitudes, subjective-
Northern Senegal. American Journal of Agricultural norms and enabling-factors model. British journal of
Economics, 101, 404-435. Le Port, A, Bernard, T, Hidrobo, M, Birba, O, Rawat, R and
nutrition, 91, 779-787.
Ruel, M T (2017) Delivery of iron-fortified yoghurt,
Buchanan-Smith, M and Barton, D (1999) Evaluation of through a dairy value chain program, increases Seid, A, Seyoum, B and Mesfin, F (2017) Determinants of
the Wajir Relief Programme: 1996–1998. Consultancy hemoglobin concentration among children 24 to 59 acute malnutrition among children aged 6–59 months in
Report Prepared for Oxfam GB (mimeo), 1-55. months old in Northern Senegal: A cluster-randomized Public Health Facilities of Pastoralist Community, Afar
Bush, J (1995) The Role of Food Aid in Drought and control trial. PloS one, 12, e0172198. Region, Northeast Ethiopia: a case control study. Journal
Recovery: Oxfam's North Turkana (Kenya) Drought Relief of nutrition and metabolism, 2017.
Marshak, A, Young, H, Bontrager, E N and Boyd, E M (2017)
Programme, 1992–94. Disasters, 19, 247-259. The relationship between acute malnutrition, hygiene Sesay, F F, Gebru, B W, Le, M T, Majeed, S E, Codjia, P and
Carr-Hill, R A (2013) Measuring progress toward the practices, water and livestock, and their program Volege, M (2018) Feasibility of a milk matters initiative to
Millennium Development Goals and the missing millions. implications in Eastern Chad. Food and nutrition bulletin, enhance milk intake in children over six months of age in
World health & population, 14, 4-11. 38, 115-127. Somalia. Field Exchange 58, 23.

CDC (2002) Nutritional Assessment of Children After Mayer, A-M, Myatt, M, Aissa, M A and Salse, N (2009) New Stefanak, M and Jarjoura, D (1989) Weight gain in
Severe Winter Weather - Mongolia, June 2001. MMWR. method for assessing acute malnutrition in nomadic supervised and take-home feeding programmes in Chad.
Washington DC, USA. pastoralist populations. Field Exchange 35, 30. Journal of tropical pediatrics, 35, 214-217.

Chege, P M, Kimiywe, J O and Ndungu, Z W (2015) Reese-Masterson, A, Maehara, M and Gathii, M M (2016) Vossenaar, M, Knight, F A, Tumilowicz, A, Hotz, C, Chege, P
Influence of culture on dietary practices of children under Stunting and wasting in children under two years old in a and Ferguson, E L (2017) Context-specific complementary
five years among Maasai pastoralists in Kajiado, Kenya. semi-nomadic pastoralist population in Kenya. Field feeding recommendations developed using Optifood
International Journal of Behavioral Nutrition and Physical Exchange 52, 11. could improve the diets of breast-fed infants and young
Activity, 12, 1-6. children from diverse livelihood groups in northern
Sadler, K and Catley, A (2010) Milk Matters: Improving
Kenya. Public health nutrition, 20, 971-983.
Chotard, S, Mason, J B, Oliphant, N P, Mebrahtu, S and Health and Nutritional Status of Children in Pastoralist
Hailey, P (2010) Fluctuations in wasting in vulnerable child Communities. Available: Wild, H, Mendonsa, E, Trautwein, M, Edwards, J, Jowell, A,
populations in the Greater Horn of Africa. food aNd https://www.ennonline.net/fex/38/milk [Accessed Gebregiorgis Kidanu, A, Tschopp, R and Barry, M (2020)
NUTriTioN bULLETiN, 31, S219-S233. 01/04/2010 00:00:00]. Health interventions among mobile pastoralists: a
systematic review to guide health service design. Tropical
Czuba, K, Ayala, A P and O'Neill, T J (2017) The Impact of Sadler, K and Mitchard, E (2012) Impact of livestock
Medicine & International Health, 25, 1332-1352.
In-Kind Food Assistance on Pastoralist Livelihoods in support on animal milksupply and child nutrition in
Humanitarian Crises. Ethiopia. Field Exchange 44, 8.

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 Summaries
Report ......................................................................
Asia and the Pacific Regional Since the causes of undernutrition are multi-
faceted and broad-ranging, the cost of a healthy
diet is a critical factor to ensure food security
Overview of Food Security and nutrition for all. In the region, 1.9 billion
people are unable to afford a healthy diet; therefore,
integrated policies and approaches to address
and Nutrition Report summary1 food affordability, availability and accessibility
are needed.
Globally, there is consensus that to address

T
he third annual Food Security and Nu- Five years on from the launch of the SDGs, these issues, an integrated and coordinated systems
trition report, jointly written by the the report reveals that, overall, the region is not approach is needed, involving institutions and
Food and Agriculture Organization, on track to achieve the 2030 targets. In 2019, actors across the water and sanitation, health,
the World Health Organization, 350.6 million people in the region were estimated social protection and education systems. Social
UNICEF and the World Food Programme explores to be undernourished, more than half of the behaviour change communication needs to be
the progress of countries in the Asia and Pacific global total. An estimated 74.5 million children mainstreamed throughout these systems for
region towards the Sustainable Development Goals under five years of age were estimated to be greater uptake and sustainability of healthy be-
(SDG) and World Health Assembly (WHA) targets stunted and a total of 31.5 million children under haviours and diets. Strong political will, com-
on nutrition. Split into two parts, the report firstly five years of age in the region were classified as mitment and leadership are needed to mobilise
tracks progress on key SDG targets up to 2019 wasted. The prevalence of overweight and obesity stakeholders in a multi-sector approach. To make
and explores some scenarios which highlight the is also growing. the most efficient use of scarce resources, it is
potential impact of the COVID-19 pandemic. important to invest in the most cost-effective
The second part of the report focuses on potential While the true impact of COVID-19 on food and impactful interventions to improve maternal
solutions to improve the diets of mothers and security and nutrition is yet to be established, it is and child diets. With only 10 years left to achieve
children in the Asia and Pacific Region as well as projected that these 2019 estimates will be driven the 2030 agenda, a combination of these efforts
noting some of the challenges. The report aims to even higher as a result of the pandemic. There is is needed to support the active promotion of
raise awareness of the importance of maternal thus a clear need for governments and partners to maternal and child diets.
and child diets as well as to support conversations intensify commitments to implement evidence-
1
around shaping policies and practices across the based policy and programmes to accelerate progress https://www.unicef.org/rosa/media/12181/file/
Asia%20and%20the%20Pacific%20Regional%
region in order to achieve food security and nu- towards the SDGs as well as building resilience 20Overview %20of%20Food%20Security%
trition for all. against future disasters and epidemics. 20and%20Nutrition.pdf

The effects of food systems interventions on food

security and nutrition outcomes in low- and
middle-income countries Report summary1

T
here is a significant global focus on over 100 impact evaluations each and at least 20 erment. The majority of studies examined either
improving food systems to address systematic reviews. These predominantly focused final or intermediate outcomes with only one
malnutrition and food insecurity in on direct food provision or targeted consumer fifth exploring outcomes along the causal chain.
low- and middle-income countries behaviours by providing supplements, fortification,
While this EGM was primarily developed as a
(LMICs). However, the complicated and disor- classes, peer support and counselling.
tool to identify relevant literature, it also provided
ganised nature of the evidence base makes navi-
The literature predominantly focused on ran- some useful recommendations for future research
gating it a challenge for policy makers, donors
domised trials (approximately three quarters of to fill the identified evidence gaps. For example,
and practitioners. To address this, the International
all impact evaluations) at local and sub-national for widely implemented interventions, such as
Initiative for Impact Evaluation (3ie), with support
levels. Mixed methods approaches were less com- those related to labelling and advertising regulations
from Innovative Methods and Metrics for Agri-
monly used and interventions at national and and governmental price manipulations, evaluations
culture and Nutrition Actions, was commissioned
transnational levels were lacking, despite their are needed to explore their potential for negative
by Deutsche Gesellschaft für Internationale
wide reach. There was also a lack of qualitative consequences and ensure the efficient use of funds.
Zusammenarbeit to develop an evidence gap
data to inform the context-specific impacts of More research into the effects of interventions on
map (EGM) on the literature relating to food
interventions. Few studies conducted cost analyses different populations should also be explored.
systems interventions to food security and nu-
which are important in understanding how to Furthermore, qualitative research or impact eval-
trition outcomes in LMICs.
best allocate resources. Several interventions were uations that examine the intermediate steps in the
An interdisciplinary approach was used to under researched, with no impact evaluations theory of change, together with the final intervention
identify a total of 178 systematic reviews and identified for advertising regulations, food waste outcomes, are needed to develop more effective
1,838 impact evaluations. The majority of the education programmes or food packaging. While interventions.
impact evaluations were conducted in sub-Saharan women play a major role within food systems,
Africa (33%), South Asia (20%) and East Asia limited evidence was available for interventions
and the Pacific (17%) with over half focusing on to support their decision-making and for those 1
https://www.3ieimpact.org/sites/default/files/2021-
rural areas. The most common interventions had that measured outcomes related to their empow- 01/Food-system-EGM-brief.pdf
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 Report Summaries
.......................................................................................................................................

Simplified approaches for the treatment of child

wasting: A rapid evidence review Report summary1
By Emilie Buttarelli, Grace Funnell and Sophie Woodhead
Dr Emilie Buttarelli is a bio- Grace Funnell is a Programme Sophie Woodhead is a Nutrition
cultural anthropologist currently Specialist with the UNICEF Consultant with UNICEF
working with the Communication Nutrition Section in New York Programme Division, New York.
for Development team at the where she supports the agency’s Prior to joining UNICEF, Sophie
UNICEF West and Central Africa strategic goals on wasting and worked with the World Food
regional office. Prior to joining leads the global coordination Programme, Action Against
UNICEF, Emilie conducted social science research and implementation of simplified approaches. Hunger and other organisations on nutrition and
and managed emergency projects in the West Prior to joining UNICEF, Grace served as Action early childhood development programmes in
and Central Africa region. Against Hunger USA’s Technical Director. countries across sub-Saharan Africa and South Asia.

dosage. However, recovery rates tend to be less

GLOBAL satisfactory for children admitted with MUAC
under 115 mm (severe wasting) receiving either
What we know: Simplified approaches for the treatment of child wasting are increasingly standard or modified dosages. Recovery rates
being implemented in countries to improve the coverage and cost-effectiveness of treatment for children admitted with a MUAC between
services. 115 mm and 124 mm (moderate wasting) are
always far higher than Sphere standards. Recovery
What this article adds: The effectiveness of 36 projects testing simplified approaches in
rates for MUAC-only admissions are generally
21 countries was reviewed. Simplifications include the use of mid-upper arm
satisfactory when compared with Sphere stan-
circumference (MUAC) as the only admission criteria, the family MUAC approach,
dards. However, as noted when dosages are
modified dosage of ready-to-use food, use of a single product for the treatment of both
modified, recovery rates are generally lower for
severe and moderate wasting, modification of admission criteria and delivery of wasting
children admitted with MUAC <115 mm or
treatment by community health workers (CHWs). While the family-MUAC approach is oedema compared to those admitted with MUAC
implemented operationally, it has so far been less documented than other approaches. As between 115 mm and 124 mm. Recovery rates
a context-specific approach is promoted, the evidence is heterogeneous and includes for the delivery of wasting treatment by com-
gaps. The evidence on modified dosages shows that nutritional outcomes (recovery, non- munity health workers (CHWs) were found to
response, defaulting, death) are usually non-inferior to the standard dosage although be unanimously better when compared to stan-
further research is needed. Nutritional outcomes for admissions based on MUAC-only dard treatment and defaulter rates were lower.
and for the delivery of wasting treatment by CHWs are satisfactory when compared to
standard treatment. The evidence is promising for some simplifications, implemented Discussion
alone or in combination and when tailored to the specific context. The evidence base on simplified approaches has
been growing, especially over the last five years,
and the West and Central Africa region has
one webinar presentation. Among these 63 re- been increasingly at the centre of testing and
Objective
sources, we identified 36 projects of which implementing different sets of simplifications.
This rapid review aimed to provide an overview
detail on precise simplifications existed in 33 The evidence is promising for some simplifica-
of the current evidence and practice on the
(shown in Figure 1). The available evidence tions alone (CHW approach, family-MUAC,
treatment of child wasting using simplified ap-
on simplified approaches covers 21 countries: MUAC-only programming) and for combined
proaches. Simplified approaches include a range
10 in West and Central Africa, six in Eastern approaches (such as the OptiMA and ComPAS
of adaptations of treatment protocols and pro-
and Southern Africa, four in South Asia and research protocols which combine various sim-
grammes for the community-based management
one in the Middle East and North Africa and a plifications). The positive results documented
of acute malnutrition (CMAM) that aim to im-
multi-country secondary analysis to design the when CHWs deliver treatment may be linked
prove coverage and cost-effectiveness. This review
ComPAS2 dosage table. Action Against Hunger, to the fact that, with community level care,
compiles the existing evidence, synthesising the
ALIMA, the International Rescue Committee caregivers do not have to travel to health centres
variety of simplifications implemented to date,
and UNICEF are the four organisations that which can be far away from their villages, thereby
as well as treatment outcomes. overcoming the well-documented barrier of dis-
have contributed the most to the available evi-
Methodology dence on simplified approaches. tance to the nearest health facility. Evidence
The rapid review examined peer reviewed liter- related to the combination of different simplifi-
Using mid-upper arm circumference (MUAC) cations is more recent, heterogeneous and in-
ature, grey literature (final reports, online pub- as the only admission criteria is the most frequently cludes some gaps given that context-specific ap-
lications) and other unpublished material (pro- used simplification, followed by the use of a mod- proaches are promoted. This heterogeneity is
tocols, internal reports, webinars, briefs). The ified dosage of ready-to-use food, the use of a
effectiveness of the simplified approaches was single product for treatment of both severe and
assessed using standard programme indicators. moderate wasting and the modification of ad-
1
UNICEF (2020) Treatment of Wasting using Simplified
Approaches. A Rapid Evidence Review.
mission criteria. Some of the projects reviewed
Results tested a combination of simplifications, such as
https://www.acutemalnutrition.org/en/resource-library/
3KWsCWIxdQXSiXFOCME2fj
We reviewed a total of 63 resources: 19 protocols,
the ComPAS and OptiMA3 trials which have 2
The ComPAS project refers to the Combined Protocol for
16 peer reviewed papers, 10 Emergency Nutri- Acute Malnutrition Study implemented by IRC and Action
brought together MUAC only admissions, modified
tion Network (ENN) papers, five proposals, Against Hunger using a single treatment approach for
dosage and the use of one product for treatment. children with wasting
three trials, four reports, three documents on 3
OptiMA: Optimizing treatment for acute Malnutrition, is a
preliminary results/protocol, one information Recovery rates for projects including a mod- combined protocol implemented by ALIMA in several
sheet, one terms of reference document and ified dosage are usually non-inferior to standard countries across West and Central Africa
.......................................................................................................................................
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.......................................................................................................................................
Report Summaries

linked to different organisations testing different combinations

of simplifications under different circumstances making it Figure 1 Simplified approaches included in projects
challenging to directly compare results. However, the
evidence available and consolidated in this review provides
important programming insights that can inform the con-
Family-MUAC 8
tinued testing of these approaches.
Delivery of AM management by
Given that the nutrition outcomes of the various 15
Community Health Workers
simplified approaches may vary according to the context

Simplification
and pre-existing challenges (e.g., high prevalence of stunting Use o one product (RUTF) 20
and distance to health centres), we recommend that sim- for treatment
plifications continue to be selected and combined based
Modified dosage 22
on the context. Contextualising simplified approaches
involves identifying barriers to early detection and treatment Admission for all children MUAC
17
and understanding the humanitarian and nutritional <125mm and/or oedema
situation to improve the overall effectiveness of treatment
services. Outstanding questions remain regarding the MUAC only admission 23
optimal dosage for the most vulnerable children (MUAC
0 5 10 15 20 25
<115 mm); continued research is needed in this area.
Amount of Projects
For more information, please contact Grace Funnell at
[email protected] MUAC = mid-upper arm circumference; AM = acute malnutrition; RUTF = ready-to-use therapeutic food

Children eating well in cities:

A roadmap for action to
support nutritious diets and
healthy environments for all
children in urban settings

N
ew forces are influencing the global surging food prices. Given these factors, urban- acknowledges the important role of governments
1
Reporty summary
burden of child malnutrition. One isation clearly presents several challenges for at all levels to coordinate efforts and innovate to
such force is that of urbanisation, as tackling malnutrition. support good nutrition within urban environ-
people around the world increasingly ments. In many countries, through devolution
Understanding how children and their care-
leave the countryside for urban areas. As a result, processes, local governments are increasingly
givers experience urban environments is thus a
many families are changing the way they feed gaining responsibility for nutrition and already
critical starting point for designing actions to
their children. Traditional diets are increasingly have been noted to be driving innovative ap-
improve malnutrition rates. Given this, UNICEF
being replaced by diets high in processed food, proaches to reduce malnutrition. Several prom-
developed a roadmap for action to support nu-
low in essential nutrients and high in salt, sugar ising city-level practices now exist to illustrate
tritious diets for families and children in urban
and fat. There is increasing consumption of com- how a city can initiate work on food and nutrition
contexts. This roadmap sets out how UNICEF
mercially produced snack foods and reliance on and the roadmap outlines several examples of
can support urban nutrition activities through
foods produced outside of the household. These city-level success stories. The roadmap also pres-
offering nutrition expertise, multi-sector action
trends not only increase the risk of overweight, ents a schematic overview of how responsibilities
and collaboration with partners and existing
obesity and diet-related noncommunicable dis- and roles can be allocated between the local and
city platforms. It aims to place child rights at
eases, they can also increase risk of micronutrient national level to drive forward targeted nutrition
the centre of the urban food agenda.
deficiencies and undernutrition. Although urban actions. This includes actions for governance for
dwellers have more access to basic goods including Using the Innocenti Framework on Food Sys- children’s access to nutrition and health, com-
food, they typically buy their food, which makes tems for Children and Adolescents, the roadmap mitment to child rights, social protection, par-
income a key factor in what they eat. While outlines actions for urban contexts across the ticipation and engagement, food and nutrition
cities offer many opportunities for employment, supply side, external and personal environments, in public institutions, water and hygiene, physical
cities house high concentrations of poor people and behaviours of caregivers. It recognizes that activity, food retail, food standards and labelling,
who live in polluted or insecure environments other systems, including health, water and sani- health and nutrition-related taxes, marketing
and who are not able to meet the costs of basic tation, education and social protection, also have and conflicts of interest.
goods. Cities are also more disconnected from crucial roles to play as part of a coordinated
food system supply chains which increases their multi-sector approach to address diets and prac- 1
https://www.unicef.org/media/89396/file/Children-eating-
vulnerability to unreliable food provision and tices in urban contexts. The roadmap further well-in-cities.pdf

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102
 Evaluation ..........................................................
© Sudharak Olwe, 2018

Early lessons from Swabhimaan,

a multi-sector integrated health
and nutrition programme for
women and girls in India
By Monica Shrivastav, Abhishek Saraswat, Neha Abraham,
R.S. Reshmi, Sarita Anand, Apolenarius Purty, Rika Shalima Xaxa,
Jagjit Minj, Babita Mohapatra and Vani Sethi

Monica Shrivastav is a consultant with the UNICEF Apolenarius Purty is State Programme Manager, The authors acknowledge the support of
supported ROSHNI-Centre of Women Collectives Health and Nutrition, Bihar Rural Livelihoods Deendayal Antyodaya Yojana-National
led Social Action, Lady Irwin College, New Delhi, Promotion Society (JEEViKA), Government of Bihar, Rural Livelihoods Mission (DAY-NRLM),
India, supporting evidence generation and Patna, India. DAY-NRLM’s women collectives’ leaders and
technical assistance to the National Rural representatives from Kasba, Jalalgarh,
Livelihoods Mission, Ministry of Rural Rika Shalima Xaxa is the State Programme Bastar, Koraput Sadar and Pallahara Blocks,
Development. Manager - Social Inclusion and Social the State Rural Livelihoods Missions of
Development at Chhattisgarh State Rural Bihar, Chhattisgarh and Odisha and the
Dr. Abhishek Saraswat is a demographer, Livelihoods Mission ‘BIHAN’, under the UNICEF State Office Bihar, Chhattisgarh
currently affiliated with the International Institute Department of Panchayat and Rural Development, and Odisha.
for Population Sciences, Mumbai, India, working Raipur, Chhattisgarh, India
as a data analyst for the Swabhimaan project. The impact evaluation partner for this work
Jagjit Minj is Programme Executive of the Social is the International Institute of Population
Neha Abraham is a Knowledge Management Inclusion and Social Development at Chhattisgarh Sciences, Mumbai, India. The authors also
Consultant at the ROSHNI-Centre of Women State Rural Livelihoods Mission ‘BIHAN’, under the acknowledge the contribution of the
Collectives led Social Action. Department of Panchayat and Rural Development, Swabhimaan consortium: Rabi N Parhi,
Raipur, Chhattisgarh, India Sandip Ghosh and Parimal Chandra
Dr. R.S. Reshmi is an Assistant Professor at the (Nutrition Section, UNICEF Bihar, Patna,
Department of Migration and Urban Studies at Dr. Babita Mahapatra is the Additional Chief India), Mahendra Prajapati (Nutrition
the International Institute for Population Executive Officer at the Odisha Livelihoods Mission Section, UNICEF Chhattisgarh, Raipur,
Sciences, Mumbai and is the coordinator of the (OLM) under the Panchayati Raj and Drinking India), Bharati Sahu (ROSHNI-CWCSA, New
Swabhimaan project. Water Department of Government of Odisha. Delhi, India), Sourav Bhattacharjee, Sonali
Sinha (Nutrition Section, UNICEF Odisha,
Dr. Sarita Anand is an Associate Professor at the Dr. Vani Sethi is a Nutrition Specialist at the Bhubaneshwar, India), Sayeed Unisa
Department of Development Communication and Nutrition Division of UNICEF India, working on (International Institute for Population
Extension, Lady Irwin College and is Centre Lead advancing adolescent and women’s nutrition Sciences, Mumbai, India) Arjan De Wagt
for the ROSHNI-Centre of Women Collectives led through Ministry of Health and Family Welfare and (Child Development and Nutrition, UNICEF
Social Action. the National Rural Livelihoods Mission platforms. India, New Delhi, India)

INDIA
What we know: Poor nutrition status before and during pregnancy is a serious problem in India and a key driver of low birth
weight and child undernutrition.

What this article adds: Swabhimaan is a five-year initiative (2016-2021) integrated within the Government of India’s flagship
poverty alleviation programme, Deendayal Antyodaya Yojana-National Rural Livelihoods Mission (DAY-NRLM), across three
states in India, carried out in partnership with UNICEF. The programme aims to mobilise women via village-level women’s
collectives to develop and implement integrated nutrition microplans and strengthen local government services in order to
improve the nutrition outcomes of women and adolescent girls. The results are presented of a midline evaluation carried out in
2018-2019 covering villages in five different sites across the three states (including 3,171 adolescent girls, 1,856 pregnant women
and 3,277 mothers of children under two years of age). The results reveal strong progress in implementation with 336 village-
level microplans developed, 77,000 females screened and 15,122 identified as being at nutritional risk and referred for nutrition,
agriculture and social protection support. Midline results show a reduction in thinness in adolescent girls (13.8% versus 18.5%
at baseline) and mothers with children under two years of age (44.6% versus 48.4% at baseline) and an increase in the average
mid-upper arm circumference of pregnant women (24.0cm versus 23.5cm at baseline). Evidence also shows improved
household food security and improved uptake of government health, water, sanitation and hygiene and social protection
services. Results suggest that utilising and funding women’s collectives to respond to nutrition needs in their communities with
integrated responses are feasible. The results of the endline evaluation and an impact evaluation will be forthcoming.
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Background lescents (NFHS-4, 2015–2016). Despite national powerment, and harnessing the ability of women
The poor nutritional status of a woman before and state level policies and programmes to to plan and implement context-specific pro-
and during pregnancy is a major cause of foetal deliver maternal care services in India, high gramme activities. A 2016 scoping study suggested
stunting and low birth weight (LBW). In India, quality coverage remains low. that DAY-NRLM village organisations have the
stunting affects around 47 million (38%) children potential to manage grants for improving the
The Indian Government’s flagship poverty
aged under five years (NFHS-4, 2015–16). An last mile delivery of essential nutrition services
alleviation programme, Deendayal Antyodaya
estimated five million Indian children (19%) for women provided they are enabled, supervised
Yojana-National Rural Livelihoods Mission
are born with LBW, around 4.4 million of whom and incentivised (Sethi et al, 2017).
(DAY-NRLM), implemented under the Ministry
are born small for gestational age (NFHS-4, of Rural Development, aims to break the inter- On the basis of these findings, Swabhimaan
2015-16). Most Indian women enter pregnancy generational cycle of poverty through the eco- was set up as a five-year initiative launched in
with poor nutrition – 23% of women of repro- nomic empowerment of vulnerable women and 2016 by DAY-NRLM in partnership with
ductive age are too thin for their height (body families. DAY-NRLM’s women’s collectives pro- UNICEF India across three states in India (Bihar,
mass index (BMI) less than 18.5 kg/m2) and 53 vide an opportunity to strengthen the delivery Chhattisgarh and Odisha). The programme aims
% of women are anaemic (increasing to 58% and promotion of women’s nutrition services at to improve the nutrition outcomes of women
among pregnant women). Additionally, 8% of community-level, linking livelihood promotion, and adolescent girls using DAY-NRLM women’s
pregnant women (around 4.5 million) are ado- women’s nutrition promotion and women’s em- collectives as the key mode of delivery focusing
on four primary target groups: adolescent girls,
newlywed women, pregnant women and mothers
Table 1 Swabhimaan package of nutrition-specific and nutrition-sensitive interventions of children under two years of age (secondary
target groups include husbands, mothers-in-
Relevant target group law and farmer producer groups). Community-
Adolescents Pregnancy Lactation led actions are delivered by DAY-NRLM. Systems
& newly wed strengthening activities also take place in con-
Improve food and nutrient intake vergence with four government departments to
increase access to government services: the De-
Access to generalised household ration through Public ✓ ✓ ✓
Distribution System, a food subsidy scheme partment of Women and Child Development
to increase the reach and quality of Integrated
Balanced energy protein supplementation through access to ✗ ✓ ✓
supplementary rations Child Development Services (ICDS), the De-
partment of Health and Family Welfare for
Access to knowledge and choices about how to increase maternal ✓ ✓ ✓ Village Health, Sanitation and Nutrition Days
dietary diversity
(VHSND), the Department of Water and Sani-
Access to knowledge and support for nutrition-sensitive agriculture ✓ ✓ ✓ tation to improve water quality and achieve
at home (kitchen gardens promoting nutritious foods and diet
diversity) and community-based food insecurity coping strategies
open defecation free villages and the Department
of Food and Civil Supplies to increase the
Prevent micronutrient deficiencies and anaemia coverage of food subsidy schemes. The pro-
Iron and folic acid supplementation ✓ ✓ ✓ gramme is funded by UNICEF India in Bihar,
which serves as a demonstration and learning
Universal use of iodised salt ✓ ✓ ✓
site, while the programme is led by the State
Deworming ✓ ✓ ✗ Rural Livelihoods Mission (SRLM) in Chhat-
Calcium supplementation ✗ ✓ ✓ tisgarh and Odisha with UNICEF providing a
Access to information and commodities such as insecticide ✓ ✓ ✓ portion of the support costs. Built into this pro-
treated bed-nets for malaria prevention gramme are baseline, midline and endline studies.
Access to information on preventing tobacco and alcohol use in ✗ ✓ ✗ The results of the midline study are presented
pregnancy here to help to fill the evidence gap on maternal
nutrition interventions delivered via women’s
Increase access to health services and special care to nutritionally ‘at risk’ women
collectives in India.
Early registration (in first trimester) in outreach services ✗ ✓ ✗
Recording and monitoring of nutritional status and special ✓ ✓ ✓ Intervention
community-based at nutritional risk package Swabhimaan provides a comprehensive package
of 18 nutrition-specific and nutrition-sensitive
Quality reproductive health, antenatal and postnatal care ✓ ✓ ✓
interventions spanning the health, nutrition,
Access to knowledge and entitlements for promotion of ✓ ✓ ✓ agriculture and livelihoods sectors targeted at
institutional deliveries and maternity benefits
women at preconception, during pregnancy
Increase access to education and commodities for water, and after birth (Table 1). These interventions
sanitation and hygiene
are delivered through a combination of com-
Sanitation and hygiene (including menstrual hygiene) education ✓ ✓ ✓ munity-led and systems strengthening actions
Access to safe drinking water and sanitation commodities ✓ ✓ ✓ (Table 2).
Prevent early, poorly spaced or unwanted pregnancies For the delivery of community-led actions,
Promotion of secondary education and education for delaying ✓ ✗ ✗ communities are engaged to customise a maternal
the age at marriage to legal age nutrition delivery package responsive to local
Access to information and family planning commodities for ✓ ✓ ✓
needs and to manage grants to implement the
delaying age at first pregnancy and prevention of repeated interventions. The community comes together
pregnancies under women’s collectives promoted under DAY-
Women’s collective voice and empowerment for decision-making ✓ ✓ ✓ NRLM made up of female representatives from
to prevent child marriage, violence against women, child spacing self-help groups (SHGs) and their federations
and other gender-related issues (Village Organisations (VOs) and Cluster Level
✓ = relevant target group; x = non-relevant target group
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acid (IFA) supplements, contraceptives, sanitary

Table 2 Community-led and systems strengthening actions under Swabhimaan napkins), INR1500 (~USD$22) to review each
Responsible Intervention Frequency
VO’s integrated nutrition microplan and INR5000
agency/service (~USD$77) to develop farmer training school
provider sites. Community-led interventions are monitored
through the collation and analysis of monthly
Community-led actions
reports submitted by CRPs for each VO that are
Village Organisation (VO) then reviewed by CLFs and block-level supervisors.
Social action committee Selection of Poshan Sakhi (one per VO) Once
The system strengthening interventions in-
Poshan sakhi/ Integrated nutrition microplanning (12 days over two months) Once, followed clude quarterly training of government accredited
community resource by annual review social health activists (ASHA) and auxiliary
person
Maitri baithak (translated as ‘friendly meeting)’ of women Monthly nurse midwives (ANM) to strengthen the delivery
open to non-group members using participatory learning of the fixed monthly health camps (VHSND)
and action (PLA)
for the provision of antenatal care (ANC) check-
One additional monthly home visit/group meeting of Monthly ups, counselling, micronutrient supplementation,
nutritionally ‘at risk’ women take-home rations under the supplementary
Krishi mitra/village Maitri kishan baithak (translated as ‘friendly farmers meeting’) Monthly nutrition programme, immunisation, weight
resource person (VRP) on nutrition-sensitive agriculture PLA monitoring, family planning and the identification
Home-based Poshan (translated as ‘ nutrition’) beds or Monthly and care of groups at nutritional risk. Training
garden/backyard poultry is also provided to strengthen Adolescent Health
Cluster-level federation (CLF) Days to improve access to adolescent health
and nutrition services. In addition, health service
Social action committee Families with women and children at risk of Monthly
providers (ASHA, ANM, Anganwadi workers
undernutrition linked to agri-poultry linkage and social (AWW) and lady supervisors of ICDS and the
protection schemes
Public Distribution System (PDS) fair price
Loans for secondary education Monthly shop owners are regularly engaged with to im-
Creating farmer training school sites Monthly prove the delivery of the service package and
Training for Poshan sakhi and Krishi mitras Quarterly entitlements. Regular review and convergence
meetings are conducted with the departments
Newlywed couples’ meetings and social drives Biannual
involved in service delivery. Reporting on system
Entitlement camps and health check-ups for self-help group Biannual strengthening is activity-based (monthly for
members
VHSNDs and biannually for trainings/refresher
Review of integrated nutrition plan Annual trainings) and overall programme reports are
Systems strengthening actions reviewed annually by the national government.
Strengthening of Village Health, Sanitation and Nutrition Monthly Evaluation methodology
Days including services for at nutritional risk and newlyweds.
To test the delivery and impact of the Swabhimaan
Training of auxiliary nurse midwives on VHSND Quarterly programme, baseline, midline and endline cross-
Convergence review at district and block level to address Quarterly sectional surveys were undertaken between 2016
VHSND bottlenecks and 2021 in three selected Indian states covering
Orientation of service providers Public Health Distribution Annual villages across five different sites. The baseline
System, Integrated Child Development Services and survey was conducted between October 2016
Department of Water and Sanitation to ensure communities and January 2017 and included 6,352 adolescent
receive entitled services girls, 2,573 pregnant women and 8,755 mothers
of children under two years of age. The midline
Federations (CLFs)). Each federation develops and measurements for screening nutritionally survey was conducted between September 2018
an integrated nutrition microplan that identifies ‘at risk’ adolescent girls and women (MUAC <19 and June 2019 with 3,171 adolescent girls, 1,856
and prioritises nutrition and related problems cm and <23 cm, respectively) (Bulliyyag, 2007; pregnant women and 3,277 mothers of children
among target groups in their village/s, an annual Tang, 2013) and participatory learning and action under two years. The endline survey will be
plan of activities and a budget. These budgets (PLA) techniques to facilitate monthly meetings conducted in 2021. Sample size calculations
are collated at block level, reviewed and approved for women and adolescent girls. Following their were conducted for each state that accounted
by DAY-NRLM and submitted to the SRLM, an training, CRPs facilitate the development of in- for a 5% refusal rate and a design effect of 1.5.
autonomous body under the state government, tegrated nutrition microplans, supervised by the Respondents were recruited using a simple ran-
which then provides the annual grant to each SRLM, and also provide home-based counselling dom sampling technique.
VO accordingly. for target groups, food demonstrations and sup- A standardised, bilingual quantitative ques-
port for the development of household nutrition tionnaire (in English and the local language)
The development of nutrition microplans is gardens (gardens growing fruits and vegetables
facilitated by a social action committee (SAC) was administered to all target groups. Infor-
for household consumption).
for each VO. The SAC nominates an active SHG mation obtained from the surveys included
member to be the Community Resource Person The CRPs receive INR450 (USD$7) to develop sociodemographic and household characteris-
(CRP). Women are eligible for nomination who an integrated nutrition microplan and thereafter tics, educational attainment, diet diversity,
are literate, effective communicators and who a similar monthly incentive for facilitating the household food security, the availability of a
have graduated out of poverty. CRPs, known lo- implementation of planned activities. CLFs homestead kitchen garden and access to health,
cally as Poshan Sakhis and Kishori Sakhis, receive grants including INR500 (~USD$7) for ICDS and SRLM services and decision-making
undergo three days of pre-service training on meetings with newlywed couples, INR500 practices. Anthropometric measurements
integrated nutrition microplanning, the use of (~USD$7) for each ‘welcome kit’ given to new- (weight, height and MUAC) were taken using
mid-upper arm circumference (MUAC) tapes lywed couples with essential items (iron-folic standard techniques. Quantitative data collected
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Evaluation

Coverage of health and nutrition services for adolescent girls, pregnant women and mothers of children under two in intervention
Table 3 areas in Swabhimaan in baseline (2016-17) and midline (2018-19) surveys
Adolescent girls (AG) Pregnant women (PW) Mothers (M2)
Indicators (%) Baseline Midline P-value Baseline Midline P-value Baseline Midline P-value
(N=3054) (N=1535) (N=1274)
(N=886) (N=4441) (N=1625)
Adolescent girls with BMI < -2SD 18.5 13.8 4.7*** - - - - - -
Mean MUAC among pregnant women (in cm) - - - 23.5 24.0 0.5 - - -
Mothers of children under two with <18.5 kg/m2 - - - - - - 48.4 44.6 3.8***
Mothers of children under two with severe thinness - - - - - - 7.0 6.5 0.5
Achieving minimum dietary diversity score (five of 10 food 41.3 48.0 -6.7*** 43.5 51.5 -8.0*** 37.0 52.1 -15.1***
groups)
Consuming IFA tablets (≥4: AG =25: PW in the month preceding 15.0 40.5 -25.5*** 24.8 29.4 -4.6*** 18.4 23.2 -4.8***
the survey =100 in last pregnancy: M2)
Living in a household with iodized salt 97.0 90.0 7.0 90.8 87.6 -2.8 96.2 89.4 6.8
Living in food secure households - - - 31.3 38.8 -7.5*** 22.2 34.4 -12.2***
Receiving their minimum PDS entitlement in month preceding - - - - - - 60.7 71.9 -11.2***
survey
Living in households with a kitchen garden 43.5 13.3 30.2 36.0 12.3 23.7 32.5 11.3 21.2
Living in households with an improved toilet 18.2 43.0 -26.5*** 16.4 40.7 -24.3*** 19.7 39.1 -19.4***
Using safe pads or sanitary pads 31.6 57.3 25.6*** - - - - - -
Antenatal check-up (first trimester: PW at least four ANC in last - - - 34.2 51.2 -17.0*** 18.2 34.1 -15.9***
pregnancy: M2)
Weight was monitored* PW, weighed at least four times last - - - 66.0 86.2 -20.2*** 24.1 29.4 -5.3***
pregnancy M2
Received one dose of albendazole in second trimester - - - 10.6 18.5 -7.9*** 21.4 32.5 -11.2***
Took calcium tablets in 2nd trimester* - - - 23.8 55.4 -31.6*** 29.7 60.4 -30.7***
Using a modern family planning method (before the current - - - 7.1 13.4 -6.3*** 16.3 19.9 -3.6***
pregnancy: PW, currently: M2)
Attended at least three VHSNDs in six months - - - 14.9 14.4 -0.5 24.4 26.7 -2.3**
Receiving ICDS entitlement for supplementary food in month - - - 34.7 55.8 -21.1*** 44.5 77.0 -32.5***
preceding survey
Delivered in a health facility in last pregnancy - - - - - - 73.3 76.4 -3.1***
Accessed maternity benefit scheme - - - - - - 53.0 47.5 5.5
Attending three monthly meetings on health and nutrition - - - 11.0 7.4 3.6 7.2 7.9 -0.7
related themes in last year
Level of significance: * p < 0.10, ** p < 0.05, *** p < 0.001

was entered using the Census and Survey Pro- viduals at nutritional risk for customised coun- Swabhimaan has also successfully strength-
cessing System and analysed using STATA 15.1. selling, home visits, food demonstrations, the ened the supply side of health services by sup-
A midline process evaluation was also under- development of a nutrition garden or backyard porting a change in government policy that
taken using a mixed-method approach com- poultry and, for some, links with government means that women are now screened for nutri-
prised of a cross-sectional survey and qualitative social protection schemes. By the end of 2019, tional risk within VHSNDs, with those identified
data collection. The impact evaluation has CRPs had facilitated a total of 37,079 monthly as being at risk then linked to the appropriate
been registered with the Registry for Interna- meetings (maitri baithaks) across the intervention services. This has led to a significant increase in
tional Development Impact Evaluations (RI- areas. Newlyweds had been oriented to maternal the participation of target groups in VHSND
DIE-STUDY-ID-58261b2f46876) and the Indian health issues in special biannual camps, provided from 29.5% across the three states at the start of
Council of Medical Research National Clinical with ‘welcome kits’ (contraceptives, IFA, sanitary the programme to 85% by 2019.
Trials Registry of India (CTRI/2016/11/007482). pads, soap), inducted into SHGs and were mo-
The impact evaluation’s endline survey and bilised to attend maitri baithaks. Over 1,000
Changes in maternal and adolescent
programme evaluation of Swabhimaan will be adolescent groups have also been formed and health and nutrition outcomes and
conducted in 2021. are currently active across the three states. practices
Table 3 presents comparison results between
Results VOs and CLFs have successfully collaborated the baseline and midline evaluations. Pre-in-
Progress of implementation with agriculture universities/training centres to tervention, the proportion of thin adolescent
Programme monitoring of Swabhimaan shows design nutrition-sensitive farms and backyard girls (BMI <-2SD) was 18.5% which reduced
all 336 VOs across the three states developed gardens. Households with target individuals at significantly to 13.8% (p<0.001) in 2019 after
integrated nutrition microplans that identified nutritional risk have been prioritised to develop programme implementation. The proportion of
community priorities and actions. By the end nutrition gardens in backyards and/or initiate thin mothers of children under two years (BMI
of 2019, VOs had screened over 77,000 adolescent poultry activities through small loans provide <18.5 kg/m2) was 48.4% in 2016-17 (compared
girls, pregnant women, mothers of children by the SHGs. By the end of 2019, over 5,000 nu- to the national average of 23%) and, by 2019,
under two years of age and newlywed women trition gardens had been developed across the the proportion of thin mothers reduced to
using MUAC, identifying nearly 15,122 indi- three states. 44.6%. The mean MUAC among pregnant women
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monthly women’s meeting Evaluation
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of labour in the household, domestic violence

and low decision-making power as barriers to
ensuring improved health and nutrition outcomes
of women and girls.

Lessons learned for scale up

The results between the baseline and midline
evaluations indicate improvement in the coverage
of health and nutrition services among all target
groups in the intervention areas including ado-
lescent girls, pregnant women and mothers of
children under two years of age across the three
©Sudharak Olwe, 2022

states of Bihar, Chhattisgarh and Odisha. The

results also demonstrate statistically significant
improvement in dietary diversity scores in all
target groups, BMI in adolescents and mothers
of children under two years of age and some
improvement (although not statistically signifi-
cant) in MUAC scores in pregnant women.
was 23.5cm which increased to 24.0cm by 2019. (baseline 24.1%, midline 29.4%) increased Access to maternal nutrition services have also
Severe thinness among mothers of children (p<0.001). Pregnant women and mothers who improved, although uptake remains low for
under two years of age was 7.0% in 2016 which received one dose of albendazole in their second some services including IFA supplementation
reduced to 6.5% by 2019 (Government of India trimester increased by 8-11% (p<0.001) by the for pregnant women and mothers, attendance
cut-off for thinness in adults is <23 cm) midline. A drastic improvement was recorded at a minimum of four ANC sessions and the
(IIPS,2016a; IIPS,2016b; IIPS 2016c; Ministry in the proportion of mothers (baseline 29.7%, participation of mothers in VHSNDs. Access to
of Health and Family Welfare, 2017). midline 60.4%) and pregnant women (baseline toilets still remains low with over half of the
23.8%, midline 55.4%) who took calcium tablets participants still not having access to a toilet
In comparison to the baseline, a higher pro-
in their second trimester (p<0.001). despite focused programmes implemented by
portion of pregnant women (baseline 43.5%,
the Department of Water and Sanitation.
midline 51.5%) and mothers (baseline 37.0%, The use of modern family planning methods
midline 52.1%) achieved minimum dietary di- among women was extremely low at baseline Lessons from programme implementation
versity scores than adolescent girls (baseline (pregnant women 7.1%, mothers 16.3%). How- provide evidence that VOs and CLFs can develop
41.3%, midline 48.0%) (p<0.001). At midline, ever, modest improvements were recorded in microplans and manage grants to strengthen
all target groups showed significant improvement the use of modern family planning methods by the provision of a maternal nutrition service
in IFA compliance as compared to baseline. The both pregnant women and mothers (4-6%, package for women and girls at nutritional risk
highest improvement was recorded among ado- p<0.001) at midline. A slightly higher proportion in underserved areas. This is a shift from the
lescent girls whose IFA consumption increased of mothers attended at least three VHSNDs by earlier approach of last mile delivery of health
by 25.5% (p<0.001). At midline, a 5% increment midline (26.7%, p<0.05) than at baseline (24.4%). services being a voluntary task that required
in IFA compliance was registered among pregnant ICDS entitlements were better utilised and sig- much investment from the health volunteers
women and mothers, however, the overall con- nificant improvements were recorded in the themselves. Early results also show that CRPs
sumption still remains low at 29.4% and 23.2%, utilisation of ICDS services by pregnant women can successfully mobilise women and adolescent
respectively (p<0.001). (baseline 34.7%, midline 55.8%) and mothers girls and organise monthly discussions on priority
(baseline 44.5%, midline 77.0%) (p<0.001). nutrition issues using a PLA approach despite
Data shows an 8-12% improvement in the Mothers who opted for institutional delivery societal resistance and challenges in mobilisation.
proportion of women living in food secure increased from 73.3% in 2016 to 76.4% by the The microplanning process is a critical initiator
households (p<0.001) from baseline to midline, baseline (p<0.001). of collective thinking, consensus on nutrition
however over 60% of women still lived in food problems and resolute action. The context where
insecure households. By midline, 71.9% of moth- Midline qualitative results revealed that CRPs
Swabhimaan operates is marked by stark social
ers’ households had access to PDS entitlement (Poshan Sakhis) conducted regular meetings,
and gender inequities (Reshmi, 2019). CRPs
as compared to only 60.7% at the baseline counselling and follow-ups with the target
have been able to overcome these resistances
(p<0.001). At midline, about 40-43% of the groups. Responses suggested that adolescent
and have made women’s health important for
target groups’ households had improved toilets, girls and pregnant women have adopted appro-
the communities through regular monthly meet-
with a 27%, 24% and 19% increase in adolescent priate behaviours related to dietary intake and
ings. VOs and CLFs are also able to collaborate
girls’, pregnant women’s and mothers’ households Water, sanitation and hygiene (WASH) practices
with agriculture universities/training centres to
having an improved toilet (p<0.001). At baseline, and have increased the number of visits to
design nutrition-sensitive farms and backyard
only 31.6% of the adolescent girls used sanitary health service points, such as Anganwadi Centres
gardens and enable access to grants to facilitate
pads which had significantly increased to 57.3% and VHSNDs, to access health and nutrition
this. VO and CLF activities under Swabhimaan
(p<0.001) by the midline. services. CRPs observed an increased awareness
can be scaled up at INR90000 (~USD$13,000)
about the entitlements and services available
in a resource block. The initiative in the three
At midline, 51.2% of pregnant women and and a visible change in the practice and knowledge
states has resulted in the creation of learning
34.1% of mothers had received an ANC in the of the community on food and WASH behaviours.
and implementation resources and trained CRPs
first trimester and at least four ANCs in their They also shared their experience of improved
and VRPs, such that the scale-up cost is mainly
last pregnancy respectively which corresponds coordination with health service providers
funding the training of new CRPs/VRPs and
to a 16-17% (p<0.001) improvement as compared (AWW, ASHA and ANM) which supported
incentives for service delivery. Gradually, it is
to the baseline. The proportion of pregnant access to services by the target groups. However,
possible to build these costs into the annual
women who had their weight monitored during they reported challenges in mobilising target
plans of the SRLMs.
their current pregnancy (baseline 66.0%, midline groups regularly for meetings and observed
86.2%) and mothers whose weight was monitored gender-related issues in the target groups, such In addition to community-led activities, nu-
at least four times during the last pregnancy as women eating least and last, a skewed division trition outcomes are dependent on the availability
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and access to timely health and nutrition services. maternal nutrition service package. Regular will act as resource persons in the remaining
This requires effective interventions that target handholding and supervision support to the clusters. Further, phase II will also focus specifi-
supplies. The second strategy of this programme CLFs and VOs is critical to ensure their activities cally on addressing gender norms and social
focuses on systems strengthening, supported are nutrition-sensitive and responsive. These issues that impact upon women’s nutrition and
by technical assistance from the UNICEF State community institutions can be strengthened and access to entitlements. Phase II will also focus
Offices of Bihar, Chhattisgarh and Odisha. The capacitated through investments in integrated on replicating the nutrition-sensitive integrated
coordination of government departments is crit- training and capacity-building to respond to the farming systems (NSIFS), a nutrition-based
ical to ensure that essential women’s nutrition health and nutrition needs of the community. livelihood option, in the scale-up areas. This is
interventions are available. Convergence under in keeping with the Bihar SRLM’s health, nutrition
the POSHAN Abhiyaan promotes coordinated, Way forward and sanitation strategy to address undernutrition
multi-sector efforts involving all line departments DAY-NRLM, in partnership with UNICEF, will in marginalised communities.
that contribute towards nutrition such as health scale up Swabhimaan’s maternal nutrition ap-
and family welfare, water and sanitation and proach through NRLM platforms in alignment Conclusion
rural development. This is possible through the with its POSHAN Abhiyaan mandate. The nested Over the three years of implementation of the
joint planning and review of activities and quar- impact evaluation showed promising results, Swabhimaan programme, the findings suggest
terly convergence meetings at block and district informing the SRLMs of the three states to that both the community-led and systems
level are used as a platform to undertake this. initiate scale-up with the horizontal expansion strengthening components of the programme
This is critical as this process enables the regular of these interventions while retaining the impact have significant impact on increasing the coverage
review of nutrition indicators based on the evaluation sites and protecting them from con- of essential nutrition-specific and nutrition-sen-
village microplans with all the line departments tamination until the endline evaluation. sitive interventions for women and girls. A key
supporting in addressing implementation gaps component is the development of integrated nu-
in service delivery. To improve the quality and Within two years of programme implemen-
trition microplans developed by the community,
reach of health and nutrition services of Health tation, each of the SRLMs has initiated the scale-
utilising the funds provided by the SRLMs. The
and ICDS departments, the Swabhimaan pro- up of the programme. In Chhattisgarh, based
results of the midline evaluation demonstrate
gramme facilitated the revision of the VHSND on the success of Swabhimaan in the pilot block
that this is a feasible approach and that women’s
guidelines and integrated maternal calcium sup- of Bastar, the SRLM has approved the scaling
collective institutions are able to use cash grants
plementation, deworming and the screening of up of Swabhimaan in 16 blocks across 12 districts.
to respond to community-based needs and are
women at nutritional risk using maternal MUAC This is being done in a phased manner with
able to implement actions to address health and
into the guidelines for all three states (Bihar, eight blocks across six districts in 2018 and the
nutrition problems in their community. The
Chhattisgarh and Odisha). It also expanded the remaining eight blocks in the subsequent years.
results of the endline and impact evaluations
target base by including newlywed and adolescent Forty CRPs have been chosen from the pilot
are forthcoming and will provide further evidence
girls in the target group. The training of service block as resource persons/master trainers to
to inform maternal and preconception nutrition
providers on the revised VHSND guidelines at roll out training in the scale-up blocks. In
policy at national and state level in support of
state, district and block levels ensured quality Odisha, the Odisha Livelihoods Mission (OLM)1
the scale-up of mechanisms that integrate nutrition
implementation. This effective integration of a plans to saturate 12 blocks across both inter-
interventions into large-scale poverty alleviation
systems strengthening intervention, which in- vention districts by 2020. These will then serve
programmes delivered via women’s collectives.
cludes regular follow-up, review and monitoring, as incubation blocks and learning from these
and the training of service providers for im- locations will be taken up across the state. The For more information, please contact Dr. Vani
provement of service delivery led to improve- mission intends to develop 700 community re- Sethi at [email protected]
ments on the supply side. source persons to support the scale-up of inter-
ventions in 14 blocks of three districts. The Watch a video about this programme at
Limitations and challenges OLM has also chosen to set up vertical nutrition https://www.youtube.com/watch?v=bqn-
As in most programmes that operate in real programmes to provide support for capacity- qV2V4tiw
settings, systemic challenges exist. These are building of state and district level programme
related to delays in the flow of funds for govern- staff. Similarly, in Bihar, scale-up was initiated
1
Odisha Livelihoods Mission (OLM) is Odisha’s SRLM, an
ment schemes on which the delivery of maternal autonomous society under Department of Panchayati Raj,
in 2019 and will see the intensification of inter- Government of Odisha, implementing National Rural
nutrition services hinge, delays in the procurement ventions and the saturation of each implemen- Livelihoods Mission, India’s large-scale poverty alleviation
and/or distribution of supplies (medicines/sup- tation block by 2021. Existing cadres of staff programme.
plements and rations) and health worker strikes.
Secondly, the SHG-VO-CLF platform has varying
maturity and stability across and within states, References IIPS. Swabhimaan baseline factsheet: Chhattisgarh 2016
IIPS. Swabhimaan baseline factsheet: Odisha 2016
with some groups well established while some Bulliyya, G, Mallik, G, Sethy, G S, Kar, S K (2007)
Hemoglobin Status of Non-School Going Adolescent Girls Ministry of Health and Family Welfare, Government of India
are fairly new. Consequently, the pace of imple-
in Three Districts of Orissa, India. International Journal of and WHO (2017) Guidance document: Nutritional care and
mentation is non-uniform. In order to reduce Adolescent Medicine & Health. 2007.19; (4):395–406 support for patients with tuberculosis in India. 2017
this bias, Swabhimaan has retained the originally
Butta, Z, Das, J K, Rizvi, A, Gaffey, M F, Walker, N, Horton, S Reshmi RS et al Context for layering women’s nutrition
identified collectives (SHG-VO-CLF) in the re- et al (2013) Evidence-based interventions for interventions on a large scale poverty alleviation
search despite the emergence of newer collectives improvement of maternal and child nutrition: what can programme: Evidence from three eastern Indian states.
in its implementation sites. As new collectives be done and at what cost? Lancet. 2013; 382: 452–477. PLoS ONE 2019. 14(1): e0210836.
https://doi.org/10.1016/S0140-6736(13)60996-4 PMID: https://doi.org/10.1371/journal.pone.0210836
are mobilised at the same implementation sites, 23746776
they will also be included in the programme Sethi V, Bhanot A, Bhalla S, Bhattacharjee S, Daniel A,
Goudet, S, Murari, Z, Torlesse, H, Hatchard, J, Busch-Hallen, Sharma DM, et al: Partnering with women collectives for
with the support of the existing structure. Fur- J (2018) Effectiveness of programmeme approaches to delivering essential women’s nutrition interventions in
thermore, as these are essentially savings groups, improve the coverage of maternal nutrition interventions tribal areas of eastern India: a scoping study. J Health
layering on nutrition interventions is a slow and in South Asia. Matern Child Nutr. 2018;14(S4):e12699. Popul Nutr. 2017; 36 (20).
cautious process. DAY-NRLM has mentors in International Institute for Population Sciences (IIPS) and Tang AM, Dong K, Deitchler M, Chun M, Maalouf-
its operational structure to provide handholding Macro International 2015-16 Manasseh Z, Tumilowicz A, Wanke C. Use of Cutoffs for
support on the thrift and credit activities who Mid-Upper Arm Circumference (MUAC) as an Indicator or
National Family Health Survey (NFHS-4), 2015–16: India
Predictor of Nutritional and Health Related Outcomes in
could also be trained in programme planning Factsheet
Adolescents and Adults: A Systematic Review. 2013.
and grant management for the provision of the IIPS. Swabhimaan baseline factsheet: Bihar 2016 Washington, DC: FHI 360/FANTA

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Field Exchange issue 65, May 2021, www.ennonline.net/fex
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 Field Exchange issue 65, May 2021, www.ennonline.net/fex
......................................................................................................................................
ENN Directors: Marie McGrath, Tanya Khara, Emily Mates, About ENN
Rebecca Lewin
Emergency Nutrition Network (ENN) is a UK registered charity that strives to enhance the effectiveness of
Office support: Laura Delfino, Judith FitzGerald,
Abigail Riggs, Annabel Miller, Megan Titchell, Gill Price,
nutrition policy and programming by improving knowledge, stimulating learning and building evidence. We are
Clara Ramsay, Natalie Naber passionate about being field-driven and are globally recognised as thought leaders and conveners in nutrition.
Design: Orna O’Reilly/Big Cheese Design.com ENN is based in the UK but works globally and is made up of a team of technical experts in nutrition with
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governmental organisations or charities, and research institutions worldwide to look critically at existing
Communications: Alex Glynn
practices, raise awareness of issues and drive change so that those working to tackle malnutrition can do the
Website: Oxford Web Applications best possible job. We do this by:
1. Capturing what works and what is needed to reduce malnutrition – working with people implementing
Contributors for this issue:
programmes to help them examine their experiences and document their achievements and challenges.
Abdalmonim Osman Ken Limwame 2. Coordinating technical bodies to increase the global understanding of malnutrition – particularly focusing
Abhishek Saraswat Kenda Cunningham
on the most nutritionally vulnerable including infants and children, adolescent girls and mothers who are
Alemayhu Beri Keshab Shrestha
pregnant or are feeding their infants.
Alessandro Iellamo Kibet Chirchir
Alexandra Rutishauser-Perera Lenka Blanárová 3. Supporting global efforts to reduce malnutrition – bringing our knowledge and technical expertise to
Anastasia Marshak Linda Shaker Berbari strengthen the activities of organisations working to reduce malnutrition at the global level.
André Briend Liya Assefa
Andrianianja Raonivelo Lucy Kinyua Field Exchange Team
Anne Radday Lucy Maina-Gathigi Marie McGrath Nicki Connell Anne Bush Chloe Angood
Annet Birungi Lydia Ndung’u Editor Editor Surge Editor Sub-editor/
Apolenarius Purty Mara Nyawo Content
Babita Mohapatra Marion Blanloeuil coordinator
Bayan Ahmad Mary Chelang'at Koech
Beka Teshome Bongassie Mary T Murphy
Natalie Sessions Gwénola Desplats Orna O’ Reilly
Bijoy Sarker Maureen L. Gallagher
Sub-editor/ Sub-editor/ French Design and
Bishar Osman Hussein Md. Lalon Miah
Communications content coordinator production
Brigitte Tonon Md. Shahin Emtazur Rahman lead
Chantal Autotte Bouchard Merry Fitzpatrick
Chrisla Joseph Monica Shrivastav
Christine Jodloman Moussa Moctar My right-hand woman
Desire Rwodzi Mphatso Nancy Chisala As the ink dries on this 65th edition of Field Exchange, it marks the beginning of a whole new chapter for one
Dhruba Dhital Natalie Sessions of my longstanding team colleagues, Chloe Angood, Field Exchange Sub-editor and Content Coordinator,
Dipak Raj Sharma Natalie West who is leaving ENN for adventures new. Chloe and I have worked closely together for 12 years, since she
Douglas Jayakasekaran Natasha Lelijveld joined ENN after working for the University of Southampton and the International Malnutrition Task Force in
Emilie Buttarelli Neha Abraham Tanzania. After working with Chloe on her Masters research project we marked her out as a ‘good catch’ with
Emily Helary Nola Jenkins great promise, and our instincts proved spot on. Since joining ENN 12 years ago, Chloe has been a truly
Emily Mates R.S. Reshmi wonderful colleague. Enthusiastically turning her hand across Field Exchange, Nutrition Exchange, infant and
Emmanuel Barasa Rika Shalima Xaxa young child feeding in emergencies (IFE) and more besides, she is best known and loved by all in her Field
Emmanuella Olesambu Ritu Rana
Exchange role. There is far more to pulling together an edition of Field Exchange than meets the eye, which
Gerard Bryan Gonzales Ruth Climat
those authors on the receiving end will appreciate. It involves the obvious – attention to detail, deadlines and
Grace Funnell Sahra Moalim Ahmed
Grace Heymsfield Said M Yaqoob Azimi organisational skills, coupled with a healthy dose of pragmatism, empathy with the demands of busy field
Gwenaëlle Luc Saidou Magagi workers, an ability to craft a story and an unabated enthusiasm to learn from others. Chloe has exceled on all
Hassan Ali Ahmed Samuel Mahinda Murage fronts. Not only has she grown within her role, but she has shaped it for the better; lightening my load and
Hatty Barthorp Sarita Anand nurturing the capacity of a wonderful sub-editorial team that she will leave in her wake. We will all miss Chloe
Helen Young Smaila Gnegne personally and professionally but so too, are excited for her road ahead.
Hyppolite Gnamien Sophie Woodhead
Jagjit Minj Sumra Kureishy Chloe, on behalf of the Field Exchange team and the Field Exchange authors
Jean-Robert Bwanaissa Sweta Banerjee and readers over many years, we wish you all the very best and look forward
Shabani Vani Sethi to featuring your new experiences in a future edition!
Jessica Bourdaire Youssouf Koita
Jogie Abucejo Agbogan Yubraj Shrestha
Katrien Ghoos Yves-Laurent Régis
Supported by:
Thanks to all who contributed or helped source pictures for
this issue.
Front cover
A mother practicing Kangaroo care, at the Regional Hospital
of Korhogo, Côte d'Ivoire. ©UNICEF/Frank Dejongh, 2020
Back cover The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156)
and a company limited by guarantee and not having a share capital in the UK (company registration no:
Children at school in Toumodi-Sakassou, Côte d'Ivoire. 4889844). Registered address: 2nd Floor, Marlborough House, 69 High Street, Kidlington, Oxfordshire,
©UNICEF/Frank Dejongh, 2020 OX5 2DN, UK. ENN Directors/ Trustees: Dr Graham MacKay, Marie McGrath, Dr Bruce Laurence, Nigel
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