· Field Exchange issue 61, November 2019, Contents 1 Editorial Field Articles 3 Improving minimum dietary diversity for children aged 6-23 months

November 2019 Issue 61

Nutrition surveillance in South Sudan and SyriaProposed indicator to estimate acute malnutritioncaseloads in AfghanistanBarriers to minimum dietary diversity of infants inBangladeshCost of the diet analysis in Central Africa RepublicAddressing undernutrition in pregnancy in India

ISSN 1743-5080 (print)

Field Exchange issue 61, November 2019, www.ennonline.net/fex

Contents1 EditorialField Articles3 Improving minimum dietary diversity for children aged 6-23 months in northeast Bangladesh7 Improving practical skills for breastfeeding vulnerable infants in low resource settings: A case study from Rwanda 11 Estimating ‘people in need’ from combined GAM inAfghanistan

40 Challenges in protecting non-breastfed infants in the Rohingya response in Bangladesh

44 International Medical Corps strengthens nutrition alert and surveillance systems in South Sudan 57 Scale-up of malnutrition screening by the World Health Organization in Syria62 Integrating nutrition services into mobile health teams: Bringing comprehensive services to an underserved population in Afghanistan

Special focus on GTAM47 Global Technical Mechanism for Nutrition (GTAM)

48 Global Technical Assistance Mechanism for Nutrition (GTAM): The story so far

52 Baseline technical needs assessment for the Global Technical Assistance Mechanism for Nutrition (GTAM)53 A review of technical discussion on en-net: Recurring questions and gaps experienced by programmers

News8 An innovative, low-cost tool for a more efficient weight- for-height/length (WHZ/WLZ) assessment9 Nutrition Exchange (NEX) South Asia: Maternal nutrition 10 SPRING through the seasons 10 Health systems strengthening course10 Continuity of care in acute malnutrition treatment in East Africa and West and Central Africa: a mapping exercise

Research 14 Ensuring pregnancy weight gain: An integrated community- based approach to tackle maternal nutrition in India 18 Dynamics of the nutritional status of children under five years old in northwest Syria20 Cost of the Diet analysis in Bria, Central African Republic 24 Barriers to infant feeding in emergencies programming in middle and high-income countries 26 The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 201627 Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018 29 Postscript – Further perspectives on scurvy outbreak

Research Snapshots30 Adolescent girls’ nutrition and prevention of anaemia: a school-based multisectoral collaboration in Indonesia30 Impact on child acute malnutrition of integrating a preventative nutrition package into facility-based screening for acute malnutrition in Burkina Faso31 Impact on child acute malnutrition of integrating small- quantity lipid-based nutrient supplements into community-level screening for acute malnutrition in Mali31 Supportive supervision to improve the quality and outcome of outpatient care among malnourished children in Uganda32 Inpatient and outpatient treatment for acute malnutrition in infants under six months: a qualitative study from Senegal32 Prevention and treatment of acute malnutrition in humanitarian emergencies: a multi-organisation collaboration to increase access to synthesised evidence32 Efficacy of F-100, diluted F-100, and infant formula for treatment of infants under six months with severe acute malnutrition 33 Women’s empowerment, food security and nutrition of pastoral communities in Tanzania 33 Alternative ready-to-use therapeutic food yields less recovery than the standard for treating acute malnutrition in children from Ghana34 Analysis of trends in SMART nutrition survey data from South Sudan between 2004 and 2016

34 Defining, measuring and interpreting the appropriateness of humanitarian assistance 35 How Ebola virus disease affected nutrition in Sierra Leone: a food value-chain framework to improve future response strategies35 Ebola virus disease and breastfeeding: time for attention

36 Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition in Burkina Faso

36 Individualised breastfeeding support for acutely ill, malnourished infants under six months of age

36 Conflict of interest in nutrition research37 Association of early interventions with birth outcome and child linear growth in low-income and middle-income countries37 Practical pathways to integrate nutrition and water, sanitation and hygiene38 The WASH benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea38 Soya, maize and sorghum-based ready-to-use therapeutic food with amino acid for treatment of severe acute malnutrition 39 Understanding how Rwanda created an enabling environment for improvements in nutrition39 Soya, maize and sorghum ready-to-use therapeutic foods (RUTF) are more effective in correcting anaemia and iron deficiency than standard RUTF

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1Field Exchange issue 61, November 2019, www.ennonline.net/fex

EditorialsDear readers,Chers Lecteurs,

We dedicate this edition ofField Exchange to the life andwork of Claudine Prudhon,who sadly and prematurely

died in October this year. Anyone who metClaudine will have been touched by heropen-mindedness, curiosity, kindness andnatural interest in people, combined with awonderful sense of humour. Any of you whodidn’t meet her in person may well havebeen touched by her professionally throughher years of dedicated work to internationalnutrition.

Cette édition de Field Exchange est dédiéeà la vie et au travail de Claudine Prudhon,auxquels nous souhaiterions rendre hommage.C’est avec tristesse que nous avons appris ladisparition prématurée de Claudine en octobrede cette année. Son ouverture d’esprit, sa cu-riosité, sa gentillesse, son intérêt naturel pourles autres - sans compter son magnifique sensde l’humour- n’auront pas manqué de toucherprofondément toutes celles et ceux qui l’ontconnue.

On a personal level, Claudine was thirstyfor any kind of culture (art, music, literature,theatre, dance) and had an equally deep pas-sion for food and gastronomy (and wine!).Her professional life was just as rich, a careerthat began back in 1990 as a research assistantat the Hospital for Sick Children (Necker) inParis. Following a course in Statistics andEpidemiology, she embarked on a PhD spe-cialising in Nutrition in Developing Countries.is marked the beginning of her internationalcareer, first spending six years with ACF inParis as Nutrition and Research Officer andprogressing to Head of the Nutrition De-partment there (they wisely saw her potential).

Claudine avait toujours soif de culture (l’art– de préférence contemporain, la musique, lalittérature, le théâtre, la danse) et montrait unappétit insatiable pour tout ce qui touche à lagastronomie (et au vin!). Sa vie professionnelleaura été tout aussi riche, avec une carrière quidébute en 1990 comme assistante de rechercheà l’Hôpital des Enfants Malades de Necker, àParis. Après un DEA en épidémiologie et statis-tiques, elle se lance dans un doctorat portantsur la nutrition dans les pays en voie de développe-ment. Cela marque le début de sa carrière in-ternationale, d’abord en tant que personneressource en nutrition/recherche à ACF-Parispendant 6 ans, puis comme responsable du dé-partement de nutrition (son potentiel ayanttout naturellement été remarqué par ACF).

In 2002 she went on to join the UN Stand-ing Committee on Nutrition in Geneva as aNutrition Epidemiologist and aer six years,she joined WHO Health and Nutrition Track-ing Service, staying with WHO up to 2014(perhaps six was her magic number?!). Fromthen until just recently, she worked in awealth of consultancy roles, including at ENNand as a researcher with Save the ChildrenUK on infant and young child feeding inemergencies. In amongst all this she somehowmanaged to ‘secretly’ squeeze in a MSc inEpidemiology by Distance Learning at theLondon School of Hygiene & Tropical Med-icine in 2015, graduating in March 2016.

En 2002, Claudine rejoint le Sous-Comitéde la Nutrition des Nations Unies à Genève entant qu’épidémiologiste spécialisée en nutrition.Six années plus tard, elle intègre le départementde Health and Nutrition Tracking Service(HNTS) de l’OMS, et cela jusqu’en 2014 (à sedemander si le 6 n’était pas son nombrefétiche?!). Depuis et jusqu’à très récemment,Claudine a eu un rôle de consultante dans unnombre impressionnant de structures, y comprispour ENN, et a travaillé comme chercheuseavec Save the Children UK sur l’alimentationdu nourrisson et du jeune enfant dans les sit-uations de crise. En 2015, elle obtient unMasters en Épidémiologie qu‘elle a suivi se-crètement à distance à la London School ofHygiene and Tropical Medicine.

Claudine was diagnosed with Amyotrophiclateral sclerosis (ALS) in October 2016, a rare,degenerative neurological disease. Many of uswill remember her in a wheel chair attendingthe ACF Research for Nutrition meeting inParis in November 2017. She met many peoplethere, smiling as usual, although she wasalready very weak at that time. She showedtremendous courage from her diagnosis tothe very end to continue working and makingthe most of what she could do, a courage mo-

tivated by her incredible appetite for life. efact that she continued to work until her closingbreaths speaks volumes to her resilient spiritand her dedication to alleviating human sufferingthrough her commitment to improving publichealth response in emergencies.

En octobre 2016, une sclérose latérale amy-otrophique (SLA), une maladie neurodégénéra-tive rare, a été diagnostiquée chez Claudine.Nous sommes nombreux à nous souvenir d’elleen fauteuil roulante à la réunion ACF sur larecherche en nutrition, en novembre 2017.Souriante, tout comme à son habitude, elle yfit de nombreuses rencontres, alors qu’elle étaitdéjà très affaiblie. Elle aura fait preuve d’uncourage immense depuis son diagnostic jusqu’àla toute fin, continuant de travailler et deprofiter au maximum de ce dont elle pouvaitencore profiter – courage motivé par son in-croyable appétit pour la vie. Le fait d’avoircontinué à travailler autant qu’elle l’a pu dé-montre de façon forte sa résilience et son en-gagement pour apaiser la souffrance humaineet notamment améliorer les interventions desanté publique dans les situations de crise.

Claudine was and remains a wonderfulsoul who will live on in the hearts, mindsand work of our collective community. Wewill remember her with warmth and remainin awe of who she was and what she achievedin the time she had with us and extend oursincere condolences to her family and friendsfor their loss.

Claudine était et restera une âme excep-tionnelle qui continuera à vivre dans les cœurs,les esprits et au sein de notre communauté.Nous nous souviendrons de Claudine avecchaleur et affection, et restons en admirationdevant sa personne et tout ce qu’elle a accomplidurant son temps précieux à nos côtés. Nousprésentons nos condoléances les plus sincères àsa famille et ses amis face à leur perte.

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Dear readers,

Suchana project beneficiary harvestingproduce from her vegetable garden,

Sylhet Division, Bangladesh, 2017

Editorial

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Welcome to the 61st edition of FieldExchange. In this general issue, threefield articles speak to the need forrobust information to aid effective

nutrition responses. A field article by the WorldHealth Organization describes the developmentand evolution of a nutrition-surveillance system inSyria leveraging the existing national growth-mon-itoring system. Data indicates that global acutemalnutrition (GAM) prevalence has declined since2015. This is attributable to multiple factors, includ-ing better early case detection and referral ofsevere and moderate acute malnutrition cases as aresult of this system. Integrating surveillance withinan existing government system no doubt increasesthe potential for scale and sustainability. Mean-while, in South Sudan, an International MedicalCorps team was established to fill a gap in qualityand timely information to inform emergency pro-gramming, and provide information to the nationalsurveillance system. The team describes the nutsand bolts of carrying out quality nutrition assess-ments and surveys in this context.

Anarticle by Action Against Hunger examinesthe suitability of GAM to estimate caseloads ofacute malnutrition in Afghanistan. There is poorcorrelation between weight-for-height z-score(WHZ) and mid-upper arm circumference (MUAC)in this context. Combined GAM (cGAM) is an aggre-gate indicator that includes all cases of GAM byWHZ <-2, MUAC <125 mm, and/or bilateral pittingoedema. The article makes a good case for estimat-ing caseloads in this way and suggests a need forglobally validated cut-offs.

Two articles describe challenges and initiativesto roll out services in hard-to-access populations.A field article by the United Nations Children’sFund (UNICEF) team in Afghanistan describes theintegration of nutrition into mobile health teamsto reach very remote populations with health andnutrition services as part of the national basicpackage of health services. This was a short-termoption while the government scaled up nutritionservices to those areas of the country. The strategyincreased coverage successfully and createddemand for services which otherwise didn’t exist.The experience highlights that sometimes ‘unsus-tainable’ surges of support are needed in chal-lenging contexts – in this instance, where accessto services was a key barrier.

The second article describes the results of acost-of-diet (CoD) analysis in Central AfricanRepublic (CAR) in a conflict-affected area. Resultsshow that blanket food distributions to internallydisplaced persons (IDPs) and host populations arenot enough to meet even basic energy needs forthe poor and very poor. Interventions are neededto boost household food production, as well asextended rations.

Another article from a very different context,Bangladesh, also reports on a COD analysis;

specifically, how households can achieve mini-mum acceptable diets for young children toinform a multi-sector programme. Results demon-strate the need to boost household incomethrough multi-sector programming; social behav-iour-change communication strategies are notenough on their own.

Maternal and adolescent nutrition also figureprominently in this edition. A study by a researchinstitute in India examined the results of a pilot pro-gramme that aims to improve maternal nutrition,focusing on improving pregnancy weight gain.Routine nutrition support for pregnant mothersaligned with government policies and protocolswas intensified, with some effect on weight gain,although weaknesses in the study design make itdifficult to interpret the results. One interestingobservation was the complexity of implementinga programme like this in the context of the doubleburden of disease; pregnant mothers includedsome who were undernourished and some whowere obese. Blanket interventions are difficultwhen needs differ so greatly between individualsin the same communities. Training of health work-ers and intervention designs must consider thesedifferences; the authors provide some valuableinsights into how they did this.

A short study by UNICEF in Syria highlights theneed for more research into the association betweenchild marriage and stunting and the need to includestunting prevention in emergency programmingacross sectors (in this instance, child protection).Levels of child stunting are very high in Syria, in con-trast to wasting prevalence, which has declined andis extremely low. The authors hypothesise that ado-lescent pregnancy (which is associated with lowbirth weight and stunted offspring) and conflict-related rises in child marriage may be importantcontributing factors to stubbornly high stuntingprevalence. An expanded SMART survey to explorethis proved inconclusive due to methodologicalflaws. However, this lack of direct ‘evidence’ is notholding the team back; UNICEF has now initiated anintegrated health, nutrition and child protection(including disability and family abuse/detection sur-veillance) response. This experience highlights howstunting is an anthropometric marker of risk that isnot specific to nutrition, and that we must considerfactors and interventions beyond nutrition-specificactivities when it comes to prevention. It also reflectsthe fact that stunting is still seen as a developmentconcern, rather than a humanitarian one; it is only

being taken seriously seven years into the Syria‘emergency’ response, even though prevalence ofstunting has been consistently high for a number ofyears and is increasing in some areas.

We also feature an article that highlights effortsto support non-breastfed infants in the Rohingyaresponse. Save the Children documents its frus-trated attempts to meet the needs of these infantsin accordance with World Health Assembly-endorsed, international guidance. Protractednegotiations to secure a breastmilk substitute(BMS) supply for identified infants eventually ledto development of draft policy, but no country-level endorsement or resolution of programmingshortfalls. Ensuring a predictable, secure BMSsupply chain for infants in need has been a long-standing barrier to timely support to thisparticularly at-risk group. After considerable advo-cacy, significant change is finally afoot: UNICEF isfinalising new Standardised Operating Procedureson handling BMS that stipulate that it will be‘provider of first resort’ of BMS supplies. UNICEFhas also been doing much work behind the scenesto prepare supplies division and proceduresaccordingly. A truly important development, it isnow critical to invest in UNICEF country team ori-entation, support and capacity-development tosupport translation of this policy into practice.

Finally, we’d like to highlight a special sectionon the Global Technical Assistance Mechanism forNutrition (GTAM); a common global mechanism,endorsed by over 40 Global Nutrition Cluster part-ners, to provide predictable, timely nutritiontechnical assistance on nutrition. The GTAM storyso far is described in several articles, actively sup-ported by ENN in its dedicated ‘knowledgemanagement’ role in the coordination team.

As ever, a selection of the latest, most relevantresearch has been summarised as ‘snapshots’ forquick reads. There are also several ‘bonus online’articles that don’t appear in print, but are just asinteresting a read – more of these to come, so keepchecking in as we post them online.

Happy reading!

Chloe Angood, Marie McGrath and Jeremy Shoham,Field Exchange Editors

www.ennonline.net/fex

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1 Operational Guidance on Infant Feeding in Emergencies www.ennonline.net/operationalguidance-v3-2017

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Location: Bangladesh What we know: Mutli-dimensional approaches are needed to achievea minimum acceptable diet for young children to prevent stunting,including increasing household income.

What this article adds: Two studies were carried out to inform theSuchana programme (2015-2022) that aims to reduce stuntingprevalence in Sylhet, Bangladesh through social and behaviour-change communication (SBCC), promoting optimal infant and youngchild feeding (IYCF) and household food production activities toincrease household income and food availability. A barrier analysisamong 106 mothers from 16 villages was performed to identifybarriers to and boosters of minimum dietary diversity (MDD) amongchildren aged 6-23 months. Household income and food price wereimportant facilitators and misconceptions on consumption of anMDD and its benefits. Failure to remember to include diverse foodswas a main barrier. Adaptations to the SBCC component weresubsequently made to address this. A cost-of-the-diet (CotD) analysiswas then performed to estimate the hypothetical minimum amountof money a typical household needs to purchase food to meetrecommended nutrient intakes, analysed against current householdincome, expenditure, production and consumption. Findings show thatall major nutrient requirements can be met using local markets andhouseholds can potentially afford a diet that meets energy, protein, fatand micronutrient requirements and takes into account typicaldietary habits within existing levels of income, but not when non-food expenditures are taken into account. Free food from home foodproduction activities goes some way to filling affordability gaps;however, more needs to be done to increase household income toachieve an MDD and intended programme outcomes.

Field ArticlesImprovingminimum dietarydiversity forchildren aged 6-23 months innortheastBangladeshBy Md Masud Rana, Sheikh Shahed Rahman, Md Al-Amin Shovan, Bazlul Kabir Joarder and Mohammad Raisul Haque

Md Masud Rana is a nutrition advisor forSave the Children, with a particular focus onsupporting nutrition programmes in SouthAsia and East Africa region. Masud hasworked for over 10 years in the design,delivery and evaluation of nutrition, food

security and livelihoods programmes in Asia and Africa.

Dr Sheikh Shahed Rahman is Chief of Party forthe Suchana programme, Save the ChildrenInternational in Bangladesh. He has worked infood security and nutrition programmes indevelopment and emergency settings formore than 15 years. He is a medical graduate

and obtained his MPH from Emory University, USA.

Md Al-Amin Shovan is Manager –Monitoring, Evaluation, Accountability andLearning (MEAL) of the Suchana programme.He has over 15 years of experience workingas a MEAL Specialist in the developmentsector in Bangladesh.

Bazlul Kabir Joarder is Technical Manager –Nutrition for Save the Children inBangladesh in the Suchana programme. Hehas over 14 years of experience of working inhealth and nutrition-focused programmesfor multiple non- governmental

organisations (NGOs) in Bangladesh.

Dr Mohammad Raisul Haque is SeniorAdvisor – Nutrition for Save the Children inthe Suchana programme. He has over twodecades of public health service delivery andprogramme management experience formultiple NGOs and donor agencies. He holds

a master’s degree in population and reproductive healthresearch and a PhD in demography.

The authors would like to thank the donors of the Suchanaprogramme, including the European Union (EU) and the UKDepartment for International Development (DFID). Thefindings, interpretations and conclusions in this article arethose of the authors. They do not necessarily represent theviews of Save the Children, EU or DFID and should not beattributed to them.

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IntroductionBangladesh has made remarkable progress in reducing stunting and wasting inchildren under five years of age over the last 20 years. However, the rate of declinein the annual stunting rate has slowed in the last decade and an estimated sixmillion children remain chronically undernourished (NIPORT and ICF International,2016). More than one in three children suffer from impaired linear growth (i.e.stunting) with higher prevalence in rural areas (37.9%, versus 30.8% in urbanareas) and among children from the lowest wealth quintile (49.2%, vs 19.4% in the

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Suchana project beneficiary motherfeeding her child, Sylhet Division,Bangladesh, 2017

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1 A Bengali word which means “the beginning of something positive”.2 For further information, see: (i)

https://bangladesh.savethechildren.net/sites/bangladeshsavethechildren.net/ files/library/Suchana.pdf (ii) https://devtracker.dfid.gov.uk/projects/GB-1-204131

Determinants(MDD for children 6-23 months)

Doers(#, %)(n=53)

Non- Doers(#, %)(n=53)

Difference OddsRatio

Estim. Relative Risk

p-value

1. Perceived self-efficacy: What makes it easy for you to feed your baby foods from at least four of these different food groups each day?

Produce own food at home(vegetable gardens and/orpoultry rearing)

42 (79%) 36 (68%) 11% 1.8 1.62 0.135

Market not far from home 24 (45%) 2 (4%) 42% 21.1 6.03 0.000Adequate household income 6 (11%) 38 (72%) 60% 0.05 0.09 0.000

2. Perceived self-efficacy: What makes it difficult for you to feed your baby foods from atleast four of these food groups each day?

High food price 4 (8%) 8 (15%) 8% 0.46 0.52 0.179Not enough income 35 (66%) 49 (2%) 26% 0.16 0.29 0.001Market too far from home 7 (13%) 5 (9%) 4% 1.46 1.34 0.380

3. Perceived positive consequences: What are the advantages of feeding your baby foodsfrom at least four of the different food groups each day?

Increased immunity 40 (75%) 34 (64%) 11% 1.72 1.56 0.145Child will grow faster 28 (53%) 27 (51%) 2% 1.08 1.06 0.500Child will be more intelligent 35 (66%) 27 (51%) 15% 1.87 1.66 0.084Increased weight 7 (13%) 1 (2%) 11% 7.91 3.51 0.030

4. Perceived negative consequences: What are the disadvantages of feeding your baby foodsfrom at least four of these different food groups each day?

Indigestion and/or diarrhoea 39 (74%) 35 (66%) 8% 1.43 1.34 0.263Vomiting 12 (23%) 12 (23%) 0% 1.00 1.00 0.592May suffer from breathingproblem

2 (4%) 12 (23%) 19% 0.13 0.17 0.004

5. Perceived social norms: Who are the people that approve of you feeding your baby foodsfrom at least four of these food groups each day?

Mother-in-law 35 (66%) 23 (43%) 23% 2.54 2.11 0.016Husband 44 (83%) 43 (81%) 2% 1.14 1.11 0.500Relatives 12 (23%) 8 (15%) 8% 1.65 1.47 0.229

6. Perceived social norms: Who are the people that disapprove of you feeding your babyfoods from at least four of these food groups each day?

Mother-in-law 3 (6%) 9 (17%) 11% 0.29 0.35 0.061Husband 2 (4%) 8 (15%) 11% 0.22 0.27 0.046

7. Perceived access: how difficult is it to get what you need to feed your baby foods from atleast four of these food groups each day?

Very difficult 9 (17%) 28 (53%) 36% 0.18 0.24 0.000Somewhat difficult 27 (51%) 21 (40%) 11% 1.58 1.44 0.165Not difficult at all 17 (32%) 4 (8%) 25% 5.78 3.32 0.001

8. Perceived cues for action/reminders: When you prepare meals for your child, how difficult isit to remember to include foods from at least four of these food groups?

Very difficult 2 (4%) 4 (8%) 4% 0.48 0.54 0.339Somewhat difficult 19 (36%) 2 (47%) 11% 0.63 0.69 0.162Not difficult at all 32 (60%) 24 (45%) 15% 1.84 1.63 0.086

9. Perceived susceptibility/risk: How likely is it that your child will become malnourished inthe coming year?

Very likely 1 (2%) 16 (30%) 28% 0.04 0.06 0.000Somewhat likely 28 (53%) 37 (70%) 17% 0.48 0.57 0.055Not likely at all 24 (45%) 0 (0%) 45% - 8.31 0.000

10. Perceived severity: How serious will it be if your child becomes malnourished in the coming year?

Very serious 14 (26%) 33 (62%) 36% 0.22 0.29 0.000Somewhat serious 32 (60%) 20 (38%) 23% 2.51 2.08 0.016Not serious at all 7 (13%) 0 (0%) 13% - 5.61 0.006

11. Perceived action efficacy: How likely is your child to get malnourished if you feed it foodsfrom at least four of these food groups each day?

Very likely 1 (2%) 2 (4%) 2% 0.49 0.55 0.500Somewhat likely 14 (26%) 13 (25%) 2% 1.10 1.08 0.500Not likely at all 38 (72%) 38 (72%) 0% 1.00 1.00 0.585

12. Divine will: Do you think that God approves of you feeding your child foods from at leastfour of these food groups each day?

Yes 3 (6%) 2 (4%) 2% 1.53 1.39 0.500No 50 (94%) 51 (96%) 2% 0.65 0.72 0.500

13. Culture: Are there any cultural rules/taboos against feeding your child at least four ofthese food groups each day?

Yes 7 (13%) 2 (4%) 9% 3.88 2.54 0.080

No 46 (87%) 51 (96%) 9% 0.26 0.39 0.080

Timeline of major nutrition-related activities innorth-eastern Nigeria Table 1 highest wealth quintile). Geographically, Sylhet division in the

North-East of the country has the highest burden where aroundhalf of all children under five years are moderately to severelystunted (NIPORT and ICF International, 2016). While causalfactors are multiple and poorly understood, research hasidentified several, including severe food insecurity; poormaternal nutrition; poverty; poor sanitation and hygienepractices; and inappropriate complementary feeding (Choudhuryet al, 2016; Ahmed et al, 2016).

In response to the multi-dimensional challenges of malnu-trition, the UK Department for International Development(DFID) and European Union (EU)-funded Suchana1 programmeaims to reduce prevalence of stunting in Sylhet Division.Suchana is a six-year (2015-2022), £48 million programmethat aims to reach over 220,000 poor households (representingaround 1.1 million people) by targeting women of reproductiveage and/or adolescent girls. e programme provides a set ofnutrition-specific and nutrition-sensitive interventions toimprove household-level nutrition and food security and childcare practices to break the inter-generational cycle of under-nutrition.2 Suchana’s nutrition-specific component includes acomprehensive set of social and behaviour-change communi-cation (SBCC) interventions promoting optimal infant andyoung child feeding (IYCF) and maternal and child nutritionin the first 1,000 days. e nutrition-sensitive component pro-motes increases in household income and availability of foodthrough home food production (HFP) interventions.

To ensure both types of interventions address context-specific immediate, underlying and basic causes of undernu-trition, Suchana carried out a barrier analysis and cost-of-the-diet (CotD) assessment in Sylhet and Moulvibazar districtswithin Sylhet Division. is article shares experiences andfindings related to improvement of dietary diversity amongyoung children that were used to inform the programme toimprove outcomes further.

A barrier analysis: Identifying barriers toachieving minimum dietary diversity(MDD) of children in Sylhet andMoulvibazar districts MethodsIn October 2017, Suchana commissioned a barrier analysisto identify barriers to and boosters of minimum dietarydiversity (MDD) among children aged 6-23 months in responseto multiple programme monitoring assessments identifyingMDD as the worst performing IYCF indicator. e baselinestudy undertaken in mid-2017 found only 14.7% of girls and15% of boys received a diversified diet containing four ormore food groups. e study primarily employed a ‘doer/non-doer analysis’ to identify behavioural determinants (barriersand enablers) among those who consumed a diversified diet(‘doers’) and those who did not (‘non-doers’). It followed thebarrier analysis methods specified in the ‘designing forbehaviour change framework’ (TOPS, 2017; Kittle, 2013) andemployed a cross-sectional survey of 106 mothers of childrenaged 6-23 months (53 doers and 53 non-doers) from 16villages in the two districts.

Results Table 1 shows a summary of the barriers and facilitators constructsgenerated from the data. Overall, an overwhelming proportionof respondents from both groups (doers and non-doers) identifiedeconomic factors (e.g. household income and food price) as the

Field Article

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main facilitator for achieving MDD. As mosthouseholds were primarily reliant on markets foraccess to food, distance to the market was also abig predictor. e barrier analysis additionallyidentified existing misconceptions around con-suming a diversified diet (e.g. certain foods cancause indigestion/breathing problems) and a lackof full understanding of the benefits, as well asperceived difficulty of remembering to includefoods from different food groups, as other im-portant determinants of MDD. Approval andsupport of husbands and mothers-in-law werefound necessary for practising the behaviours.However, no social, cultural or religious restrictionsor taboos against consumption of a diversifieddiet by women or children were identified.

Follow-up actions:Based on the findings of this analysis, the existingSBCC strategy and activities were revised inearly 2018, as follows: • Specific messages were developed to raise awareness of the necessity and benefits of women and children aged 6-23 months consuming a diversified diet. All of the project-specific SBCC guidelines and materials were subsequently adapted to include these messages, using multiple communication channels to reinforce impact.• To increase family members’ support, mothers-in-law were included in existing monthly mother and child group courtyard sessions and separate male groups were formed to inform husbands/male household members. In addition, frontline staff were trained to involve family members in discussions during household-level counselling sessions. • A new poster on MDD was distributed which visually displays different food groups to help households remember to choose food from different groups. • One of the major contributions of the barrier analysis was an understanding of the extent to which financial constraints affect consumption of a diversified diet in this context and the important contribution of the nutrition-sensitive component of the programme (i.e. income generation) in improving household affordability. To further inform this aspect of the programme, a CoDt assessment was subsequently conducted.

3 Further information about the CotD method is available from www.heacod.org

A CotD analysis: Whenaffordability is a major barrierRationale and objectives While the Suchana programme’s regular moni-toring data was suggesting a notable increase inhousehold income and increased availability offood from the HFP intervention, the barrieranalysis identified affordability of nutritious foodas a major barrier to dietary diversity. In response,a CotD analysis was conducted in Sylhet andMoulvibazar districts to investigate the extent ofthe gap between household income and expen-diture. is would inform necessary adjustmentsin programme implementation to maximise theimpact on child nutrition. Specifically, the as-sessment set out to estimate the minimum costof a nutritionally adequate and culturally ac-ceptable diet for typical households and estimatethe potential effect of income-generating activities(IGAs) and the HFP intervention on a household’sability to afford a nutritious diet.

Method e CotD3 method and soware were developedby Save the Children in order to estimate thehypothetical minimum amount of money a typ-ical household would need to purchase food tomeet recommended intakes of energy, protein,fat and micronutrients, using locally availablefoods (Deptford et al, 2017). Food price datawere collected through a market survey involving16 urban, peri-urban and rural markets in Sylhetand Moulvibazar. Local food consumption pat-terns and cultural practices were identifiedthrough individual interviews covering 84 in-dividuals and 12 focus group discussions (FGDs).Household income and expenditure, householdsize and composition, and HFP and consumptiondata were obtained from the most recent pro-gramme survey.

Key findings Overall, the analysis found that markets inSylhet and Moulvibazar have a diverse range offood items and can fulfil all major macro- andmicro-nutrient requirements for households.However, calcium was found to be most difficultto obtain; i.e. the most significant cost driver,followed by folic acid and vitamin B12.

e cost of four hypothetical diets was esti-mated using CotD soware for a typical house-

Annual cost of the various diet type for astandard household with six members andaverage annual income

Figure 2The percentage of energy and the recommendednutrient intakes for micronutrients met by aFHAB diet for the whole family

Figure 1

Season 1 (Kharif - 2/Aman) Season 2 (Kharif - 1/Aus) Season 3 (Robi/Boro)

Perce

ntag

e of e

nerg

y and

nutri

ent t

arge

ts m

et

Ener

gy

Prot

ein Fat

Vita

min

A

Vita

min

C

Vita

min

B1

Vita

min

B2

Niac

in

Pant

othe

nic

Acid

Vita

min

B6

Folic

Acid

Vita

min

B12

Calci

um Iron

Mag

nesiu

m

Zink

400.0

350.0

300.0

250.0

200.0

150.0

100.0

50.0

0.0

Annual cost of energy only(EO) diet

Annual cost ofmacronutrient (MAC) diet

Annual cost of nutritious(NUT) diet

Annual cost of food habits nutritious (FHAB) diet

Amou

nt in

Ban

glad

eshi

Taka

(BDT

)

120000

100000

80000

60000

40000

20000

0

40630 41523

+ 164% + 159% + 67%

64311

107459

hold of six individuals (including a 12-23 month-old child and a breastfeeding mother); including:(i) a lowest-cost diet that only meets recom-mended average energy requirements (energyonly (EO) diet); (ii) a lowest-cost diet that meetsthe average energy and the recommended proteinand fat requirements (macronutrient(MAC)diet); (iii) a lowest-cost diet that meets specifi-cations for energy, protein, fat and micronutrientsbut does not take into account typical dietaryhabits (minimum-cost nutritious (NUT) diet);and, (iv) a lowest-cost diet that meets specifica-tions for energy, protein, fat and micronutrientsand takes into account typical dietary habitsand cultural acceptability (food habit nutritious(FHAB) diet).

e lowest annual cost of an EO, MAC andNUT diet for a six-person household was BDT40,630.00, BDT 41,523.00 and BDT 64,312.00respectively (Figure 2). However, the cost of aFHAB diet was 67% higher than the NUT diet,at BDT 107,459 per year. Within the household(Figure 3), the cost of meeting the nutritionalrequirements of a breastfeeding women washighest (22% of the household cost of diet), fol-lowed by the adult male (21%) and 10-11 yearold children (20%).

e affordability calculation (Figure 4) showsthat households can potentially afford the FHABdiet, but cannot afford to meet both the cost ofthe diet and additional non-food expenditures(NFE) with their existing level of income. eaffordability gap ranges from BDT 193 to BDT14,181 per year, depending on the beneficiarytype and their livelihoods options. However,when the effect of the HFP element of the pro-gramme, which provides free food for the house-hold, was also taken into account (Figure 5),the annual cost of an FHAB diet was reducedby between 2.2% and 3.2% (16-24% reductionin the household affordability gap); this demon-strates some gain, albeit not as much as theproject team expected.

Discussion and recommendations It is well known that interventions focused onreducing poverty (i.e. generating income) aspart of a multi-sector nutrition programme are

Field Article

6

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Perce

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e (%

) of t

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diet

100%

80%

60%

40%

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not enough to have a positive impact on nutri-tional outcomes. Household income must gobeyond a certain threshold to enable householdmembers to practice recommended child feedingpractices. is CotD analysis set a benchmarkfor the livelihoods component of the Suchanaprogramme, by which increases in householdincome could be monitored to ensure that theyare large enough to meaningfully impact house-hold food security and nutritional status. Resultsof the analysis indicate that the programmeshould consider identifying beneficiary house-holds that are below this benchmark and strug-gling to cross the threshold to prioritise themfor linkages with existing government socialprotection programmes.

When results of this CotD analysis are com-pared to a previous CotD analysis conducted inthe same region in 2013, it appears that thecurrent affordability gap (BDT 193 to BDT14,181 per year) of very poor beneficiary house-

ReferencesAhmed, T., Hossain, M., Mahfuz, M., Choudhury, N., &Ahmed, S. (2016). Imperatives for reducing child stuntingin Bangladesh. Maternal & Child Nutrition, 12, 242-245.doi: 10.1111/mcn.12284#

Choudhury, N., Raihan, M., Sultana, S., Mahmud, Z.,Farzana, F., & Haque, M. et al. (2016). Determinants of age-specific undernutrition in children aged less than 2years-the Bangladesh context. Maternal & Child Nutrition,13(3), e12362. doi: 10.1111/mcn.12362

Deptford A., Allieri T., Childs R., Damu C., Ferguson E.,Hilton J., Parham P., et al. (2017). Cost of the Diet: AMethod and Software to Calculate the Lowest Cost ofMeeting Recommended Intakes of Energy and Nutrientsfrom Local Foods. BMC Nutrition 3 1: 26.

Kittle, B. (2013). A Practical Guide to Conducting a BarrierAnalysis. New York, NY: Helen Keller International.Retrieved from https://coregroup.secure.nonprofitsoapbox.com/storage/barrier/Practical_Guide_to_Conducting_a_Barrier_Analysis_Oct_2013.pdf

NIPORT, Mitra and Associates, and ICF International. (2016).Bangladesh Demographic and Health Survey 2014. Dhaka,Bangladesh, and Rockville, Maryland, USA: NationalInstitute of Population Research and Training (NIPORT),Mitra and Associates, and ICF International. Retrieved fromhttp://dhsprogram.com/pubs/pdf/FR311/FR311.pdf

TOPS. (2017). Designing for Behavior Change: A PracticalField Guide. Washington, DC: The Technical andOperational Performance Support (TOPS) Program.Retrieved from www.behaviourchange.net/docs/ designing_for_behavior_change_a_practical_field_guide.pdf

holds is significantly lower than the previousgap of BDT 39,300 per year. is reductioncannot necessarily be attributed to the programmeintervention alone; however, there are strongreasons to believe that programme interventionsare meaningfully contributing to it. Furthermore,the CotD modelling exercises show that theHFP interventions appear to be improving theavailability and consumption of nutritious foodat household level.

Nevertheless, gains were not as great as ex-pected and more needs to be done to increaseproduction to eliminate affordability gaps andto improve consumption to meet an MDD. eprogramme should therefore continue to aimto increase household income and food pro-duction and promote equitable intra-householdfood distribution and consumption through itsSBCC activities. e Suchana programme isconsidering the following recommended actionsas a result of the findings presented here: • Revisit the programme’s current livelihoods strategy and market system strategy to improve year-round production, linking beneficiaries with markets (and actions to identify potential ways) to further improve return on investment and household income.• Strengthen activities that link the most vulnerable households with the government’s social protection scheme, health and nutrition services, and other services. • Conduct a cost-effectiveness analysis of the kitchen garden and HFP interventions to understand whether current production, loss- to-climate effect, access to market, consumption pattern and rate of return are cost- effective and investigate further opportunities to improve productivity and consumption.• Use the FHAB diet cost as a benchmark to track the progress of beneficiary groups in upcoming socio-economic surveys and assessments and observe changes in affordability gap to assess whether new initiatives have worked. • Promote the consumption of cheap, nutrient- rich foods identified by the CotD analysis through existing SBCC activities.

FHAB Veg Chicken Duck Fish Veg+Chicken Veg+Duck Veg+Fish

Perce

ntag

e of I

ncom

e (%

)

108.000

107.500

107.000

106.500

106.000

105.500

105.000

104.500

104.500

104.000

103.500

The potential effect of different HFP activitieson the annual cost of an FHAB diet for ahousehold with six members, including achild aged 12-23 months

Figure 5

Phase 1: Off-Farm Phase 1: On-Farm Phase 2: Off-Farm Phase 2: On-Farm

120.0

100.0

80.0

60.0

40.0

20.0

0.0

The x-axis bars refer to different project beneficiary types. Phase 1 and Phase 2 refer to the benefi-ciary selection cycle. On/Off-Farm refer to the ‘Income-generating activity (IGA)’ supportbeneficiaries received from the project. On-Farm IGAs are linked to food production throughagriculture, poultry/livestock and aquaculturem; e,g. training, inputs and provision of seeds,fertilisers and pesticides. Off-Farm IGAs are livelihoods options other than farming/food produc-tions, including water fishing, tea stalls, vegetable trading, bamboo crafting and a ferry business.

0.00%

-0.50%

-1.00%

-1.50%

-2.00%

2.50%

-3.00%

-3.50%

-4.00%

The affordability of an EO, NUT and FHAB diet bySuchana beneficiary type (IGA intervention typeand phase)

Figure 4

% NFE forSuchanabeneficiarytype

% extra costof foodhabitsnutritiousdiet

% extra costof nutritiousdiet

% income ofenergy onlydiet

28.1

28.9

15.9

27.2

28.4

33.1

18.2

31.2

31.9

30.7

16.8

28.9

27.8

31.2

17.1

29.4

107.459

-0.9%

-1.2%

-1.7%

-2.3%

106.468

104.042

104.628

105,138104.947

105.616

106.127

-2.2%

-2.6%

-3.2%

Women, >60 years, 18%

BF Women, 30-59 years, 22%

Man, 30-59 years, 21%

Child, 11-12 years, 20%

Child, 9-10 years, 15%

Child, 12-23 months, 4%

Individual cost of the dietexpressed as a percentage of total cost of the FHAB diet

Figure 3 • Intensify efforts to further engage male family members in SBCC activities. eFGDs in the CotD data collection and previously conducted formative research highlighted the dominant role of husbands or male family members in household expenditure, food purchase decisions, access to markets and ultimately income generation. Without significantly engaging the male members in the process (and changing norms), the SBCC activities are unlikely to have a significant and lasting impact on changing behaviours and practices.

An independent evaluation is planned for theend of 2019, aer which the impact of theSuchana programme on stunting prevalencewill be reported.

For more information please contact MasudRana at [email protected]

Field Article


De Silva, H and Asir, M. Improvingpractical skills for breastfeedingvulnerable infants in low-resourcesettings: A case study from Rwanda.https://www.ennonline.net/fex/61/practicalskillsforbreastfeeding

By Himali de Silva and Maya Asir,with contributions from KathrynBeck, Catherine M Kirk, GatoSaidath, Marie Louise Manirakizaand Egide Karangwa

Himali de Silva is aspeech andlanguage therapistworking for theNational HealthService (NHS) in the

UK, where she works as a clinicalspecialist in infant feeding. She hasworked in several countries providingtraining to healthcare professionals.

Maya Asir is aspeech andlanguage therapistworking for theNHS in the UK,where she works as

a clinical specialist in infant feeding ina hospital setting. She has worked inseveral countries providing training tohealth professionals.

Kathryn Beck is theSenior NutritionProgrammeManager at PartnersIn Health/ InshutiMu Buzima, Rwanda.

Catherine M Kirk isthe Director ofMaternal and ChildHealth at PartnersIn Health/InshutiMu Buzima, Rwanda.

Gato Saidath is aMaternal and ChildHealth ProgrammeOfficer at PartnersIn Health/InshutiMu Buzima, Rwanda.

Marie LouiseManirakiza is aregistered nurseand Mental HealthProgrammeManager at

Partners In Health/ Inshuti MuBuzima, Rwanda.

Egide Karangwa isa Maternal andChild HealthProgramme Officerat Partners InHealth/Inshuti

Mu Buzima, Rwanda.

Asignificant proportion of premature infantsand infants with birth asphyxia and congenitalanomalies who may appear to be able tofeed using generic intervention strategies

are unable to coordinate sucking, swallowing andbreathing required for safe feeding. Without specificintervention strategies to minimise risks, these infantscan go on to develop lower respiratory tract infectionsfrom aspirated material and malnutrition. Informedby a review of existing materials, the Working withInfants with Feeding Difficulties (WIFD) trainingpackage was developed to fill an identified gap intraining content on feeding issues among such infantsfor frontline healthcare staff of neonatal intensive careand special-care baby units in low-resource settings(De Silva and Asir, 2017). WIFD focuses on timelyidentification and intervention to prevent deteriorationof feeding and can be delivered as a standalone trainingor integrated into other relevant training programmes.e package is currently delivered by two coursedirectors employed by Multi Agency InternationalTraining and Support (MAITS)1 and consists of fourhours of interactive, classroom-based training and fivehours of practical work with guided observations,hands-on training and clinical discussions, usually de-livered over two days. A five-to-six-day Training ofTrainer course is also offered to train ‘Master Trainers’to train, guide and supervise other health workers intheir country and region, with continued support fromthe course directors. WIFD has so far been trialled inMalawi, Uganda, Sri Lanka and Rwanda across ninehospitals. A total of 175 healthcare staff have receivedtraining to date, including three Master Trainers.

Rwanda case study WIFD was delivered to 21 health workers in Rwandain February 2018 through a partnership between Partnersin Health (PIH) and MAITS. e practical sessionswere delivered in the neonatal care, post-partum, cae-sarean section and maternity units of RwinkwavuDistrict Hospital, a government hospital located in theeastern province of Rwanda. ree Master Trainerswere trained by the course directors, selected on thebasis of their backgrounds as nutritionists, nurses andmidwives and desire to share knowledge and skills withothers. Pre- and post-test evaluations demonstrated aself-reported rise in trainees’ confidence, knowledgeand practical skills in this topic (average pre-test score54% and average post-test score 90%). Significant im-provements were seen aer the WFID training (March-July 2018) compared to the pre-training period (October2017-February 2018) in the initial two hospitals wheretraining was conducted: breastfeeding on the day ofbirth increased from 11.3% (n=37/237) to 26.9%(n=111/413, p<0.001); delayed introduction of breastmilkuntil two days or later aer birth reduced from 49.6%(n=235/474) to 36.2% (n=193/533, p<0.001); andexclusive feeding from the breast at discharge increasedfrom 63.1% (n=279/442) to 75.9% (n=441/581, p<0.001).

Improving practical skills for breastfeedingvulnerable infants in low resource settings:A case study from Rwanda

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ere were non-significant trends of decline in neonatalunit mortality from 11.0% (n=61/493) of admissionsto 8.1% (n=51/593, p=0.092) and no change in lengthof stay (mean of 10.4 days pre-training (n=554) and10.5 days post-training (n=645, p=0.134) in the periodimmediately aer training.2

Since the original training, two additional MasterTrainers have been trained by the Master Trainers inRwanda, with remote support from the course directors,and the Master Trainers have gone on to train an ad-ditional 70 health providers working across 10 districthospitals in all five provinces of Rwanda, reachingmore than 4,400 mothers and babies. To ensure sus-tainability and consistent support for mothers inneonatal and post-partum units, a new hospital-basedposition of ‘Expert Mother’ was created. is positionis now functioning in all three PIH-supported districthospitals in Rwanda, with two Expert Mothers perhospital. Expert Mothers are women who previouslyhad a child on the neonatology unit and have receivedtraining and mentoring from Master Trainers toprovide breastfeeding peer counselling to other mothersthrough mentorship, teaching and peer support.

Next steps The Master Trainers in Rwanda will continue to providementorship to hospital neonatology and maternity unit-based staff, as well as the six Expert Mothers who havebeen trained with ongoing support from the course di-rectors. ere is also potential to use these MasterTrainers to train other Master Trainers in other countriesin the same region. PIH plans to continue to monitorthe impact of the WIFD training, including the ExpertMothers intervention, and seek opportunities to expandthe reach of the Master Trainers, both within Rwandaand in other countries. Currently, the Master Trainersare leading ongoing research assessing the effectivenessof the breastfeeding interventions, including the WIFDtraining and the Expert Mothers. Further evaluation ofthe impact of the training on health outcomes forinfants is required, as well as investigation into caregiverviews on support received pre- and post-training. Op-portunities are also being investigated to integrateWIFD into the World Health Organization kangaroomother care training, which is well established inRwanda, to enable more facilities to access the training.

For more information please contact Himali de Silvaand Maya Asir at [email protected]

ReferencesDe Silva, H & Asir, M (2017) Working with infants with feedingdifficulties: a training programme for healthcare staff in low-resource setting, MAITS, UK

1 MAITS is a charity that aims to improve access to healthcare and education for people with disabilities through training.

2 Impact on length of stay and mortality of the training and other interventions is being examined to feature in future peer review publication (and Field Exchange summary).

Summary of an online-onlyfield article

Field Article .....................................................Summary

8


Yared Abebe is amedical doctor andSenior Nutrition Advisorfor USAID Transform.

Fitsum Aregawi is aNutrition Officer forUSAID Transform:Primary Health CareProject.

Solomon Berhane is aNutrition Officer forUSAID Transform:Primary Health CareProject.

Taye Wondimu is aNutrition Expert inOromia regional healthbureau.

Bayleyegn Bimerew is aNutrition Expert inAmhara regional healthbureau.

Zelalem Abera is aNutrition Officer inUSAID Transform:Primary Health CareProject.

Mengish Bahreselasie isa Nutrition Expert inTigray regional healthbureau.

This study was supported financially byUSAID Transform: Primary Health CareProject. We also thank Heran Demesie,Knowledge Management Advisor for theproject, whose assistance and commentsgreatly improved the article.

By Yared Abebe, Zelalem Abera, Figsum Aregawi, Solomon Berhane, Taye Wondimu, Bayleyegn Bimerew and Mengesh Bahreselasie

An innovative,low-cost toolfor a moreefficientweight-for-height/length (WHZ/WLZ) assessment

IntroductionEarly identification and treatment of wasting is animportant element in the reduction of childhood mor-tality and long-term negative health impacts, includingstunting. Wasting is diagnosed in children throughweight-for-height/length z-score (WHZ/ WLZ) assess-ments and by measuring mid-upper arm circumference(MUAC). WHZ/WLZ assessment requires three steps,including taking weight and height/ length measure-ments and looking up the results in tables/charts. Eachstep is time-consuming and prone to error. For thisreason, the World Health Organization does not recom-mend the use of WHZ/WLZ for the assessment of childnutrition status at the community level.

Some countries, such as Ethiopia, have effectivelydecentralised management of acute malnutritionservices to sites closer to communities. In Ethiopiaover 90% of these sites use MUAC to diagnose wast-ing. MUAC and WHZ/WLZ assessments, however,identify two distinct groups of patients at risk of deathand the overlap between the two indicators is verylow. For this reason, scholars are asking for innovativesolutions that simplify WHZ/WLZ assessments. Inresponse, a new tool has been developed that aims toaddress some of these drawbacks, thereby minimisingerrors in WHZ/WLZ assessments and potentiallysaving health worker time and energy.

The new tool The new method involves a decision-making cali-brated-chart on a height board in place of the usualmeasuring tape. This chart, called a Y’s chart, reducesthe steps needed for a WHZ/WLZ assessment fromthree to two by avoiding the need for separate refer-ence materials (Figure 1).

New height boards were produced with groovedspaces to post the calibrated charts. As an alternative,the graduated charts were also produced as stickersto be attached to existing height boards. As the newcharts also have linear measurement markings in cen-timeters, the placement of the stickers on the existingboards was not difficult when done with due care.

Field testing To measure potential gains of the new tool, field testswere conducted by four regional state health bureausin collaboration with USAID Transform: Primary HealthCare project between December 2017 and December

2018. A half day’s practical training was providedto a total of 16 health workers (clinical nurses andhealth officers), after which half used the standardmethod and half used the new tool to measureWHZ/WLZ in a group of 195 children. ‘Time saved’and ‘proportion of errors committed’ were meas-ured and compared between groups. Fourcommunity health extension workers (HEWs) werealso trained on the new method and conductedWHZ assessments as a separate group. A pair ofanthropometry experts reassessed the same chil-dren as normal, with moderate acute malnutrition(MAM) or with severe acute malnutrition (SAM) andtheir assessment was taken as gold standard. Theamount of time spent on each WHZ assessmentwas measured by data collectors.

Results showed that the assessment took anaverage of 77 seconds to conduct with the standardmethod and 44 seconds with the new method. Atotal of 154 children were reassessed by experts.The proportion of errors committed by health work-ers who used the standard method versus newmethod was 11.6% and 4.4% respectively. HEWswho used the new method committed 7.3 % errorsin classifying children as normal, MAM and SAM.

Conclusion and recommendation The new tool was found to be more efficient,saving 33 seconds per assessment (p < 0.001). Thisis a 43% reduction of time and energy and is a sig-nificant gain, especially for busy health facilities.The new tool also produced less errors. However,as prevalence of malnutrition is low, a largersample study is needed to make definitive conclu-sions. A randomised clinical trial is currentlyunderway (clinicaltrial.gov, ID: NCT03780348) toinvestigate potential gains in accuracy. The newtool was also effectively used by community HEWS,indicating its potential for community-level use.

The health bureaus in the four most populousregional states in Ethiopia have endorsed the tooland it is currently in use in 100 health facilities. Thefeedback from health workers in these facilities isconsistently positive. Multi-country testing for itsintroduction into global practices is recommended.

For more information, please contact YaredAbebe at [email protected]

Existing method - height board with measuring tape New method- height board with a decision-making chart (Y’s chart)

Steps with the new methodSteps with the existing methodStep 1 Measure weightStep 2 Check WHZ/WLZ score using Y’s chart on the height/length board after positioning the child as per the standard

Step 1 Measure height or length in standard postionStep 2 Measure weight Step 3 Check reference charts or curves to find WHZ/WLZ score

News ...........................................................................

Figure 1 Venn diagram visualising discrepancies between cGAM, GAM per WHZ and GAMper MUAC

9


In its first-ever regional issue, Nutrition Ex-change has partnered with the United NationsChildren’s Fund (UNICEF) Regional Office ofSouth Asia (ROSA) to build on the momentum

from the ‘Stop Stunting: the Power of MaternalNutrition’ conference held in Nepal in 2018. Nu-trition is high on the political agenda in SouthAsia, with many countries having developed andresourced multi-sector nutrition plans to meetglobal targets on child stunting, wasting andoverweight. However, there is a danger thatwomen will be left behind in the regional mo-mentum to improve nutrition unless greater at-tention is given to their nutritional care.

The nutritional status of women is improvingin South Asia, but progress is uneven and slow.One in five women is underweight (body massindex <18.5 kg/m²); one in 10 are of short stature(height <145 cm); and anaemia is a severe ormoderate public health problem in seven out ofeight countries (UNICEF-WHO, 2019). Meanwhile,the prevalence of overweight is increasing at analarming rate in women and now exceeds un-derweight in all countries in the region, exceptBangladesh and India.

The focus of the issue was to share the expe-riences and lessons learned from national gov-ernment stakeholders and their developmentpartners on how they are improving maternalnutrition at country and sub-national level, andwhat challenges remain. NEX South Asia containsnine articles from seven countries (Afghanistan,Bangladesh, Bhutan, India, Nepal, Pakistan andSri Lanka), providing a range of different contexts.Each country is at a different stage of developmentin terms of maternal nutrition policies and pro-grammes, and has adopted varying approachesto strengthening its maternal nutrition services.

One of the predominant themes to emergefrom the articles was the emphasis placed onnutrition counselling; particularly as deliveredvia community-based actors and platforms. Thisis very much in line with World Health Organization(WHO) global guidance (WHO, 2016). InAfghanistan, the creation of a new cadre of nu-trition counsellors at health-facility level is resultingin increased interaction with pregnant womanand new mothers, despite the ongoing securitychallenges (Maroof et al, 2019).

Two articles from Nepal explored the role ofthe country’s large workforce of female communityhealth volunteers (FCHVs). This role was seen ascrucial to the country’s success story in reducingthe prevalence of maternal anaemia through thework of the FCHVs in promoting iron and folicacid uptake (Bichha et al, 2019). A second articlefrom Nepal highlights efforts to strengthen theintegration of maternal nutrition activities intothe health system with support from a develop-ment partner. The focus was on social and be-haviour-change communication strategies andcapacity-building of the FCHVs to deliver theseactivities (Pun et al, 2019).

The Indian states of Bihar and Uttar Pradeshhave addressed building the technical capacityof health practitioners at all levels, includingmedical training for doctors and midwives, toimprove the quality of maternal nutrition-coun-selling services (Ghosh et al, 2019). Having show-cased the importance of this training, there areplans to scale up to other states in the country.

Lack of data and information on the coverageand quality of services is another theme that fea-tures in a number of articles. In Bangladesh, adeliberate focus on prioritising indicators for ma-

ternal nutrition and strengthening the country’snutrition information system has led to an increasein the resources available for scaling up servicesfor pregnant women (Rahman et al, 2019). How-ever, in Pakistan, there are ongoing constraintsdue to the lack of quality data (Ahmed et al,2019). And, even in countries with a strong en-abling environment for maternal nutrition, suchas Bhutan, the article emphasises that work isstill needed to improve programme coverageand quality (Dzed et al, 2019).

Public-sector services such as health are de-centralised in a number of the featured countries,which can offer opportunities to both integratewith other sectors and add new activities withinsectors. In Punjab province, Pakistan, overlappingprogrammes and interventions for maternal andchild health have been combined under one um-brella programme for an integrated health-sectorresponse (Ahmed et al, 2019). Challenges remain,however, to involve other sectors, despite theexistence of multi-sector mechanisms at provinciallevel. In Karnataka state, India, state-level re-sources under the Anganwadi services schemeare being used to deliver a hot mid-day meal aspart of the health-service provision for pregnantwomen, with the aim of increasing their calorieintake and uptake of services such as counsellingand antenatal care (Mahadevan et al, 2109).

Finally, Sri Lanka is one of the few countriesin the region with maternal nutrition policy andprogramming that is attempting to address thenew reality of double burden among women(Nilaweera et al, 2019). It is doing this throughthe counselling of pregnant women to promotehealthy eating and physical activity to preventexcessive weight gain. However, challenges remain;in particular, with a blanket supplementation dis-tributed to all pregnant and lactating women.This programme was originally introduced to ad-dress undernutrition, but now needs to adopt atargeted approach in light of increasing obesityand overweight.

The second NEX South Asia issue is due out inJune 2020. This issue will focus on country articleson complementary feeding, following the ‘StopStunting: Improving Young Children’s Diets in SouthAsia’ conference in Nepal, 2019.

NutritionExchange (NEX)South Asia:Maternalnutrition

ReferencesDr Khawaja Masuood Ahmed, Dr Saba Shuja and Dr WisalKhan (2019). Providing maternal nutrition services at sub-national level in Punjab Province, Pakistan. NutritionExchange South Asia 1, June 2019. p23. www.ennonline.net/nex/southasia/maternalnutritionpunjabprovince

Dr Ram Padarath Bichha, Kedar Raj Parajul, PradiumnaDahal, Naveen Paudyal and Stanley Chitekwe (2019).Nepal’s success story: What helped to improve maternalanaemia? Nutrition Exchange South Asia 1, June 2019. p14.www.ennonline.net/nex/southasia/nepalssuccessstory

Laigden Dzed, Vandana Joshi, Loday Zangpo, TashiTshomo and Chandralal Mongar (2019). Creating an enablingenvironment for delivering maternal nutrition interventionsin Bhutan. Nutrition Exchange South Asia 1, June 2019. p12.www.ennonline.net/nex/southasia/mater nalnutritionbhutan

Dr Sebanti Ghosh, Dr Kaushal Kishore, Dr Vinita Das, DrKiran Pandey and Dr Shailesh Jagtap (2019). Harnessingthe potential of India’s medical colleges to bring maternal

nutrition services to scale. Nutrition Exchange South Asia 1,June 2019. p6.www.ennonline.net/nex/southasia/indiasmedicalcolleges

Uma Mahadevan, Vani Sethi, Khyati Tiwari and Arjan deWagt (2019). Combining a mid-day meal, health servicepackage and peer support in Karnataka State, India.Nutrition Exchange South Asia 1, June 2019. p20. www.ennonline.net/nex/southasia/middaymealindia

Dr Zakia Maroof, Dr Homayoun Ludin, Dr Zelaikha Anwari,Suzanne Fuhrmann and Maureen Gallagher (2019).Addressing maternal nutrition service delivery gaps inAfghanistan: Policy and programming opportunities.Nutrition Exchange South Asia 1, June 2019. p9.www.ennonline.net/nex/southasia/deliverygapsafghanistan

Dr Irosha Nilaweera, Dr Dhammica Rowel, DrNilmini Hemachandra, Dr Safina Abdulloeva, DrNethanjalie Mapitigama (2019). Delivering care to addressa double burden of maternal malnutrition in Sri Lanka.Nutrition Exchange South Asia 1, June 2019. p17.www.ennonline.net/nex/southasia/doubleburdensrilanka

Bhim Kumari Pun, Khim Khadka, Basant Thapa, KrishnaPrasad Lamsal, Pooja Pandey Rana and Dr KendaCunningham (2019). Integration of maternal nutrition intoNepal’s health service platforms: What’s happening?Nutrition Exchange South Asia 1, June 2019. p26.www.ennonline.net/nex/southasia/maternalnutritionnepal

Dr Mustafizur Rahman, Dr Zeba Mahmud, Dr Mohsin Aliand Pragya Mathema (2019). Strengthening nutritioninformation systems to improve maternal nutrition inBangladesh. Nutrition Exchange South Asia 1, June 2019.p29. www.ennonline.net/nex/southasia/informationsystemsbangladesh

UNICEF-WHO (2019). Low Birthweight Estimates. Levelsand trends 2000-2015 www.unicef.org/media/53711/file/UNICEFWHO%20Low%20birthweight%20estimates%202019%20.pdf WHO (2016). Recommendations on antenatal care for apositive pregnancy experience for women.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .News

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The Strengthening Partnerships,Results, and Innovations in NutritionGlobally (SPRING) project has nowclosed. SPRING was funded by the

United States Agency for International Develop-ment (USAID), under a seven-year cooperativeagreement, and implemented by a team ofexperts from JSI Research and Training InstituteInc, Helen Keller International (HKI), the Interna-tional Food Policy Research Institute (IFPRI), Savethe Children, and the Manoff Group. SPRING’sgoal was to strengthen global and country efforts

and is available in a specially curated section ofSPRING’s website.2

A JSI-led consortium is now being established toimplement USAID’s flagship global multi-sectornutrition programme. The launch of the pro-gramme will be announced in due course.

Visit: www.spring-nutrition.org

1 www.spring-nutrition.org/results-glance2 www.spring-nutrition.org/six-years-multi-sectoral-learning-

spring

SPRING through the seasons

Ahealth systems strengthening (HSS)course, originally developed toequip United Nations Children’sFund (UNICEF) staff by UNICEF with

the University of Melbourne and the Nossal Insti-tute for Global Health, is now open access. Thecourse is aimed at middle and high-level health

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health systemsstrengthening course

An article featured in Field Exchange issue 601

shared findings of two mapping exercises under-taken by ENN in East Africa and West and CentralAfrica to gain insight into the continuum of UN-

supported service provision for acute malnutrition treatment.While good examples of continuity of care were found inboth regions, in general there were considerable shortcom-ings reflected in what data was available and experiencesshared. Contributing factors included different targetingstrategies and coverage ambitions for services, variable inte-gration within national systems, lack of normative guidancefor moderate case management, and resource shortfalls. Rec-ommendations are consistent across both regions andinclude more in-depth reviews of service availability andalignment in multiple contexts, product supply chain, referralsystems and practices, and protocol adaptations.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

to scale up high-impact nutrition practices andpolicies to prevent stunting and maternal andchild anaemia in the first 1,000 days. In its lifetime,SPRING supported hundreds of institutions,shared thousands of resources, hosted 100events and trained more than 168,000 people innutrition1, fostering many diverse, multi-sectorpartnerships for governments and local partnersto build on. Although the project has closed,SPRING’s website remains available. Much of thelearning related to critical nutrition-specific andnutrition-sensitive topics has been documented

professionals, including health administratorsand policy makers, doctors, nurses and otherswho work to shape health systems. Studentsexplore the complexity of health systems andapply systems thinking to HSS in low- andmiddle-income country contexts. Students aretaught to critique major health system frame-

works, analyse health system inequities, andinterrogate the evidence for HSS approaches. Thecourse aims to equip learners with knowledgeand skills to develop HSS interventions acrossareas such as health policy, health financing,human resources, supply chain management,quality of care and private sector engagement.The course is freely available and requires threehours of study per week for eight weeks.

Find out more and sign up at: www.futurelearn.com/courses/health-systems-strengthening

Continuity of care in acutemalnutrition treatment in EastAfrica and West and Central Africa:a mapping exercise

News

The full reports of both mapping exercises are avail-able on ENN’s website.

East Africa: www.ennonline.net/resources/map-pingexerciseeastafrica

West and Central Africawww.ennonline.net/resources/mappingexer-cisewestcentralafrica

For more information, please contact Marie McGrathat [email protected]

1 https://www.ennonline.net/fex/60/sammammapping

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Taking MUAC measurement of asmall child, Afghanistan, 2016

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

Estimating‘people inneed’ fromcombined GAMin Afghanistan

Backgrounde World Health Organization (WHO) rec-ommends the use of weight-for-height z-score(WHZ) to estimate prevalence of global acutemalnutrition (GAM), also referred to as wast-ing, among children aged 6-59 months (WHOand UNICEF, 2009). Population WHZ is com-pared against the 2006 WHO growth standardsfor boys and girls. Individual cases with WHZ≥-3 and <-2 are categorised as moderate acutemalnutrition (MAM), while WHZ <-3 casesare categorised as severe acute malnutrition(SAM). WHO also recommends the use ofmid-upper arm circumference (MUAC) as anindependent diagnostic criterion (WHO andUNICEF, 2009). MUAC relies not on sex-spe-cific growth references, but on a global cut-off indicating severity; MUAC ≥115 mm and

By Alexandra Humphreys, Bijoy Sarker,Baidar Bakht Habib, Anteneh Gebremichael Dobamo and Danka Pantchova

Alexandra Humphreys is theNutrition AssessmentTechnical Advisor with theTechnical Rapid ResponseTeam and formerly FlyingNutrition Assessment and

Evaluation Expert for Action Against Hunger,with survey experience in several countries. Sheholds a master’s degree from Tufts University inFood Policy and Applied Nutrition.

Bijoy Sarker is the SMARTRegional Advisor for Asia andformerly Nutrition Cluster Co-Lead in Afghanistan withAction Against Hunger. Heholds a master’s degree in

Public Health and has nearly 10 years’experience in emergency nutrition andsurveillance across several countries, includingas a Roving health and Nutrition Expert for Asia.

Baidar Bakht Habib is theSMART Nutrition ProgramManager for Action AgainstHunger Afghanistan. He is amedical doctor with over eightyears of nutrition experience,

four of which were implementing nutritionsurveys across Afghanistan.

Anteneh GebremichaelDobamo is working for theGlobal Nutrition Cluster andwas formerly Nutrition ClusterCoordinator in Afghanistanwith UNICEF. He has 15 years

of experience in public health nutrition indevelopment and emergency contexts andholds a master’s in Public Policy andManagement.

Danka Pantchova is theNutrition Surveillance andPrevention Advisor at ActionAgainst Hunger France. Shehas worked in thehumanitarian field since 2004,

with experience in acute and chronicemergencies across several countries.

<125 mm is categorised as MAM, while caseswith MUAC <115 mm are categorised as SAM.

WHZ and MUAC are generally presentedindependently in SMART1 and UNHCR Stan-dardised Expanded Nutrition Surveys (SENS)to estimate the prevalence of acute malnutrition,since it is well established in the literaturethat WHZ and MUAC correlate poorly (Rober-froid et al, 2015). A 2018 analysis of 744 pop-ulation-representative surveys from 41 countriesconcluded that the prevalence of acute mal-nutrition by WHZ and MUAC varied consid-erably, even within the same region and country,while the prevalence of global acute malnutritionGAM by WHZ was higher than GAM by

1 Standardized Monitoring and Assessment of Relief and Transitions

Location: Afghanistan What we know: The correlation between weight-for-height z-score (WHZ) andmid-upper arm circumference (MUAC) prevalence varies by context; this hasimplications for programme caseload projections.

What this article adds: The proportions of global acute malnutrition (GAM) andsevere acute malnutrition (SAM) cases among children aged 6-59 months inAfghanistan captured by different indicators (WHZ, MUAC and a proposedaggregate indicator (cGAM)) was determined. Anthropometric databases from31 SMART surveys from 30 out of 34 provinces (2015-2018) were used, totalling28,301 children. Only 25.7% of GAM cases and 14.7% of SAM cases met bothWHZ and MUAC criteria. Numbers of GAM cases identified were: 2,936(WHZ); 3,068 (MUAC); and 4,777 (cGAM). Caseloads for SAM were: 814(WHZ); 751 (MUAC); and 1,364 (cSAM). Three caseload calculations wereperformed in 22 priority provinces based on WHZ, MUAC and cGAM tocompare the differences. The caseload estimate was 1,021,039 by WHZ;1,090,620 by MUAC; and 1,578,465 by cGAM. Poor correlation between WHZand MUAC in the Afghanistan context necessitates use of cGAM to estimatecaseloads. The authors recommend that cGAM is routinely reported frompopulation-representative nutrition surveys globally, in addition to WHZ andMUAC, to enable context-specific decision-making. Globally validated cut-offsfor cGAM are needed.

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2 www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/afg_ imam_guideline_2018_final.pdf

3 Due to the physiological effects of oedema causing retention of fluid in the body, weight data is not considered for children with nutritional oedema.

4 Per the SMART Methodology plausibility check

MUAC approximately 75% of the time (Bilukhaand Leidman, 2018). WHZ is standardised forsex and height (and thus indirectly for age).Recommended global MUAC cut-offs are notstandardised for sex, height, or age and tend toidentify younger and stunted children (Grelletyand Golden, 2016, Roberfroid et al, 2015). epotential for WHZ and MUAC to capture differentchildren is why they are reported separately andused independently as enrolment criteria for thetreatment of acute malnutrition among childrenaged 6-59 months. However, the discrepancybetween WHZ and MUAC, and how this canaffect overall caseloads, is rarely considered atfield level for programmatic purposes.

Countries adopt different approaches towardsindividual detection and enrolment criteria foracute malnutrition management according to thecontext. In Afghanistan, population-representativeanthropometric SMART surveys have suggesteda distinct discrepancy between the prevalence ofGAM by WHZ and MUAC, with the prevalenceby MUAC being higher in most surveys. e In-tegrated Management of Acute Malnutrition Na-tional Guidelines2 (January 2018) recommendsthe use of WHZ, MUAC, oedema and clinicalstatus. In order to represent the burden of acutemalnutrition among children aged 6-59 monthsmore accurately, Action Against Hunger, withthe support of local partners and the Ministry ofPublic Health Public Nutrition Directorate, beganreporting on the prevalence of GAM combiningboth WHZ and MUAC in 2015. Combined GAM(cGAM) is an aggregated indicator including allcases of GAM by WHZ <-2, MUAC <125 mm,and/or bilateral pitting oedema.

is article examines the practical implicationsof using cGAM in the Afghan context and con-siders the implications of using cGAM in settingswhere WHZ and MUAC are poorly correlated.

e humanitarian programme cycle (HPC)is a coordinated series of actions undertaken tohelp prepare for, manage and deliver humani-tarian response. e critical first step of theHPC is the humanitarian needs overview (HNO),which helps to inform strategic response planning.During the process of HNO development, eachsector cluster calculates its estimated caseloadrequiring humanitarian assistance, known asthe ‘people in need’ (PiN) estimation. InAfghanistan, the PiN is calculated in advanceof each year in alignment with the Afghanistanmulti-year Humanitarian Response Plan (HRP)strategy. Previously, caseload calculation inAfghanistan had relied on malnutrition estimatesbased on WHZ. With the frequent observationsthat the prevalence of acute malnutrition byMUAC was higher in most provinces than WHZ,nutrition stakeholders began advocating forboth indicators to be considered in PiN estimates.

Methods An analysis of the proportions of GAM andSAM cases among children aged 6-59 monthsin Afghanistan captured by different indicators(WHZ, MUAC, cGAM) was performed. Datacleaning and analysis was conducted usingSTATA Version 15. e anthropometric databasesfrom 31 SMART surveys supported by ActionAgainst Hunger between January 2015 and Sep-tember 2018 were appended to create a completedatabase of children aged 6-59 months. Duringthe data cleaning process, observations weresystematically excluded from the dataset, asonly children with both MUAC and WHZ datawere retained for analysis. Eighty-one observa-tions were removed due to missing MUAC data.irty observations were removed due to missingWHZ data, including cases of oedema (9)3. Dueto the assumed heterogeneity of the sample ofnationwide data, the data were assessed usingWHO flags (+/- 5 standard deviations from themean (μ=0)) in order to exclude outliers basedon biological implausibility. Seventy-four ob-servations were flagged as outliers per WHOflags and removed from the dataset. Overall,185 (0.6%) observations were removed fromthe dataset. e final analysis assessed 28,301children aged 6-59 months.

Children categorised as GAM by WHZ (<-2z-scores) were cross-tabulated against childrencategorised as GAM by MUAC (<125 mm) toexamine the relationship between the two indi-cators. e same method was conducted tocompare SAM by WHZ (<-3 z-scores) and SAMby MUAC (<115 mm).

Separately, to compare the difference in case-load calculations based on the different anthro-pometric indicators (WHZ, MUAC and cGAM),three separate caseload calculations were per-formed using Excel 2016 following the methoddeveloped by the Global Nutrition Cluster(GNC):

Caseload = N x P x K where N=population size,

P=prevalence of malnutrition, K= correction factor

A girl being measured for height,Kandahar, Afghanistan, 2018

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Twenty-two priority provinces were used forcalculation, with the Nutrition Cluster inAfghanistan defining a province as priority if ithas a GAM prevalence by WHZ ≥10.0%. epopulation size (N) was derived from the 2018-2019 population estimates available from theCentral Statistics Organization (CSO) ofAfghanistan. e estimated prevalence of acutemalnutrition (P) by WHZ, MUAC and cGAMper province was sourced from the most recentSMART surveys. Lastly, a correction factor (K)of 2.6 was used per GNC recommendations forcalculating nutrition caseload for a year.

Resultse anthropometric data were examined from31 population-representative, cross-sectionalSMART surveys conducted across 30 of the 34(88.2%) provinces of Afghanistan from 2015 to2018, suggesting a sample reflecting all regionsof the country. e sample was 48.6% femaleand 51.4% male. e age ratio of children aged6-29 months compared to children aged 30-59months was 1.03 (higher than the expected pro-portion of 0.854).

Overall, there were 2,936 cases of GAM perWHZ and 3,068 cases of GAM per MUAC, aspresented in Figure 1. Despite a similar numberof cases using either indicator, there remains alarge discrepancy in cases captured by both,with only 25.7% of cases identified as GAM ac-cording to both indicators. More GAM caseswere identified using MUAC than WHZ; however,using MUAC alone would capture only 64.2%of cases. Alternatively, using WHZ alone wouldcapture just 61.5% of these cases. ConsideringcGAM (WHZ and/or MUAC), there were atotal of 4,777 GAM cases.

Overall, there were 814 cases of SAM perWHZ and 751 cases of SAM per MUAC, as pre-sented in Figure 2 below. Despite a similarnumber of cases using either indicator, thereremains a large discrepancy in cases capturedby both, with only 14.7% of cases identified asSAM according to both indicators. More SAMcases were identified using WHZ than MUAC;however, using WHZ alone would capture only59.7% of cases. Alternatively, using MUAC alonewould capture just 55.1% of these cases. Con-sidering cSAM (WHZ and/or MUAC), therewere a total of 1,364 SAM cases.

e results of the caseload calculation basedon three scenarios presented in Table 1 demonstratethe difference in caseloads based on WHZ, MUACand cGAM. All three scenarios examined thesame 22 priority provinces, thereby utilising thesame total population and total population underfive years old data, while examining a differentprevalence of malnutrition per province basedon the indicator. As expected, the caseload estimateby WHZ was the lowest, with an estimated

Field Article

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1,021,039 children under five years old acutelymalnourished. e caseload estimate by MUACwas higher, with an estimated 1,090,620 childrenunder five years old acutely malnourished. ecaseload estimate by cGAM was the highest,with an estimated 1,578,465 children under fiveacutely malnourished (UNOCHA, 2018).

DiscussionWHZ and MUAC are currently used independ-ently to assess acute malnutrition among indi-vidual children as well as the overall populationof children aged 6-59 months. Both methodspossess strengths and weaknesses, lending totheir potential to capture different subsets ofchildren. In the Afghan context, the higher pro-portion of children identified using MUACprompted humanitarian practitioners to inves-tigate how many children were being capturedby both indicators. is analysis demonstratesthat there is a large discrepancy between casesof acute malnutrition identified by WHZ andMUAC in Afghanistan, with only one in fourchildren being captured by both indicators.

ese findings have important implicationsfor estimating the burden of acute malnutrition.Traditionally, most countries have relied on theprevalence of WHZ for caseload calculation asit is standardised for age and sex and tends togenerate a higher prevalence than MUAC; oenperpetuating the assumption that, because it isa larger prevalence, it also captures and accountsfor the children who are acutely malnourishedby MUAC. e poor correlation between WHZand MUAC as demonstrated in recent literature,

in addition to the results of this analysis, supportsthe argument that cGAM should be routinelycalculated and reported by countries to recogniseany discrepancy between the two indicators.

ere are also programming implicationsfor countries or regions that rely exclusively onMUAC as a criterion for enrolment into a pro-gramme for the treatment of acute malnutrition.Using only MUAC can exclude the portion ofthe population aged 6-59 months that wouldbe eligible only by WHZ, who are more likelyto be older children considering MUAC’s knownbias towards identifying smaller and youngerchildren. Depending on the discrepancy betweenthe two indicators for the context, a sizableportion of the eligible children could be excludedfrom treatment. In Afghanistan, MUAC is mainlyused for community-based screenings, increasingthe likelihood that a portion of acutely mal-nourished children is missed altogether.

e Afghanistan national Integrated Man-agement of Acute Malnutrition (IMAM) guide-line includes both WHZ and MUAC as inde-pendent admission criteria for SAM and MAMtreatment centres. Practically, this means thatany child under five years old with WHZ <-2and/or MUAC <125mm should be referred to anutrition centre for appropriate malnutritiontreatment and care. WHO recommends that,to improve planning, the same criteria used foradmission into programmes should be used forestimating caseload (WHO and UNICEF, 2009).Accurate caseload calculation is crucial in plan-ning the appropriate resources to meet the needs

Figure 1 Venn diagram visualisingdiscrepancies between cGAM,GAM per WHZ and GAM perMUAC

Combined GAM (WHZ or MUAC)100.0% (n=4777)

GAM WHZ 61.5% (n=2936)

GAM MUAC 64.2% (n=3068)

exclusivelyGAM WHZ

35.8%(n=1709)

GAM WHZand

GAM MUAC 25.7%

(n=1227)

exclusivelyGAM MUAC

38.5%(n=1841)

Figure 2 Venn diagram visualisingdiscrepancies between cSAM,SAM per WHZ and SAM perMUAC

Combined SAM (WHZ or MUAC) 100.0% (n=1364)

SAM WHZ 59.7% (n=814)

SAM MUAC 55.1% (n=751)

exclusivelySAM WHZ

44.9% (n=613)

SAM WHZand

SAM MUAC 14.7%

(n=201)

exclusivelySAM MUAC

40.3% (n=550)

Scenario TotalPopulation (2018)

Total U5population(17.3%)

GAM (range)* SAM (range) Total # ofMAM (U5)

Total # ofSAM (U5)

Total # ofGAM (U5)

Scenario1: WHZ**

17,773,741 3,074,857 (10.4% to 15.7%) (1.4% to 4.2%) 783,201 237,838 1,021,039

Scenario2: MUAC

(6.4% to 24.4%) (1.3% to 7.4%) 789,370 301,250 1,090,620

Scenario3: cGAM

(14.4% to 26.9%) (2.7% to 8.4%) 1,122,626 455,839 1,578,465

Table 1 Three scenarios for Afghanistan 2019 HNO caseload estimation among 22priority provinces (2018-19 SMART survey data)

*Range of acute malnutrition prevalence across the 22 priority provinces**WHZ data was available for children aged 0-59 months. MUAC and cGAM data was only available for children aged 6-59months (as MUAC is not a validated indicator for infants <6 months) and the results were generalised to the entire under-five population.

ReferencesBilukha O and Leidman E 2018. Concordance between theestimates of wasting measured by weight-for-height andby mid-upper arm circumference for classification ofseverity of nutrition crisis: analysis of population-representative surveys from humanitarian settings. BMCNutrition 4:24.

Grellety E, Golden M 2016. Weight-for-height and mid-upper-arm circumference should be used independentlyto diagnose acute malnutrition: policy implications. BMCNutrition 2:10.

Roberfroid D, Huybregts L, Lachat C, Vrijens F, Kolsteren P,Guesdon B 2015. Inconsistent diagnosis of acutemalnutrition by weight-for-height and mid-upper armcircumference: contributors in 16 cross-sectional surveysfrom South Sudan, the Philippines, Chad, and Bangladesh.Nutrition Journal 14:86.

UNOCHA 2018. Humanitarian Needs Overview:Afghanistan 2019.

WHO, UNICEF 2009. WHO child growth standards and theidentification of severe acute malnutrition in infants andchildren: A Joint Statement by the World HealthOrganization and the United Nations Children’s Fund.

of this vulnerable subset of the population. Ul-timately, planning based on cGAM is both viableand important in the Afghan context, with thePublic Nutrition Directorate, the Ministry ofPublic Health and the Nutrition Cluster havingendorsed the practice to ensure realistic fore-casting and programme implementation. Yemenhas also adopted combined GAM for caseloadcalculation since 2017 as part of its nationalguideline.

Given the discrepancy between WHZ andMUAC in the Afghan context, the use of cGAMfor caseload calculation is necessary to accuratelyestimate the burden of acute malnutrition. Ascontrasted in the three scenarios, using cGAMestimated 1.58 million acutely malnourishedchildren under five, while using MUAC estimated1.09 million (30.9% less) and WHZ estimated1.02 million (35.3% less). In other words, relyingon WHZ caseload estimations alone for 2019could have overlooked the necessary advocacy,resources, planning and programming for half amillion cases of acute malnutrition; one in everythree wasted children under five in Afghanistan.

RecommendationsGiven the evidence presented, it is recommendedthat cGAM be routinely reported from popula-tion-representative nutrition surveys globally.Reporting cGAM should not replace but com-plement the reported prevalence of acute mal-nutrition by GAM by WHZ and GAM by MUACto enable nutrition stakeholders to utilise anyof the three indicators for decision-making asis most appropriate for their context. cGAMshould also be considered for use in calculatingcaseload, particularly in contexts where GAMby WHZ and GAM by MUAC are poorly corre-lated. Considering that there are globally validatedcut-offs for GAM by WHZ as well as GAM byMUAC, global nutrition leaders should establisha globally validated cut-off for cGAM for betterinterpretation of findings by nutrition stake-holders and decision-makers.

For more information please contact Alexandra Humphreys at [email protected]

Field Article

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Research .............................................................

By Sreeparna Ghosh Mukherjee, Pia Sen and Dr Nagma Nigar Shah

Sreeparna Ghosh Mukherjee is Senior Programme Manager inthe Health and Nutrition Unit of Child in Need Institute (CINI).She is a senior development professional with over 15 years’experience in public health and nutrition, leading large-scaleprogrammes with organisations such as CINI, GOAL and CARE.

Pia Sen is Monitoring, Evaluation and Documentation Officer forCINI. She previously worked as a project supervisor for LiverFoundation West Bengal and as a researcher for Pratichi Institute.Pia has extensive experience in evaluating and monitoring state-run programmes in health, education and child protection.

Ensuring pregnancy weight gain: An integratedcommunity-based approach to tackle maternalnutrition in India

Dr Nagma Nigar Shah has a bachelor’s degree indental surgery and a Master’s in Public Health.She currently works in the Health and NutritionUnit at CINI, providing technical assistanceacross different issues in health and nutrition.

The authors acknowledge the support of the CINI in theimplementation of this project, as well as HCL foundation (fundingpartner) and the Department of Health and Family Welfare and theDepartment of Women and Child Development of theGovernment of West Bengal.

BackgroundIndia has the highest number of malnourishedchildren in the world. In 2015, an estimated37.9% of children under five years old in Indiawere stunted and 20.8% wasted (India DHS,2015). e health and nutrition of a mother is amajor contributory factor to the nutrition of herchild throughout the lifecycle (Black et al, 2008;Victora et al, 2008). An undernourished motheris more likely to give birth to a low birth weight(LBW) infant, which increases that child’s risk ofwasting, stunting and child mortality and, laterin life, their risk of non-communicable diseasessuch as diabetes and high blood pressure. Stuntingin childhood also leads to lower educationalachievements and, for girls, increases the chancesof them growing into women who will give birthto smaller infants themselves, perpetuating theintergenerational cycle of malnutrition (Victoraet al, 2008). In one study, nutrition support pro-

vided to pregnant mothers and their children upto the age of three was associated with an 11%increased chance of that child acquiring a graduatedegree, compared to children who received nu-trition support between the ages of three and six(Nandi et al, 2008). Optimal maternal health andnutrition are also important for a woman’s ownability to lead a healthy life.

India’s maternal mortality rate remains high,at 130 per 100,000 live births. is must behalved within the next decade to reach the sus-tainable development goal. Furthermore, Indiahas one of the highest prevalences of anaemiaamong pregnant women in the world, at 53.2%.Uptake of iron and folic acid (IFA) supplemen-tation among women of childbearing age inIndia is low (28% in West Bengal; NFHS-42015-16), despite widespread distribution, dueto apathy and common side-effects of nauseaand vomiting. is is aggravated by a lack of di-

etary diversity in regular food consumption,tending towards high consumption of starchyfoods (rice and potatoes in West Bengal).

Child in Need Institute (CINI)1 has beenworking in child, women and adolescent healthand nutrition in India for 45 years. In 2017,CINI, with support from the HCL Foundation2,initiated a maternal and child nutrition projectin three districts of West Bengal, focusing onthe first 1,000 days (conception until two yearsof age). e aim of the project is to change com-munity-level practices to tackle malnutrition byfacilitating stronger links between existing gov-ernment services and recipients in the community.

Pilot maternal nutritionintervention As part of this project, a pilot maternal nutrition

Location: India What we know: Maternal nutrition is a critical determinant of maternal health and the nutrition, health andwellbeing of children.

What this article adds: In 2018, Child in Need Institute implemented a pilot maternal nutrition project in 98government integrated child development services centres in three districts of West Bengal, covering 182pregnant women. Frontline health workers were trained to identify pregnancies as ‘nutritional risk’, includingthin, severely thin, overweight, obese and anaemic. Routine food provision (daily cooked meal), iron-folic acidsupplementation and nutrition counselling were strengthened. Participants were weighed monthly. Fifty percent of participants were malnourished at registration (30.3% severely thin or thin; 19.7% overweight or obese).Average gestational weight gain (GWG) was 9.36 kg (against 10 kg target in line with national guidelines) andwas highest in undernourished women. Prevalence of anaemia reduced by 12% by the end of pregnancy, withmost improvement in normal body-mass-index women. Rate of low birth weight among infants born of thecohort was 16%; 90% of whom were from severely thin and overweight/obese mothers. Recommendations areto identify pregnancies at nutritional risk by 12 weeks for targeted nutritional support; monthly routinetracking of GWG; improved adherence to government pregnancy supplementation programmes; and improvedguidance on community-based maternal nutrition interventions targeted to different risk categories.

1 www.cini-india.org2 www.hclfoundation.org

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intervention was implemented between April2018 and February 2019 to facilitate adequatepregnancy weight gain and anaemia control inthree blocks in three districts of West Bengal:Nagrakata block from Jalpaiguri district; Suti-Iblock from Murshidabad district; and Faltablock from South 24 Parganas district. epilot intervention was implemented in 98 inte-grated child development services (ICDS)3 cen-tres across these locations. ICDS centres covera population of 500-700 and were selectedrather than sub-health centres as the deliveryplatform as they are more accessible to thecommunity. ICDS centres were selected in dis-cussion with the block administration basedon social group (higher concentration of sched-uled caste/scheduled tribe/Muslim population);geographical accessibility (hard-to-reach areas);high prevalence of child malnutrition; and thepresence of population pockets currently un-derserved by ICDS centres.

Selection of participants All women in their first trimester of pregnancyduring May 2018 from all 98 ICDS centres wereincluded in the intervention, with no exclusions

(n=210). Over time, there were instances ofmiscarriage, abortion and migration, reducingthe final cohort to 182. e intervention involvedthe pregnant women and their families, plus221 frontline health workers (FHWs), includingall auxiliary nurses/midwifes (ANMs), accreditedsocial health activists (ASHAs) and ICDS workersin the 98 ICDS centres and 47 sub-health centrescovering them.

Intervention strategies e intervention was implemented using an in-tegrated community-based approach that em-phasised home-based care and timely utilisationof government health and nutrition services byparticipants. Key strategies included:

Strategy 1: Identification and follow-upof pregnant women ‘at nutritional risk’A pregnancy is considered ‘at nutritional risk’ ifthere are any nutritional deficiencies that canaffect the pregnant woman’s health and thehealth of her child (both during pregnancy andthe post-pregnancy period). According to thematernal nutrition services package in India,4

pregnancies are classified either as 1) not at nu-

trition risk (normal body mass index (BMI):18.5-22.9, India classification); 2) at nutritionalrisk but no medical risk (as assessed by ANMs);or 3) at both nutritional and medical risk.

A pregnancy is also considered ‘at nutritionalrisk’ when at least one of the following indicatorsis present:5

a) BMI (taken <20 weeks gestation) identifies woman as severely thin, thin, overweight or obese (Table 1);b) Age of pregnancy (below 20 and above 35 years);c) Body weight at the time of registration (40 kg or less);d) Height (less than 145 cm); e) Anaemia (severe anaemia: less than 7 g/dl, moderate anaemia: 7-10.9 g/dl);f) Inappropriate gestational weight gain (GWG) (<1 kg /month or >3 kg /month from second trimester onwards).

Under the current regime of pregnancy care inWest Bengal, all indicators are measured routinelyexcept for BMI, which makes it more difficult toidentify and categorise pregnant women accordingto their nutritional risk and provide needs-basedcounselling. is intervention incorporated aninitial nutrition and health assessment, includingBMI assessment, to define nutritional risk moreeffectively. Nutrition assessment was initiallycarried out by the CINI team and later by trainedICDS workers and ANMs.

On identification of pregnancies at nutritionalrisk, a management plan was tailored to thespecific needs of the pregnant woman. is in-cluded strengthened existing government in-terventions and new interventions, as follows: Strengthened existing interventions: i. Increased home contact with pregnant women by the FLWs and CINI team to ensure timely uptake of antenatal check- ups and other services; ii. Additional haemoglobin tests for anaemic women and follow-up for IFA supplement consumption; iii. Ensuring ultrasonography examination of all women aer second trimester (at the block hospital); iv. Ensuring fourth antenatal check-up at the ninth month for all women by an ANM (at sub-health centres). New interventions: i. Specific dietary counselling of pregnant women based on their nutritional status; ii. Joint counselling of the family members of pregnant women to ensure support and sharing of household work burden; iii. Monthly weight monitoring for assessing GWG.

3 ICDS is a programme run by government in Indian states which provides supplementary nutrition, pre-school education, primary healthcare, and awareness of immunisa-tion, health check-up and referral services for children undersix years of age and pregnant and lactating mothers.

4 Maternal nutrition services package (Ministry of Health & Family Welfare (MoHFW), Government of India).

5 Ibid.6 Ibid.

Weight category (recorded <20weeks gestation)

WHO BMI category (kg/m2) Asian BMI category (kg/m2)

Severe thinness <16.0 <16.0

Thinness 16.0-18.49 16.0-18.49

Normal weight 18.5-24.9 18.5-22.9

Overweight 25-29.9 23-24.9

Obese ≥30 ≥25

Table 1 BMI cut-offs (taken <20 weeks of pregnancy) to classify pregnant womenat nutritional risk6

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Team building game with communitiesand frontline workers, West Bengal, 2018

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kg (IOM, 2009/WHO)), there is no such differ-entiation in Government of India guidelinesand the setting of India-specific differentiatedguidelines was felt to be beyond the scope andcapacity of this study.

On-the-spot-feeding of supplementary nutritionand IFA supplementation:In West Bengal, all pregnant women are providedwith supplementary nutrition for six days perweek from ICDS centres through provision of ahot cooked meal (usually a combination of rice,pulses, vegetables/soya-bean and one egg). isis usually taken home for consumption andshared within the household. To address thisand low consumption of IFA tablets, spot-feedingof both supplementary nutrition and IFA tabletsat the ICDS centre was implemented. Instead oftaking cooked food home, the women were en-couraged to stay at the centre to consume theirmeals, aer which IFA tablets were also taken.is ensured that the women’s nutritional re-quirements were met and provided more frequentcontact with service providers, and thereforegreater opportunities for counselling. Womenwere initially reluctant to remain at the centreto consume the meal, partly due to lack of in-frastructure at ICDS centres to support mealconsumption. Repeated counselling helpedchange this practice in many of the sites.

Strategy 3: Working in an integrated,team-based approach At the heart of this intervention was the con-vergence and collaboration of multiple com-munity-level stakeholders to achieve the sharedgoal of improved pregnancy outcomes. A teamwas brought together at each centre of workersroutinely responsible for the support of pregnantwomen and their families, including: ICDSworkers, ASHAs, ANMs and self-help groupswhere present. Teams from each of the 98 ICDScentres were gathered for three different orien-tation workshops. Participative games were usedto communicate the importance of team working,coordination and communication, and to unravelvarious myths and superstitions associated withpregnancy care. Simulation exercises created asense of ownership and enthusiasm among theteam in achieving the common goal together.

Incentives were provided to pregnant womento use all the services available to them in theform of coupons. On complying with each ofthe services in a timely manner, each pregnantwoman received a coupon which also displayeda simple health-awareness message. At the endof the intervention, the pregnant woman andher family with the maximum number of couponswas recognised in front of the community as anexample to follow. e best-performing team ofFHWs was recognised in a similar way by con-gratulating team members at a ceremonial eventorganised by the block health administration.Feedback suggests that the coupons encouragedthe families of the pregnant women to engagein the process and provide better support tothem. ose provided to ANMs encouragedthem to complete all ANC visits up the fourthscheduled visit on time.

Results Initial assessment of the 182 pregnant womenat registration during their first trimester revealed50% to be malnourished. Of these, 30.3% wereseverely thin or thin and 19.7% were obese oroverweight. Of the 182 women, 41% were marriedearly (below 18 years of age at time of marriage);16% were teenagers (below 20 years of age);49% anaemic (haemoglobin levels below 11gm/dlat time of registration of pregnancy); and 70%were defined as having a ‘high-risk’ pregnancy.8

Gestational weight gain e average GWG of the cohort was 9.36 kg,which is considerably higher than the averageGWG of 7%. Sub-analyses by nutritional riskcategory showed that weight gain of 10 kg ormore was higher in undernourished (severelythin and thin) pregnant women (Figure 1), andaverage weight gain was higher in this groupcompared to overweight and obese women (Fig-ure 2). is suggests that counselling was ap-propriately tailored to the needs of the differentgroups according to their nutritional risk.

7 MoHFW maternal nutrition services package advocates for aweight gain of 9-11 kg during pregnancy, with no separate weight gain recommendation for overweight/obese women.

8 Indicators for high-risk pregnancy as per Government of India guidelines of ANM handbook.http://164.100.154.238/images/pdf/programmes/maternal-health/guidelines/sba_handbook_for_anm_lhv_sn.pdf

Additional attention was given to severely thinand thin pregnant women who, together withtheir family, received additional home visitswith repeated counselling on dietary diversity,quantity of food intake and the importance ofrest. ese women were followed up throughhome visits to encourage attendance at ICDScentres for daily food supplementation, monthlyweighing and adherence to daily IFA supple-mentation. ose not gaining weight as pergovernment guidelines (2 kg per month or over3 kg per month from second trimester onwards)7

were sent for additional check-ups at the healthcentre to screen for complications. Ultrasonog-raphy was done for all cases in the second orthird trimester to understand and detect ab-normalities in foetal growth.

Strategy 2: ICDS-based interventionsto ensure uptake of services Certain innovations (not currently implementedin the existing system) were made at ICDScentres to support appropriate GWG, including:

Monthly weight monitoring: e pregnant women were weighed monthly atthe ICDS centre by an ICDS worker and coun-selled accordingly at that visit, with tailoredmessages to underweight and overweight/obesewomen. e routine practice in the state is toweigh pregnant women once per trimester atthe health centre. GWG was calculated usingthe weight at the time of registration and thelast weight taken before delivery. A target wasset of 10 kg total weight gain during pregnancy,in line with government recommendations of9-11 kg. International guidelines for GWG arehigher, at 12-18 kg during pregnancy (IOM,2009/WHO); however, studies demonstrate thatwomen in India gain only about 7 kg on averagefor full-term pregnancy (Coffey, 2015) andreports from block-level officials, FLWs andcommunities suggest that average weight gainin West Bengal is lower, at around 5-6 kg. edecision was therefore made to lower the target,in line with government guidelines. While in-ternational guidelines recommend differentlevels of total GWG, depending on the pregnantwoman’s starting BMI (underweight women12.5-18 kg; overweight 7-11.5 kg; and obese 5-9

Percentage of pregnant women with GWG of10 kg or more among different BMI categories Figure 1

Severe thin Thin Normal Overweight Obese Entire cohort(all pregnant

women)

% p

regn

ant w

omen

67%

100

80

60

40

20

0

61%

44%40%

45%49%

BMI category

Average GWG among different BMI categories Figure 2

Severe thin and thin Normal BMI Obese and Overweight

Aver

age

wei

ght g

ain

(kg)

9.939.17

8.56

BMI category

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Levels of anaemia A 12% decrease in prevalence of anaemia in thecohort by the end of pregnancy was observed(Figure 3). Women with normal BMI were morelikely to have improved haemoglobin levels (30%,compared to 14% and 22% of overweight /obeseand thin/severely thin pregnant women respectively).

Birth outcomesA high rate of deliveries (98%) took place in in-stitutions (hospitals, nursing homes, etc), com-pared to the state average of 75.2% (NFHS 4,2015-16). is can be attributed to intensivecounselling and follow-up of the pregnant womenand their families. e majority of infants bornto intervention women (84%) had normal birthweights (2.5 kg or above); 16% (30 out of 182)of infants were LBW, compared to the prevalenceof LBW in West Bengal of 11.5% (DLHS 4).Sub-analyses showed that prevalence of LBWwas highest among severely thin andoverweight/obese mothers, at 22% and 20% re-spectively, followed by thin and normal BMI at15% and 18% respectively (Figure 4). A higherproportion of LBW babies were born to teenagemothers (30%) compared to adult mothers(26%). e prevalence of LBW among motherswith GWG of 10 kg or more was much lower(8%) than those with GWG of less than 10 kg(25%). is may point to the importance ofGWG in improving birth outcomes.

Another significant observation was that 90%of LBW infants were born to women with high-risk pregnancies. Among the different categoriesof high risk, 91% were anaemic, 77% did not gainweight up to 10 kg, and 62% had BMI that indicatedmalnutrition (undernourished or overweight/obese).is supports the literature that suggests that theprevalence of LBW increases in the case of high-risk pregnancies and low maternal nutrition.

DiscussionResults suggest that the intervention was suc-cessful in promoting weight gain among thewomen who needed it most (thin and severelythin pregnant women) and in reducing prevalenceof anaemia among pregnant women. Resultsalso emphasise the importance of focusing in-terventions on high-risk pregnancies in orderto reduce the prevalence of LBW.

e intervention highlights the importanceof proactively promoting appropriate weightgain in pregnancy among communities andhealth workers in India. GWG was rarely regardedas an important criterion for a healthy pregnancyand was not monitored regularly prior to the in-tervention. Key components that contributed tothe success of the programme were collaborationbetween FLWs, promotion of GWG among FLWsand community members, and strategies to pro-mote compliance among pregnant women togovernment supplementary nutrition and IFAprogrammes. Barriers such as distance to centres,lack of space to consume meals and resistanceto IFA supplementation were ongoing challenges.

is programme also demonstrates the com-plex challenges that arise from implementingan intervention in the context of the ‘doubleburden of disease’, where malnutrition is presentin all its forms within the same population (un-dernutrition and overnutrition, as well as mi-cronutrient deficiencies). e ICDS programmeas it exists now provides nutrition supplemen-tation for all pregnant and lactating womenwith little scope for tailoring according to BMI,although nutrition counselling was successfullytailored to the needs of different nutritionalgroups in the intervention. National guidanceon appropriate GWG according to maternalBMI is critical to inform future interventions.

Recommendations Results of this pilot study call for actions thatcan be initiated concurrently at policy and im-plementation levels to promote optimal maternalnutrition:

Early identification of ‘at-nutritional-risk’ preg-nancies at the time of pregnancy registration(by 12 weeks gestation) and subsequent follow-ups can help mitigate many risk factors in laterpregnancy. BMI screening by ANMs is not rou-tinely carried out in West Bengal for pregnantwomen and should be made mandatory in allsub-health centres.

Focusing on high-risk pregnancies would help toprevent LBW. However, currently no specificguidelines exist for managing high-risk preg-nancies without medical complications at the

community level. Guidance on a comprehensivepackage of community-level interventions tomanage high-risk cases is needed.

Prioritising GWG. Monthly tracking of pregnancyweight gain should be integrated into routine sys-tems. Appropriate counselling should be providedfor GWG during different stages of pregnancyand for varied nutritional-risk classifications.

On-the-spot-feeding of supplementary nutritionand IFA. On-the-spot feeding at ICDS centresincreases nutritional benefits for pregnant womenand increases frequency of contact with FLWsand therefore counselling opportunities. isshould be explored as an option for increasingadherence in other locations.

Development of a comprehensive package for com-munity-based management of maternal nutrition.In addition to the above, a comprehensive packageof interventions for community-level managementof maternal malnutrition is needed that includesspecific targeted guidance according to nutritionalclassification (including overnutrition and un-dernutrition). is will enable tailored program-ming and enhanced nutritional benefits for preg-nant and lactating women in India.

For more information, please contact SreeparnaGhosh Mukherjee at [email protected]

ReferencesBlack R, et al. Maternal and child undernutrition: Global andregional exposures and health consequences. Lancet.2008;371:243-60.

Coffey D. (2015). Prepregnancy body mass and weightgain during pregnancy in India and sub-Saharan Africa.Proceedings of the National Academy of Sciences of theUnited States of America, 112(11), 3302–3307.doi:10.1073/pnas.1416964112

District Level Household and Facility Survey (DLHS) 42011-2012.

Nandi A, et al. Early-life nutrition is associated positivelywith schooling and labor market outcomes andnegatively with marriage rates at age 20–25 years:evidence from the Andhra Pradesh Children and ParentsStudy (APCAPS) in India. The Journal of Nutrition. 2018Jan 1;148(1):140-6.

National Family Health Survey (NFHS-4) 2015-2016

Victoria CG, et al. Maternal and child undernutrition:consequences for adult health and human capital. Lancet.2008;371:340-57.

Prevalence of different levels of anaemia ofpregnant women at registration and end ofintervention

Figure 3

At Registrarion At the end of intervention

leve

l of a

naem

ia

2%

47%

0%

37%

63%

51%

Normal Moderate Severe

Prevalence of LBW among different BMIcategories Figure 4

Severe thin Normal Obese and Overweight

Prev

alen

ce o

f Low

Bir

th W

eigh

t (%

)

22%

100

80

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20

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15%18% 20%

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1 The sample size for northern Hama was not representative. The authors provided the data on it to show the vulnerability of the area. Currently, northern Hama is not part of the northwest Syria emergency response.

2 Data from the SMART nutrition survey 2017, northwest Syria(not available publicly).

By Bakhodir Rahimov, Tarig Mekkawi and Vilma Tyler

Bakhodir Rahimov is a Nutrition Specialist for theUnited Nations Children’s Fund (UNICEF) inGaziantep, Turkey. He has worked in UNICEF’snutrition and health programme for nine years.

Dynamics of the nutritional status of childrenunder five years old in northwest Syria

Tarig Mekkawi is Nutrition Cluster Coordinatorand Nutrition Manager for UNICEF in Gaziantep,Turkey. He has over 10 years’ experience workingwith the UNICEF nutrition programme.

Vilma Tyler is a Senior Nutrition Specialist for UNICEFRegional Office for Middle East and North Africa, based inAmman, Jordan. She has over 10 years’ experienceworking with the UNICEF nutrition programme in differentregions.

Paul Binns is a community-based managementof acute malnutrition specialist at Brixton Health.

Location: Northwest Syria What we know: Adolescent motherhood, associated with early marriage, may contribute tolow birth weight and child stunting.

What this article adds: An expanded SMART nutrition survey led by the UnitedNations Children’s Fund (UNICEF) in northwest Syria aimed to examine theassociation between child marriage and stunting. Consistent with year-on-year trends,wasting prevalence was low and stunting prevalence was high, although there wasvariation by operational area. Adolescent mothers (under 18 years old) and childmarriage were common. Survey method shortfalls meant that the association betweenstunting and child marriage could not be examined; this should be addressed in futuresurvey design. In conflict situations, child marriage may increase as a copingmechanism; work to build evidence on the problem and the consequences of earlymarriage in this region is underway across sectors. In the meantime, UNICEF hasinitiated an integrated health, nutrition and child protection (including disability)emergency programme response, and a surveillance programme to detect cases offamily abuse/violence to help prevent child marriage.

This survey was conducted and implemented by Physicians AcrossContinents Turkey (PAC); Dr Katham Saaty, Programme Manager at PACand Nutrition Cluster Co-coordinator; and Dr Beshr Alkhateeb, Al-AmeenFoundation in northwest Syria. Technical guidance was provided by MrHailu Wondim, SMART Emergency Nutrition Assessment Manager, ActionAgainst Hunger – Canada (AAH-CA) and Mrs Lindsay Baker, RegionalSMART Advisor. The authors would especially like to thank Mrs SusanAndrew, Child Protection Manager, UNICEF Amman and Mr TareqAbukhadijeh, Information Management Officer, iMMAP, for designing thechild protection module of the SMART survey questionnaire. The surveywas implemented with the financial support of the Office for theCoordination of Humanitarian Assistance (OCHA) and UNICEF in Gaziantep.

BackgroundUnited Nations Children’s Fund (UNICEF) op-erations in Syria are divided into two programmeareas with changeable borders, depending onmilitary activity: northwest Syria (Idlib Gover-norate, part of Hama Governorate, and areasunited under rural Aleppo and Euphrates Shield);and operational areas in southern Syria (undercontrol of the Syrian Government working outof Damascus). While child wasting is well con-trolled, stunting prevalence has increased in al-most all operational areas of the northwest. ehighest prevalence of stunting among childrenunder five years old is observed in the northernHama Governorate (25.5% in 20191) and inAfrin district in Euphrates Shield area (21.8%in 2019). In Idlib, stunting prevalence was 17.4%in 2019 compared with 14.2% in 2017.2

Attention tends to focus on chronic food in-security, sub-optimal child feeding practices,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

chronic infection and non-infectious diseasesas the main contributing factors to child stunting.However, reports from non-governmental or-ganisations (NGOs) and other United Nationsagencies point to additional causal factors, in-cluding poor adolescent nutrition and high ratesof early marriage and early pregnancy. Toexamine the possible association between earlymarriage (and therefore early pregnancy), aSMART nutrition survey conducted jointly byUNICEF northwest and southern Syria officeswas expanded to collect child protection infor-mation, including information on child marriage,birth registration and family composition. isarticle describes main findings and limitationsof the survey, how it has informed current pro-gramming, and recommendations for the future.

Methodologye survey was carried out in northwest Syriaoperational areas during May 2019 using standard

SMART methodology. e SMART regionaladvisory group for UNICEF Middle East andNorth Africa (MENA) validated all data collecteddaily. e quality of the field data was controlledusing data plausibility testing. Data from Hamaand Idlib operational areas were consolidatedwith data from rural Aleppo and EuphratesShield and was also analysed by single operationalareas to identify the most nutritionally vulnerablegovernorate. Eligible households with childrenunder five years old were visited and anthro-pometry of those children measured. No infor-mation was gathered on household childrenover five years of age. Mothers were interviewedregarding their age at marriage and informationwas gathered about the birth registration ofchildren under five years old and family com-position (single-parent household or motherand father present). Maternal age at marriagewas then analysed against nutrition outcomes.A total of 1,233 children (628 boys and 605girls) aged 6-59 months from 786 householdsin 63 clusters in Idlib, northern Hama, ruralAleppo, Euphrates Shield and Afrin districtwere included in the anthropometric measure-ments. e sample size was representative ofthe northwest Syria operational area.

ResultsAmong the sample, the prevalence of globalacute malnutrition (GAM), defined as weight-for-height z-score (WHZ) <-2 and/or oedema,was 0.73% (0.4 - 1.3 95% C.I.) and the prevalenceof severe acute malnutrition (SAM), defined asWHZ <-3 and/or oedema, was 0.16% (0.0 - 0.795% C.I.), with no cases of oedema (Table 1).

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Alln = 1,232

Boysn = 628

Girls n = 604

Prevalence of global acute malnutrition (GAM) (<-2 z-score and/or oedema)

0.7 % (9) 0.2 % (1) 1.3 % (8)

(0.4 - 1.3 95% C.I.) (0.0 - 1.2 95% C.I.) (0.7 - 2.5 95% C.I.)

Prevalence of moderate acute malnutrition (MAM)(<-2 z-score and >=-3 z-score, no oedema)

0.6 % (7) 0.2 % (1) 1.0 % (6)

(0.3 - 1.2 95% C.I.) (0.0 - 1.2 95% C.I.) (0.5 - 2.1 95% C.I.)

Prevalence of severe acute malnutrition (SAM) (<-3 z-score and/or oedema)

0.2 % (2) 0.0 % (0) 0.3 % (2)

(0.0 - 0.7 95% C.I.) (0.0 - 0.0 95% C.I.) (0.1 - 1.3 95% C.I.)

Table 1 Consolidated results of the SMART survey from northwest Syria, May 2019(wasting: WHZ)

Alln = 1,232

Boysn = 628

Girls n = 604

Prevalence of stunting(<-2 z-score)

19.4 % (239) 20.9 % (131) 17.9 % (108)

(16.9 - 22.2 95% C.I.) (17.2 - 25.1 95% C.I.) (15.0 - 21.2 95% C.I.)

Prevalence of moderate stunting(<-2 z-score and >=-3 z-score)

14.6 % (180) 16.1 % (101) 13.1 % (79)

(12.2 - 17.4 95% C.I.) (12.5 - 20.5 95% C.I.) (10.6 - 16.0 95% C.I.)

Prevalence of severe stunting(<-3 z-score)

4.8 % (59) 4.8 % (30) 4.8 % (29)

(3.6 - 6.3 95% C.I.) (3.3 - 6.8 95% C.I.) (3.2 - 7.1 95% C.I.)

Table 2 Consolidated results of the SMART survey from northwest Syria, May 2019(stunting: HAZ)

Prevalence of GAM was higher in girls (1.3%)than boys (0.2%), but the difference was notstatistically significant (p=0.203). e highestGAM prevalence was observed in Idlib Gover-norate (1.1%), an area greatly affected by intense,ground-level military action, especially in south-ern areas, a deteriorating food-security situationand limited access to essential nutrition services.

e prevalence of child stunting, defined asheight-for-age z-score (HAZ) <-2 was 19.4 %(16.9 - 22.2 95% C.I.) (Table 2). Stunting preva-lence was higher in northern Hama (25.5%)compared to other operational areas (which isconsistent with the 2015 SMART survey). Figure1 presents the consolidated results of the SMARTsurvey in 2019 and the dynamics of wastingand stunting among children in northwest Syriastarting from 2014. is demonstrates a cleardivergence in prevalence and patterns betweenstunting and wasting (SAM) over time, including2019. Stunting is prevalent in more than 25% ofchildren, whereas less than 1% of children are

wasted. e proportion of children who areboth stunted and wasted was not examined.

Over 45% of women reported their age ofmarriage as below 18 years (in some cases,below 13 or 14). is may be an underestimatedue to high cultural sensitivity regarding childmarriage. Unfortunately, it was not possible toexamine associations between age of marriageof the mother and stunting in her child due tomethodological problems in data collection.SMART surveys only include children underfive years old; however, many mothers who weremarried as children now had children over theage of five. As these children could not beincluded in the survey, the association betweenmaternal age at marriage and child stuntingcould not be consistently examined.

DiscussionResults confirm high levels of stunting and lowlevels of wasting in northwest Syria. Pre-crisis,Syria had very low prevalence of GAM, and in-terventions at an early stage of the conflict, in-

cluding capacity-building of the screening andtreatment of acute malnutrition, worked to pre-vent the deterioration of the situation. Nutritionsurveys (SMART 2014-2019) demonstrate analmost stable plateau of under-five GAM preva-lence in the northwest of Syria throughout thecrisis, with levels never exceeding 3%. is is inspite of the borders of northwest Syria dynami-cally changing and continued high rates ofmovement of internally displaced people (IDPs).

Stunting has risen, however, as indicated bythe results of this study. Likely direct causes ofthis are increased food insecurity, poor accessto health facilities and loss of livelihoods resultingin poor quality diets. Sub-optimal infant andyoung child feeding (IYCF) practices are alsoan important causal factor. Non-exclusive breast-feeding and poor complementary feeding arewidespread in northwest Syria operational areas,both of which likely contribute to high prevalenceof child stunting. A 2017 IYCF barriers analysis(no external report available) found that lessthan 42% of mothers practiced exclusive breast-feeding, due to perceptions of breastmilk inad-equacy and lack of family support, and onlyaround 57% of mothers practiced recommendedcomplementary child feeding, with food inse-curity cited by mothers as a major constraint tochild food diversity. Coverage of IYCF pro-grammes in northwest Syria is low. In particular,there is a lack of availability of one-to-one coun-selling, partly due to constraints associated withworking with IDPs on the move.

Investigations into indirect causes of stuntingare also required. Results of this study confirmhigh levels of child marriage in northwest Syria(45%). is reflects a context where the legalage for marriage is 15 years. NGOs report that,pre-conflict, marriage tended to be deferreduntil girls had completed high school; however,it is likely that the practice has increased duringthe conflict. According to the UNICEF ChildProtection, Health and Education Clusters ofCross-border Emergency Response programme,child marriage is a common negative copingand protective mechanism during war. ereare moves to examine this more closely; for ex-ample, information collated by the UnitedNations Population Fund (UNFPA) Sexual andReproductive Health Technical Working Groupin Gaziantep shows an increase in the numberof caesarean sections among mothers below 18years old compared with the previous five years,which could provide a useful proxy indicatorfor an increase in child marriage.

e SMART survey 2019 reported here didnot measure maternal anthropometry. However,a community surveillance survey demo projectconducted in Idlib, Aleppo and Hama governoratesfound that pregnant and lactating women (PLW)less than 18 years of age (about 12%) all had amid-upper arm circumference less than 230 mm,a higher prevalence than among PLW over 18years of age (among whom were higher levels ofoverweight and obesity). is indicates that ado-lescent mothers are at risk of undernutrition.

It was not possible to examine the association

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3.00%

2.50%

2.00%

1.50%

1.00%

0.50%

0.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%2014 2015 2015 2017 2019 2019 2019

GAM % MAM % SAM % Stunting %

Figure 1 Malnutrition trends in northwest Syria operational areas (SMART 2014-2019)

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between the age a woman was married andstunting in her children due to limitations ofthe study. e child protection team requiredthat ages were categorised during data collection,which made it impossible to perform an analysisof the association. ere is, however, considerableresearch that substantiates this link. Adolescentgirls are at risk of poor nutrition (in particularanaemia), which increases the risk of theirinfants having low birth weight, which in turnincreases the risk of the infant being stunted inchildhood (Soo Hyun Yu, 2016). To date, therehas been little scrutiny or research into the re-lationship between child marriage in northwestSyria and its consequences for adolescent andchild health. is is an area that needs more at-tention to inform interventions.

Conclusionse nutrition situation in northwest Syria isunique, with high – and, in some areas, increasing– levels of child stunting, alongside decliningacute wasting. Reports from NGOs also reportincreasing rates of child marriage related to theconflict, high levels of which were confirmed inthe SMART survey reported here.

Unfortunately, the design of the SMART nu-trition survey 2019 did not allow examinationof the associations between child marriage andchild stunting. Further analysis of the associationbetween child marriage and stunting of subse-quent children is warranted, with a better-de-signed survey to capture the data needed. Whilewe did not statistically confirm the associationbetween child stunting and child marriage, webelieve that only a holistic approach can preventchronic malnutrition and that child protectionis a fundamental component that needs to beaddressed in this context.

Given this, from July 2019 UNICEF fornorthwest Syria has been supporting partnersto implement an integrated health, nutrition(community-based management of acute mal-nutrition and IYCF), and child protection (in-cluding disability) programme response. Workis ongoing to find ways for the nutrition pro-gramme to support the identification of childprotection cases, using the nutrition-screeningprogramme as one of the entry points to detectcases of family abuse/violence; this informationcould enable the instigation of measures to pre-

vent child marriage. Educational programmesmay provide another entry point to changecommunity behaviours that sustain child mar-riage; in particular, to discourage child marriageas a negative coping mechanism for war. Socialprotection networks for the most vulnerablefamilies and adolescent health programmes arealso essential in preventing malnutrition.

To improve the overall nutrition situation,nutrition-specific field interventions aiming toaddress the immediate causes of undernutritionshould be prioritised. Additional supportingmechanisms (such as cash transfers to stimulateadequate and diverse diets, and continuous pro-motion of optimal IYCF and practices and nu-trition behaviours for PLW) should remain core,integrated emergency-response interventions.

For more information, contact Bakhodir RahimovMD MHA, Nutrition Specialist (partnership),[email protected]

ReferencesSoo Hyun Yu et al (2016) Differential effects of youngmaternal age on child growth. Glob Health Action. 2016; 9:10.3402/gha.v9.31171. Available atwww.ncbi.nlm.nih.gov/pmc/articles/PMC5112350/

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Cost of the Diet analysis in Bria,Central African Republic By Esther Busquet

Esther Busquet is a Nutrition Advisor with International Medical Corps (IMC),currently supporting the nutrition programmes in the western, central andsouthern Africa region, as well as providing global support. Before joining IMC,she worked with Save the Children UK, where she was responsible for the Cost ofthe Diet (CotD) tool for more than two years.

The author would like to thank Marius Rodrigue Koyangbanda Gomassili, IMC Central AfricanRepublic (CAR) MEAL Officer, Yewoinshet Adane Berihun, IMC CAR Nutrition Coordinator, ChristianMulamba, IMC CAR Country Director, and the Bria team of IMC CAR for all their contributions andsupport, and all data collectors and participants in this CotD study for their active participation.

These activities were made possible by a grant from the United States Agency for InternationalDevelopment (USAID) Office of Foreign Disaster Assistance (OFDA).

Location: Central African Republic (CAR)What we know: Dietary habits and food costs are key determinants of a household’scapacity to meet energy and nutrition needs.

What this article adds: A Cost of the Diet (CotD) study was carried out amonginternally displaced persons (IDPs) and host communities of Bria Town and PK3IDP camp in Haute Kotto region of CAR in November 2018 to determine whethercommunities could meet energy and nutrient requirements through food assistance(20-day ration) and purchases of locally-available foods. Results show that, for atypical family of nine, a ‘nutritious diet’ and a ‘food habits nutritious diet’ (meetsenergy and nutrient requirements and is acceptable) are both available in the rainyseason. However, for poor and very poor families, even meeting basic energy needsis unaffordable. Extending food rations to 30 days, plus the provision of freevegetables (through kitchen gardens and other possible means), would make all dietsaffordable to all wealth groups. Multisector collaboration and advocacy, includingmilitary support for access to insecure areas, is needed to enable this.

BackgroundIn Central African Republic (CAR) an estimated2.9 million out of a population of 4.6 millioncurrently require humanitarian support. Resultsof the 2018 SMART survey show a global acutemalnutrition (GAM) prevalence of 7.5% and se-vere acute malnutrition (SAM) prevalence of2.7% for Haute Kotto region. Aggravating factorsinclude insecurity, food insecurity, high numbersof internally displaced persons (IDPs) in campsand host communities, and poor infant andyoung child feeding (IYCF) practices. In siteswith a high number of IDPs (Alindao, Bambari,Bria, Kaga Bandoro, Batangafo), most householdshave limited access to land to engage in agriculturalactivities and are dependent on humanitarianfood assistance and food-market purchases. Food

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One of the CotD data collectorsweighing sweet potato on the market,Market, Bria, Haute Kotto, CAR

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and nutrition support are available but patchydue to insecurity and transportation difficultiesto the affected areas, and humanitarian food as-sistance remains inconsistent and underfunded.1As a result, food-consumption deficits and poornutrition among IDPS, returnees and host com-munities are common. e current food-securitysituation is classified by the Integrated PhaseClassification (IPC) as level 3, crisis.

Bria Town is the capital of Haute Kotto regionand the hub of the diamond business in easternCAR. A series of violent clashes took place inBria in May 2017 between the FRPC2 (commonlycalled ex-Seleka) and the anti-balaka militia(commonly called Christian militia), resultingin the majority of the resident population movinginto PK3 IDP camp,3 just outside the town. ehost community and IDPs, resident in eitherBria Town or PK3 IDP camp,3 now receive thegeneral food distribution (GFD). Rations providedare for 20 days per month per person by WorldFood Programme (WFP); insecurity limits theamount of food that can be brought into the re-gion, which hinders the supply of a full 30-dayration. According to the results of InternationalMedical Corps (IMC)’s rapid assessment (RA)in May 2017, in all sites visited, the main sourcesof foods were the GFD and local markets, whichare accessible most of the time. Culturally, it isconsidered to be the responsibility of the headof the household to provide food for householdmembers. RA focus group discussions (FGDs)revealed that households do not have access totheir land to produce the foods typically farmedpre-crisis (cassava, rice and beans), and thus nolonger have food stored. is has been exacer-bated by the increase in market food prices

during the crisis, with some products, such assugar, oil and soap, now being very expensive.Tubers, legumes, dairy products, meat and fish,eggs, fruits rich in vitamin A and other vegetableswere available in the markets in all sites visitedduring the needs assessment. However, dairy,meat and fish, and fruit rich in vitamin A wereexpensive and probably not affordable to mosthouseholds.

IMC manages primary healthcare, commu-nity-based management of acute malnutrition(CMAM) and IYCF and protection programmesin Bria Town and PK3 camp. On the basis ofthe findings above, to inform future potentialfood-security activities, IMC conducted a Costof the Diet (CotD) study to understand if andhow IDPs and the host community can meettheir energy and nutrient requirements. e ul-timate aim of the study was to inform nutritionand food security programming in the area,and influence policy and advocacy processes inthis and other similar contexts. Since October2018 people resident in both the town and camphad access to the same markets, whereas previ-ously IDPs only had access to a smaller marketin the camp, with fewer foods available and athigher prices. us, the CotD study includedboth groups.

Study objectivesA CotD study aims to estimate the lowest costand the quantity and combination of local foodsthat are needed to provide a typical family withfoods that meet their average needs for energyand their recommended intakes of protein, fatand micronutrients. e specific objectives ofthis CotD study were to: (1) understand the

Wealthgroup

Bria Town PK3 IDP camp*

Percentage of Population Family size Family size

Very poor 40% 3 – 5 2 – 5

Poor 30% 5 – 8 5 – 8

Middle 20% 12 – 15 9 – 12

Better-off 10% ≈ 20 --

100% ‘average’ ≈ 9

Table 1 Percentage of the population of Bria Town per wealthgroup and family size in Bria Town and PK3 camp perwealth group

* Percentage of each wealth group among the population in the camp is unknown, but is proba-bly very similar to the percentages for the town, as most IDPs came from Bria Town

Nutritious diet Food habits diet

Total of 12 different foods (max 8pp) from6 food groups (plus breastmilk)

Total of 17 different foodsfrom eight different foodgroups, including breastmilk

Most difficult nutrients to meet: vitaminB12 and pantothenic acid (contributingrelatively most to the total costs of the diet)

Most difficult nutrients tomeet: vitamin B12 andpantothenic acid

Out of reach for majority of people, even ifthe entire salary is used to purchase foods

Even further out of reach forvery poor, poor and middle-income families

Table 2 Details of the lowest-cost nutritious diet and foodhabits diet for a typical family of nine in Bria Town andPK3 IDP camp in the rainy season

extent to which economic poverty and typicaldietary habits prevent households and vulnerableindividuals from consuming a nutritious dietin Bria Town and PK3 IDP camp; and (2) un-derstand if and how IDPs in settings such asBria Town and PK3 camp can meet energy andnutrient requirements using locally-availablefoods.

MethodologyCotD training was conducted for nutrition andMEAL4 managers in CotD methodology andsoware (18-26 October 2018). Data collectorsin Bria were trained from 31 October to 2 No-vember 2018 and data collection took place be-tween 3 and 9 November 2018. e studyinvolved a market survey, individual interviewsand FGDs. e market survey collected data onall food items available in the town’s markets, aswell as through own food production and wildfoods. e price per 100 grams of each foodwas determined (based on the cost of the low-est-available quantity of each food item). Forwild foods, usually gathered at no cost, andfoods from own production, the market pricewas used if the food was sold on the market,and no cost was included if it was not sold onthe markets. e composition of several wildfoods (mainly fruits) was unknown, so theywere not included in the CotD analysis; however,none of these foods were actually available atthe time of the study. Individual interviews wereconducted with 24 women from several partsof the town and camp to determine the minimumand maximum frequency with which each ofthese foods was consumed per week. FGDs withthe same women helped to generate a betterunderstanding of dietary habits in Bria Townand PK3 IDP camp. ree groups of eightwomen each participated in the interviews andFGDs; one group from Amameu (PK3 camp),one group from Bornou, and one group fromLasmie (Bria Centre). e groups included adultwomen from the different wealth groups, as de-fined by Oxfam’s household economy approach(HEA) (Garba, 2015), who were in charge ofthe household and preparation of meals.

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1 FEWSNET CAR https://fews.net/west-africa/central-african-republic

2 FRPC = Front Populaire pour la Renaissance de la Centrafrique.

3 PK3 IDP Camp is managed by the Italian non-governmental organisation INTERSOS with funding from United Nations High Commission for Refugees (UNHCR).

4 MEAL = Monitoring, evaluation, accountability and learning

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Some of the foodsavailable in Bornoumarket at the time of theCotD, Bornou Market,Bria, Haute Kotto, CAR,November 2018

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Based on the information collected, variousdiets were then calculated using the CotD so-ware, as follows:• Energy-only diet: diet that only meets energy requirements and does not meet (or aim to meet) any nutrient requirements. is is used as a basis for comparison with certain food distribution and food-security programmes; • Nutritious diet: diet that meets requirements for energy, macro- and micronutrients, but does not take into account any dietary habits;• Food habits nutritious diet: diet that meets the requirements for energy, macro- and micronutrients, and takes into account dietary habits.

Based on information from the Oxfam HEAand FGDs with both the data collectors and thewomen participating in interviews, typical house-hold composition, percentage of the population

per wealth group and average income in bothBria Town and PK3 camp (Table 1) were esti-mated. A typical family in Bria was found toinclude nine people. is estimation was usedfor practical purposes to compare various dietmodels. A typical family was found to includenine members, as follows: • 1 child (either sex), 12-23 months old;• 1 child (either sex), 3-4 years old;• 1 child (either sex), 7-8 years old;• 1 child (either sex), 9-10 years old;• 1 girl, 13-14 years old;• 1 woman, 18-29 years old, 60kg, moderately active, pregnant 2nd trimester;• 1 woman, 30-59 years old, 60kg, moderately active, 7-12 months lactating;• 1 woman, >60 years old, 55kg, moderately active;• 1 man, 30-59 years old, 65kg, moderately active.

Income for each wealth group was roughly esti-mated by the team of data collectors and con-firmed in the FGDs, but no details on the ex-penditure of income were checked. In order toget more information on income and expenditureat household level, a new HEA would be neededas the data from the Oxfam HEA in 2015 wasconsidered too old to be used for this CotD.us, for this CotD, the results were comparedto the entire average income for each wealthgroup, and not with a part/percentage of incomeusually spent on food.

ResultsFor a typical family of nine, a ‘nutritious diet’and a ‘food habits nutritious diet’ are both avail-able in the rainy season (May/June to October).However, for the poor and very poor familiesin Bria and PK3 Camp (70% of town, majorityof camp population), none of the diets areaffordable (Figure 1 and Table 2); these peopleare unable to meet the ‘energy-only diet’, evenwhen using their entire income.

‘What if?’ modellinge CotD soware can help to model certaininterventions to see how the gap between incomeand costs for a nutritious diet could be bridged.It can also take account of an available foodbasket, as is the case in both Bria Town andPK3 IDP camp. e following models show theactual situation in Bria Town and models thatcould bridge (part of) the gap between nutrientneeds and income.

Food item Daily ration(gram/day

/person)

# of days permonth ration

is provided

Total providedper person permonth (gram)

Total available per person perday when spread over entire

month (gram/day/person)

Rice 300 20 6000 200

Beans 60 20 1200 40

Vegetable oil 20 20 400 13.33

Supercereal 20 20 400 13.33

Salt 5 20 100 3.33

For all children aged 6-23 months in PK3 camp:

CSB++ 100 30 3000 100

Table 3 Food rations provided by WFP to people in PK3 camp and Bria Town

XAF 120,000

XAF 100,000

XAF 80,000

XAF 60,000

XAF 40,000

XAF 20,000

XAF -

Figure 2 Cost of the diets when a 20-day food basket is providedeach month in Bria Town and PK3 camp in the rainyseason (current situation)

Very poor Poor Middle Better-off

Bria town PK3 camp Energy Only Nutritious Food habits

Figure 3 Costs of the diets if a 30-day food basket were to beprovided each month in Bria Town and PK3 campduring the rainy season

XAF 200,000

XAF 180,000

XAF 160,000

XAF 140,000

XAF 120,000

XAF 100,000

XAF 80,000

XAF 60,000

XAF 40,000

XAF 20,000

XAF -

Figure 4 Costs of the various diets compared to monthly incomewhen vegetables are available through kitchen gardeningfor a typical family of nine in Bria Town, rainy season

XAF 200,000

XAF 180,000

XAF 160,000

XAF 140,000

XAF 120,000

XAF 100,000

XAF 80,000

XAF 60,000

XAF 40,000

XAF 20,000

XAF -Very poor Poor Middle Better-off


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Figure 1 Diet costs compared to monthly income for a typicalfamily of nine in Bria in the rainy season



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Energy Only Nutritious Food habits

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XAF 180,000

XAF 160,000

XAF 140,000

XAF 120,000

XAF 100,000

XAF 80,000

XAF 60,000

XAF 40,000

XAF 20,000

XAF -

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What if a 20-day or 30-day foodbasket is provided every month?e current GFD in Bria Town and PK3 campconsists of a 20-day ration per person per month(Table 3). Very poor people (40% of population)cannot afford to meet their energy needs for theentire month; poor people (30%) can afford tomeet energy needs, but not a nutritious diet or afood habits diet (Figure 2). If this was increasedto a 30-day food basket, very poor householdsstill could not afford to meet their energy needs,but poor people could afford to meet energy-only and nutritious diet, although a food habitsdiet remains out of reach (Figure 3).

What if vegetables were available forfree; for example, through kitchengardening?If vegetables were available at no cost (forexample, through kitchen gardening) in the ab-sence of a food basket, the costs for all diets arereduced significantly, but remain unaffordablefor the very poor. For the poor, the energy-onlyand nutritious diet becomes affordable if all in-come is used for purchasing food (althoughthis is unrealistic as it doesn’t take into accountthe cost of non-food items, such as clothingand healthcare). Even if all income is used onfood, the food habits diet remains unaffordablefor the poor (Figure 4). In the camp there is nospace for vegetable gardening; an assessmentwould be needed to investigate whether micro-gardening could be possible.

What if a food basket were providedand vegetables were free?If a 20-day food basket was provided and veg-etables were free, for example through a kitchen-gardening project, an energy-only and nutritiousdiet would be affordable for the very poor, andall diets would be affordable for the poor (Figure4). If a 30-day food basket were provided andvegetables were free, all diets would be affordablefor all wealth groups, which makes this combi-nation of interventions the most successfulmodel for the current situation (Figure 5).

Several other models were tested, includingdistribution of multi-micronutrient powders forchildren aged 6-59 months and pregnant and

lactating women; smaller family size; free eggsfor consumption and sale through a livestockdistribution; and 25% reduction on all foodprices. However, these had no or nearly noeffect on costs.

Study limitations Limitations of the study are that the selectionof the standard/typical family is based on expe-rience of the CotD participants, but the realitycould be slightly different. No information onprices and availability data of food items duringthe winter season were collected, so all resultsand models are only valid for the rainy season.Monthly income was estimated by the data col-lectors and globally verified in FGDs; however,this was not a very thorough check and no in-formation was collected on expenditure withinhouseholds on non-food items such as clothing,healthcare and school fees. e HEA conductedby Oxfam provided some information, but thesituation in 2015 was very different from thecurrent situation, so it was not possible to useall the HEA data, such as income data.

DiscussionThe situation we describe in Bria Town and PK3 IDP camp is alarming, as the majority offamilies cannot afford to meet their energy needs,despite receiving a 20-day food basket for theentire household. Even more people are unableto afford a nutritious diet, or one that they wouldprefer to eat. Programming experience suggeststhat the situation may be underrepresented inthe most recent SMART survey conducted bythe Ministry of Health (MoH) and the UnitedNations Children’s Fund (September 2018), whichfound a GAM prevalence of 7.5% and SAMprevalence of 2.7% for Haute Kotto region. enutrition situation in Bria is complex and thereis no single action that can resolve the issue andensure that all families will be able to have a nu-tritious diet. A comprehensive, multisectorpackage of interventions is urgently needed. Re-sults will now be shared with the MoH, UNagencies and other stakeholders in the area.

Recommendations Based on these findings, several recommendationsare made:

• Explore with WFP the possibility for a full 30-day ration for all people in Bria Town and PK3 IDP camp, due to the clear limitations of a 20-day food basket, particularly for the most vulnerable. • Support efforts to ensure the peace agreement is being respected by all parties, so that roads and markets are safe and accessible for all. • Support the availability of free vegetables by facilitating families in Bria Town who would like to start a vegetable garden; advocate for an assessment on the possibilities for micro-gardening in the camp when households are unable to access their land; explore possible alternatives for people in the camp to obtain vegetables and fruits (for example, through distribution of fruits and vegetables) or cash to purchase them (while ensuring that markets are able to supply them without creating shortages in areas of origin within CAR). • Advocate within the Nutrition Cluster and other sectors, such as food security and livelihoods (FSL); water, sanitation and hygiene (WASH); and agriculture, to develop a comprehensive strategy and obtain multisector engagement to address the multiple issues affecting the nutrition situation in Bria. • Ensure behavior-change activities to improve IYCF and other key nutrition practices are included in all nutrition programmes.• Conduct a market survey and run the CotD analysis for the dry season to provide information on prices and affordability of a nutritious diet for both seasons.• Consider conducting a new HEA to provide updated information on current income and expenditure of families in Bria Town and PK3 camp, and collect more detailed information on foods produced by (some of) the families.

For more information, please contact EstherBusquet at [email protected]

XAF 100,000

XAF 90,000

XAF 80,000

XAF 70,000

XAF 60,000

XAF 50,000

XAF 40,000

XAF 30,000

XAF 20,000

XAF 10,000



Figure 5 The costs of the various diets compared to the monthlyincome of a typical family of nine in Bria Town and PK3camp in the rainy season when receiving a 20-day foodbasket and free vegetables

ReferencesF Garba (2015). Profil des Moyens d’Existence, Zone péri-urbaine de Bria. Oxfam Mission en RépubliqueCentrafricaine.

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Figure 6 The costs of the various diets compared to the monthlyincome of a typical family of nine in Bria Town and PK3camp in the rainy season when receiving a 30-day foodbasket and free vegetables

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Barriers to infant feeding in emergenciesprogramming in middle and high-income countriesBy Mija Ververs and Cindy Hwang

Mija Ververs is a SeniorAssociate for the Center forHumanitarian Health at JohnsHopkins Bloomberg School ofPublic Health in Baltimore, USA.She has over 35 years of

experience with over 15 organisations across 25countries in nutrition, public health, foodsecurity and livelihoods programming.

Location: Middle- and high-income countries (MICs/HICs) What we know: In every emergency it is necessary to assess and act to protect andsupport the nutrition needs and care of all infants and young children.

What this article adds: Interviews were conducted with 14 global experts with experienceof working on infant feeding in emergencies (IFE) in recent disasters in MICs and HICsto identify barriers to effective IFE programming. Findings demonstrate a lack ofunderstanding among disaster responders and healthcare professionals of the impact ofdisasters on infant feeding patterns and risk profiles of infants dependent on breast milksubstitutes (BMS), the vulnerability of infants, and the nature of and need for supportiveinfant feeding interventions to manage new risks. Lack of experience and training amongdisaster responders and perceptions that IFE is a food rather than a health issue werecommon findings. Global guidelines on IFE are considered ‘inapplicable’ in MICs/HICs;maternal choice in infant feeding decisions carries great weight, with little considerationof public health and resource implications. Advocacy and preparedness action is urgentlyneeded among disaster responders, healthcare professionals and decision-makers inMICs/HICs on context-specific IFE programming.

Introductione IFE Core Group document OperationalGuidance on Infant and Young Child Feeding inEmergencies provides concise guidance on howto ensure appropriate infant and young childfeeding in emergencies for all children undertwo years of age (IFE Core Group, 2017). Whileattention oen centres on low-income contexts,experiences from recent disasters in middle- andhigh-income countries (MICs/HICs) have demon-

1 The IFE Core Group is a global collaboration of agencies andindividuals that address policy guidance and training resource gaps hampering programming on infant and young child feeding support in emergencies. www.ennonline.net/ifecoregroup

Cindy Hwang is a registereddietitian who studied at theJohns Hopkins BloombergSchool of Public Health andobtained a Masters ofScience in Public Health. She

began her professional career as a clinicaldietitian at the Johns Hopkins Hospital inBaltimore earlier this year.

The authors would like to acknowledge thefollowing IFE Core Group members for theirparticipation in the interviews and for theirtime and insight: Christine Fernandes, KarleenGribble, Michelle Branco, AunchaleePalmquist, Maaike Aarts, Isabelle Modigell,Suzanne Brinkmann, Sarah Butler, AlessandroIellamo, Andi Kendle, Zita Weise Prinzo, MarieMcGrath, Julie Tanaka and Colleen Emary.

strated considerable challenges related to infantfeeding practices and response. Publications in2017 and 2018 alone show that problems ininfant feeding in emergencies (IFE) have beenencountered in Canada (DeYoung et al, 2018),Iraq (Haidar et al, 2017; Ververs et al, 2018),Lebanon (Akik et al, 2017; Shaker-Berbari et al,2018), Pakistan (Maheen and Hoban, 2017),Puerto Rico (Santaballa, 2018), Ukraine (Summersand Bilukha, 2018) and the migrant crises in Eu-rope (Svoboda, 2017). is study aimed to describe

the internal and external barriers that humanitarianorganisations and government agencies faced inaddressing infant feeding problems during emer-gencies in MICs/HICs as perceived by variousmembers of the IFE Core Group.1

MethodologyBetween November 2017 and March 2019, keyinformants (KIs) were selected based on theiractive membership in the IFE Core Group, ex-perience working in IFE programming and activeengagement on IFE in MICs/HICs in the pastfive years. Semi-structured interviews were held,during which the KIs were asked to describebarriers within their own organisations and otherorganisations and government agencies whenaddressing IFE in MICs/HICs. Notes were takenduring the interview; colour-coded, analysedand categorised by theme. Informed consentwas sought through a verbal consent processprior to the KI interview. e data was de-iden-tified to assure privacy of the participants.

ResultsFourteen key informant interviews were con-ducted. At the time of the interviews, the KIsworked for non-governmental organisations(NGOs) (8), United Nations (UN) agencies (3),in academia (2), or as an independent consultant(1). Interviews lasted on average between 30 to60 minutes. Table 1 illustrates the main barriersrelated to infant feeding in disasters in MICs/HICsthat emerged, described in more detail below.

A. Lack of understanding of a changingrisk profile in disaster contextsAll KIs agreed that, in a disaster context, infantfeeding patterns change. Some infants who werebreastfed before the disaster no longer receivedbreast milk, either because they were separated(temporarily or permanently) from their mothers(due to death, illness, injury or absence), orbecause mothers believed they were no longerable to breastfeed. Infants dependent on breast

Lack of understanding of a changing risk profile in disaster contexts

Lack of awareness that infants are a vulnerable group

Infant feeding not seen as lifesaving in disaster settings

Lack of experience of IFE

Lack of understanding of the response needed for IFE

Lack of knowledge on risks of breast milk substitutes used in disasters

Perception that global guidelines on infant feeding are not necessarily applicable to MICs/HICs

Perception that maternal choice and autonomy supersede increased public health risks

Lack of clear indicators to show impact of IFE programming

Lack of understanding that infant feeding is not (just) a food issue

Table 1 Barriers to optimal IFE in disasters in middle- and high-income countries (MICs/HICs)as expressed by key informants

Research

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milk substitutes (BMS) before the disaster likelyremain so during it, but their risk profile changesdramatically. Caregivers providing for BMS-de-pendent infants may find themselves withoutelectricity, gas, access to safe water and boilingfacilities, with few means to hygienically prepareBMS or access necessary infant-feeding supplies.KIs reported that many caregivers in recent criseswere preparing BMS in bathrooms of schools,sports facilities and train stations as these wereoen the only places where water was available.KIs reported a lack of understanding among dis-aster responders of the changing risk profile ofinfants during disasters in MICs/HICs and abelief among healthcare professionals that therewas no need for specific programmes for theirsupport2 as caregivers already knew how toprepare and use BMS.

B. Lack of awareness that infants area vulnerable groupKIs stated that disaster responders in MICs/HICsoen only recognise “classic” vulnerability groups,such as the elderly, people who are ill or im-munocompromised, and people who are insti-tutionalised. ey are unaware that infants arealso a vulnerable group in disasters, especiallywith regard to their feeding. Additionally, someKIs stated that decision-makers in disaster re-sponse programming were oen “middle-agedmen” who did not identify infants as specificallyvulnerable, which explained the absence of in-fant-feeding preparedness plans.

C. Infant feeding not seen aslifesaving in disaster settingsKIs stated that infant feeding was not seen aslifesaving by healthcare professionals and others,but as an issue relevant for later stages of emer-gency response aer access to shelter, curativecare, water and food had been provided. Manydisaster responders did not understand that in-fants need immediate access to either breastmilk or safely prepared BMS and that no otherfood options are suitable. KIs mentioned thatresponders oen believed survival needs to bemore or less the same for every group of peopleand that, if the prevalence of acute malnutritionwas relatively low in the disaster area, a nutritionresponse was low priority. is sometimes ledto tension within organisations that worked onhealth and nutrition in disasters among indi-viduals who saw no need for an IFE responseand others who understood the need.

D. Lack of experience of IFE KIs indicated that many organisations lackedIFE experience at programme-manager level orabove. Many disaster responders and healthcareprofessionals have limited experience in nutritionor in emergency settings specifically inMICs/HICs. Even if some NGO staff had expe-rience in low-income settings where breastfeedingis the norm, this did not adequately preparethem to deal with more complex IFE issues incontexts where breastfeeding is not the norm.KIs also specified that the emergency responsetraining curricula in MICs/HICs oen inade-quately address nutrition.

E. Lack of understanding of theresponse needed for IFEKIs agreed that there was a lack of understandingon what IFE programming entails and howlabour intensive it is, with little understandingof the need for individual infant-feeding as-sessments and counselling. Disaster respondersin MICs/HICs were likely to view the responseas a commodity-driven exercise and distributeBMS as they would food; it was reported thatsometimes medical staff are paid incentives toprescribe BMS for new mothers. BMS was oc-casionally included in blanket distributions toall caregivers, which disincentivised breastfeedingmothers. Distributions sometimes only includeda one-week supply of BMS, and rarely includedwater, detergent, brushes and fuel to clean orsterilise feeding bottles and boil water to preparethe BMS safely.

F. Lack of knowledge on risks of BMSuse in disastersKIs reported that, when the need for IFE pro-gramming was raised (including individual as-sessments and counselling prior to blanket dis-tribution of BMS), disaster responders askedfor scientific evidence showing the risks of BMSdistribution. One KI reported that healthcareprofessionals wanted to use free distribution ofBMS in a conflict-affected MIC as an incentivefor other interventions and asked the KI to pro-vide evidence of how distribution of BMS wouldharm infants, if at all.

G. Perception that global guidelineson infant feeding are not necessarilyapplicable to MICs/HICsMany KIs noted that, in MICs/HICs, localdisaster responders, including Ministry of Healthstaff, believed that globally established guidelinesand evidence did not necessarily apply to theircountries or contexts when affected by disasters.is included guidance established by the WorldHealth Organization; notably the InternationalCode of Marketing of Breast-milk Substitutes(WHO, 1981). is was also seen in countrieswhere paediatricians and other healthcare pro-fessionals were part of the incentive-driven dis-tribution system of BMS. Many humanitarianorganisations were aware of the guidance andbest practices, but were conflicted on how toimplement the guidance and consequently didnot address IFE out of fear of making mistakesor breaking the rules, leading to inaction.

H. Perception that maternal choiceand autonomy supersede increasedpublic health risks ere was a consensus among KIs that when amother of an infant less than six months of ageis absent, ill or deceased in a disaster, BMS andadditional resources need to be mobilised andprovided. However, organisations were littleprepared on how to address situations wheremothers expressed that they no longer desiredto breastfeed. Many KIs noted that healthcareprofessionals put great emphasis on maternalchoice. Oen there was no discussion when amother decided to stop breastfeeding during adisaster and no information was shared about

the risks of BMS. Healthcare professionals feltthat the disaster context was not the right contextto question the mothers’ decisions, not realisingthe significant public health consequences –particularly for infants – of this autonomy. Oncethe choice was made to use BMS, it was rarelydiscussed or agreed upon which organisation(s)would provide the additional resources neededfor the length it was required.

I. Lack of clear indicators to showimpact of IFE programmingSeveral KIs acknowledged that IFE programminglacked clear impact indicators. Some remarkedthat, unlike community-based management ofacute malnutrition (CMAM) programming, IFEprogrammes were unable to show the numberof deaths or diarrhoea episodes averted, orimpact on nutrition outcomes.

J. Lack of understanding that infantfeeding is not (just) a food issueKIs expressed concern about how IFE was per-ceived. ey stated that as long as professionalsworking in sexual and reproductive health, pae-diatricians and disaster responders perceivedIFE as merely a food issue (rather than a publichealth and child development issue), responsein disasters would be inadequate.

Discussione analysis of the interviews confirms findingsfrom other recently published articles fromMICs/HICs of a lack of understanding amonghealthcare workers on the risks, challenges andnecessary support needed for safe BMS use inemergencies, lack of experience among disasterresponders on IFE, and an overall lack of un-derstanding of what constitutes an adequate IFEdisaster response (Modigell et al, 2016; Prudhon,2016). Findings reveal that, at times, a tensionexists between IFE experts and co-workers withinthe same organisation due to differing opinionson IFE programming. ere also appears to be adrive within organisations to support maternalchoice to use BMS, without factoring in the sub-stantial resource and public health implicationsfor mothers and infants. Findings suggest that,as long as disaster responders continue to regardinfant feeding during a disaster as a food issueand not as a significant health concern, IFE pro-gramming will remain under-delivered as a nec-essary intervention to protect infant and childhealth and nutrition.

Findings of this study demonstrate a signifi-cant need for advocacy and awareness-raisingon what good (and bad) IFE programmingentails within humanitarian organisations andgovernments, as well as among healthcare pro-fessionals and disaster managers in MICs/HICs.Addressing these barriers will ultimately con-tribute to a reduction in morbidity and mortalityamong infants in disaster settings.

For more information, please contact MijaVervers at [email protected]

Research

2 Recommendations on the necessary supplies and support to manage artificial feeding in emergencies are outlined in the Operational Guidance on IFE.

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Research

ReferencesAkik C, Ghattas H, Filteau S, Knai C. Barriers tobreastfeeding in Lebanon: A policy analysis. J PublicHealth Policy. 2017;38(3):314-326. doi:10.1057/s41271-017-0077-9

DeYoung SE, Chase J, Branco MP, Park B. The Effect of MassEvacuation on Infant Feeding: The Case of the 2016 FortMcMurray Wildfire. Matern Child Health J.2018;22(12):1826-1833. doi:10.1007/s10995-018-2585-z

Haidar MK, Farhat J Ben, Saim M, Morton N, Defourny I.Severe malnutrition in infants displaced from Mosul, Iraq.Lancet Glob Heal. 2017;5(12):e1188. doi:10.1016/s2214-109x(17)30417-5

IFE Core Group. Infant and Young Child Feeding inEmergencies: Operational Guidance for Emergency ReliefStaff and Programme Managers. Oxford; 2017.

Maheen H, Hoban E. Rural Women’s Experience of Livingand Giving Birth in Relief Camps in Pakistan. PLoS Curr.January 2017.

Modigell I, Fernandes C, Gayford M. Save the Children’sIYCF-E Rapid Response in Croatia. Field Exchange.2016;(56):102.

Prudhon C. Assessment of Infant and Young Child FeedingPractices among Refugees on Lesvos Island, Greece.London; 2016.

Santaballa Mora LM. Challenges of Infant and ChildFeeding in Emergencies: The Puerto Rico Experience.Breastfeed Med. 2018;13(8):539-540.doi:10.1089/bfm.2018.0128

Shaker-Berbari L, Ghattas H, Symon AG, Anderson AS.Infant and young child feeding in emergencies:Organisational policies and activities during the refugee

crisis in Lebanon. Matern Child Nutr. 2018;14(3).doi:10.1111/mcn.12576

Summers A, Bilukha OO. Suboptimal infant and youngchild feeding practices among internally displacedpersons during conflict in eastern Ukraine. Public HealthNutr. 2018;21(5):917-926.doi:10.1017/S1368980017003421

Svoboda A. Retrospective qualitative analysis of an infantand young child feeding intervention among refugees inEurope. Field Exchange. 2017;(55):85.

Ververs M, McGrath M, Gribble K, Fernandes C, Kerac M,Stewart RC. Infant formula in Iraq: part of the problemand not a simple solution. Lancet Glob Heal.2018;6(3):e251. doi:10.1016/s2214-109x(18)30038-x

World Health Organization. The International Code ofMarketing of Breast-milk Substitutes. Geneva; 1981.

Location: Gambia

What we know: ere are gaps in understanding the relationship between wasting and stunt-ing that oen concur in populations and may concur in the same child.

What this article adds: A retrospective cohort analysis on growth-monitoring records fromclinics in rural Gambia (1976 to 2016; 5,160 children under two years old) examined whetherwasting is a risk factor for stunting, and vice versa; whether the season of birth influencesfuture wasting and stunting; and whether there are gender differences in growth deficits inGambia. Wasting was defined as weight-for-length z-score (WLZ) <-2. Stunting was definedas length-for-age z-score <-2. Wasting prevalence peaked at 12% (girls) and 18% (boys) at 10-12 months of age, and at 37% (girls) and 39% (boys) at 24 months of age. Wasted childrenwere 3.2 times more likely to be stunted three months later, and children currently stuntedwere 1.5 times more likely to be wasted three months later. Infants born at the start of theannual wet season (July-October) showed early growth faltering (WLZ) and increased risk ofsubsequent stunting. Boys were more likely to be wasted, stunted and concurrently wastedand stunted than girls, and were more susceptible to seasonally-driven growth deficits.Results suggest that stunting is in part a biological response to previous episodes of beingwasted. Where significant levels of wasting and stunting exist, treatment and preventioninterventions should consider joint approaches. More understanding is needed of thephysiologic mechanisms and environmental factors of seasonal vulnerabilities and genderdifferences in wasting and stunting.

The relationship between wasting and stunting:a retrospective cohort analysis of longitudinal datain Gambian children from 1976 to 2016 Summary of research1

Each year, around 800,000 deaths inchildren under five years of age are inpart attributable to wasting; 60% ofwhich are attributable to severe wasting.

In addition, over one million child deaths areattributable to stunting, although this associationremains poorly understood. Even though progressis being made in decreasing undernutrition inlow- and middle-income countries, stuntingand wasting during childhood continue toburden people in the poorest regions in the de-veloping world. Although both forms of under-nutrition occur together in children in manycontexts and may co-occur in the same child

1 Simon M Schoenbuchner, Carmel Dolan, Martha Mwangome,Andrew Hall, Stephanie A Richard, Jonathan C Wells, Tanya Khara, Bakary Sonko, Andrew M Prentice, Sophie E Moore. The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 2016. The American Journal of ClinicalNutrition, Volume 110, Issue 2, August 2019, Pages 498–507, https://doi.org/10.1093/ajcn/nqy326

(referred to as “concurrence”), wasting andstunting are oen considered separately withrespect to how they are managed clinically andprogrammatically and how they are researched.e rationale behind this conceptual separationof stunting and wasting in terms of etiologyand programming has been questioned in severalrecent reviews and publications (Briend, Kharaand Dolan, 2015; Khara and Dolan, 2014). esepublications highlight outstanding gaps in un-derstanding the interrelationship between thesetwo forms of undernutrition as a result of in-sufficient examination of data; in particularfrom longitudinal cohorts.

e authors of this paper contribute to fillingthis gap by describing the interrelationshipsbetween wasting and stunting in children undertwo years old through a retrospective cohortanalysis, based on growth-monitoring recordsspanning four decades from clinics in ruralGambia. ree broad research questions weretested: 1) is wasting a risk factor for stunting,and vice versa? 2) does the season of birth in-fluence future wasting and stunting;? and 3)are there gender differences in growth deficitsin the Gambia? Anthropometric data collectedat scheduled infant-welfare clinics between May1976 and September 2016 were converted to z-scores, comprising 64,342 observations on 5,160subjects (median: 12 observations per individual).Children were defined as “wasted” if they had aweight-for-length z-score (WLZ) <–2 againstthe WHO reference and “stunted” if they had alength-for-age z-score (LAZ) <–2.

Results reveal that prevalence of wastingand stunting were high in this population. eprevalence of stunting increased with age,peaking at 37% (girls) and 39% (boys) at 24months of age. Wasting showed an early declinein the first three months (reflecting a period ofpositive weight gain in the months immediatelypostpartum), followed by a peak at around oneyear of age (18% in boys, 12% girls). e preva-lence of children with concurrence peaked at9% in boys and 5% in girls, also at around one

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year of age. Infants who were wasted in the firstwet season of their life were more likely to bewasted in their second wet season, even aercontrolling for recovering during the interveningdry season (OR:3.2; 95% CI:2.3, 4.4).

Infants born at the start of the annual wetseason (July–October) showed early growth fal-tering in WLZ, putting them at increased risk ofsubsequent stunting. Time-lagged observationsshow that being wasted was predictive of stunting(OR: 3.2; 95% CI: 2.7, 3.9), even aer accountingfor current stunting. e reverse also holds: chil-dren currently stunted are 1.5 times more likelyto be wasted three months later, even aer ac-counting for currently wasting status. Boys weremore likely to be wasted, stunted, and concurrentlywasted and stunted than girls, as well as beingmore susceptible to seasonally-driven growthdeficits.

is analysis highlights several key issues ofrelevance to our understanding of the relationshipbetween wasting and stunting in early childhood.First, in this highly seasonal, rural environmentwith high rates of exclusive breastfeeding, thereis a seasonally-driven risk among young infants

of poor growth. is indicates the need to providemore targeted support to breastfeeding mothersand increase attention to infant feeding duringperiods of seasonal stress. Second, results demon-strate that being wasted leads to increased riskof subsequent stunting. is suggests that stuntingis in part a biological response to previousepisodes of being wasted and that stunting mayrepresent a deleterious form of adaptation tomore overt undernutrition (wasting). Stuntedchildren are not just short, but are children whowere earlier more seriously malnourished andwho are survivors of a composite process. ird,children who are wasted in one wet season aremore likely to be wasted in a subsequent wetseason even aer recovery, suggesting a continuedvulnerability across seasons. Further understand-ing is needed of related physiologic mechanismsand environmental factors. Fourth, and consistentwith much of the global literature, boys are morelikely to be wasted or stunted or to have concurrentwasting and stunting; all of which convey addedrisk of mortality. ere is a need to understandthis gender difference in vulnerability so thatthe policy and practice communities can takethis into account.

Results indicate that, where there are levelsof wasting and stunting of public health signifi-cance in a given context, there are compellingreasons for both treatment and prevention in-terventions to consider wasting and stuntingjointly and with awareness of the relation betweenthem. e separation of the wasted infant/childand the stunted infant/child in terms of policies,programmes and research risks opportunitiesbeing missed to detect and intervene to preventboth forms of undernutrition in this highly-vulnerable population group. e attainmentof World Health Assembly and other global tar-gets remains a very strong global and country-level intent, but these targets will not be achievedwhere approaches to infant and child undernu-trition remain siloed.

ReferencesBriend A, Khara T, Dolan C. Wasting and stunting–similarities and differences: policy and programmaticimplications. Food Nutr Bull 2015;36(1 Suppl):S15–23.

Khara T, Dolan C. Technical Briefing Paper: Associationsbetween wasting and stunting, policy, programming andresearch implications. Oxford, UK: Emergency NutritionNetwork; 2014.

Scurvy outbreak amongSouth Sudaneseadolescents and youngmen – Kakuma refugeecamp, Kenya, 2017-2018

Location: Kenya What we know: Refugee populations dependent on food assistance are at risk ofmicronutrient deficiencies.

What this article adds: An outbreak of scurvy among 45 adolescent and youngadult male South Sudanese refugees suspected cases was confirmed by Centers forDisease Control and Prevention (CDC) in 2018. ose affected had been provideda partial food ration consisting of cereal, pulses, fortified corn-soy blend (CSB+)and vitamin A-fortified oil, plus electronic cash to support dietary diversification tosupplement their diets in Kakuma refugee camp, Kenya between 2017 and 2018.From 2015, there were shortages of food assistance commodities and fundingshortfalls. Rather than purchasing fresh foods rich in vitamin C, the investigationfound those affected selected more calorie-dense cereal and pulses to supplementthe energy-deficient food ration. Symptoms resolved aer vitamin C treatment.Vitamin C retention of CSB+ aer preparation was <16%; insufficient to preventscurvy. Findings show that food and cash assistance based on average householdcomposition is insufficient for refugees with higher caloric needs; in this instance,adolescents and young adult male refugees.

Summary of research1 Refugees wait while foodis being prepared in thekitchen of Kakuma refugeecamp reception center

WFP

/Rei

n Sk

ulle

rud

1 Ververs, M., Wambugu Muriithi, J., Burton, A., Wagacha Burton, J., Oman Lawi, A. (2019). Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018. Morbidity and Mortality Weekly Report (MMWR) US Department of Health and Human Services/Centers for Disease Control and Prevention, January 25, 2019. Vol. 68/ No. 3.

Background Scurvy is a relatively rare micronutrient-deficiencydisease that can occur among refugees dependent onfood assistance due to inadequate access to freshfruits and vegetables. Kakuma refugee camp in Kenya’sTurkana district is home to 148,000 refugees, mostlyfrom Somalia and South Sudan, who receive food as-sistance. In August 2017, a number of South Sudaneseadolescent and young adult male refugees wereevaluated for calf pain, chest pain and gingival (gum)swelling. No diagnosis was initially made due to non-specific symptoms and some patients received antibioticsand analgesics. All were managed as outpatients, but

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later. e median age was 19 years (range = 12-32 years). Approximately 58% of patients reportedswelling of the lower limb, 53% ankle swelling,and 42% lower-limb pain. Interviews with healthpersonnel and patients found that approximatelyseven to 10 patients had been unable to walk.Forty of the 45 patients with suspected scurvywere treated with vitamin C. e median house-hold size of patients with suspected scurvy wasfive persons (range = one to 15 persons). Amongthe subset of 14 households for which age wascollected, nine (64.3%) included only adolescentsand young men aged 13-22 years; only fivehouseholds included a female, only one of whomwas an adult.

All patients with suspected scurvy reportedthat they ate one meal per day. None had incomefrom work or received any remittances and allreported that, rather than using the e-cash todiversify their diets, they used the full e-cashamount to purchase staple foods (e.g., cerealsand pulses) and sometimes salt. Forty-three pa-tients (96%) reported that they had not purchasedvegetables, fruits or potatoes since their arrivalin Kakuma and used the e-cash to supplementtheir diet with cereals and pulses, which providedan additional 870-1,450 kcal/pppd. All patientswho received treatment with vitamin C notedimprovement of symptoms within less than oneweek, particularly reduc¬tion in swelling ofknee and ankle joints and shin pain. All patientswho previously had been unable to walk wereable to do so aer treatment.

In response to this outbreak, in April 2018WFP tested the amount of vitamin C in CSB+aer simulating the CSB+ preparation in a lab-oratory setting. e raw product contains 90mg vitamin C per 100g, and each refugee received40g CSB+ per day (equivalent to 36 mg vitaminC per day). e cooking simulation demonstratedthat vitamin C retention aer preparation was<16%; thus, intake through consump¬tion wouldbe <6 mg vitamin C per day, which is insufficientto prevent deficiency.

Discussion Scurvy is not new to refugee settings in which alimited amount of fresh foods is available oraffordable and has previously been documentedin Kakuma refugee camp, with outbreaks reportedduring 1995-1997 (Verdirame and Harrell-Bond,2005) and 2003 (UNHCR, 2003). Vitamin Cdefi¬ciency has also been described amongrefugees and imprisoned male populations insimilar geographic areas (Desenclos et al, 1989;Seaman and Rivers, 1989; Bennett and Coninx,2002). e energy requirements for males aged14-18 years and 18-30 years are 3,000-3,400 kcalper day and 2,550-3,900 kcal per day, respectively(FAO/WHO/UNU, 2001), based on moderatephysical activ¬ity (males aged 14-18 years) andactive-to-moderately-active physical activity (menaged 18-30 years). e food ration provided inthe camp supplied 900-1,700 kcal/pppd; if all e-cash was used to purchase sorghum and splitpeas, an additional 870-1,450 kcal/pppd was po-tentially available, for a maximum theoreticalintake of 1,800-2,900 kcal/pppd, depending on

ReferencesBennett M, Coninx R. The mystery of the wooden leg:vitamin C deficiency in East African prisons. Trop Doct2005;35:81–4. https://doi.org/10.1258/0049475054036896

Desenclos JC, Berry AM, Padt R, Farah B, Segala C, NabilAM. Epidemiological patterns of scurvy among Ethiopianrefugees. Bull World Health Organ 1989;67:309–16.

Seaman J, Rivers JP. Scurvy and anaemia in refugees.Lancet 1989;1:1204. https://doi.org/10.1016/S0140-6736(89)92782-7

United Nations High Commissioner for Refugees. UNHCRglobal report 2003. Geneva, Switzerland: United NationsHigh Commissioner for Refugees; 2003.www.unhcr.org/40c6d7520.pdf

United Nations University, World Health Organization,Food and Agriculture Organization of the United Nations.Human energy requirements: report of a joint FAO/WHO/UNU expert consultation, Rome, 17–24 October 2001.Rome, Italy: Food and Agriculture Organization of theUnited Nations; 2004. www.fao.org/3/Y5686e/Y5686e00.htm

Verdirame G, Harrell-Bond B. Rights in exile: Janus-facedhumanitarianism. New York, New York: Berghahn Books;2005.

World Health Organization. Scurvy and its prevention andcontrol in major emergencies, Geneva, Switzerland: WorldHealth Organization; 1999.https://apps.who.int/iris/handle/10665/66962

household size. us, the food ration met onlyhalf of the required caloric needs. Because thee-cash intended for dietary diversification wasnot used to purchase fresh foods, such as vitaminC-rich fruits and vegetables, but rather to com-ple¬ment the food rations with more calorie-dense and cheaper staple foods to secure themissing calories, vitamin C deficiency resulted.e diet of patients with suspected scurvy con-tained, on average, <10 mg vitamin C per day;the minimum daily requirement to preventscurvy is 10 mg (WHO, 1999). Despite previousassumptions, the fortified commodity, CSB+,was not a sufficient source of vitamin C as lossesduring preparation were much higher thaninitially estimated. e geographic clustering ofsuspected cases likely resulted from the relativelyhigher number of young men living and cookingtogether in one area of the camp and sharingtheir limited food rations and e-cash.

Provision of food assistance in refugee settingsis oen based on average household composition,factoring in age, sex and caloric needs. In thisinvestigation, the adolescent and young maleshad very high nutritional needs compared withpersons in an average household. ese differ-ences in household demographics demonstratethat simply providing an average amount ofcalories calculated on assumed householddemo¬graphics is inadequate to meet nutritionalrequirements. In addition to food rations, refugeeswere provided with e-cash to purchase theirown food to add diversity and choice to theirdiet. However, this investigation indicated thatfor adolescent and young adult male refugees,both forms of assistance were inadequate toallow access to sufficient calories and the dietarydiversification needed for intake of sufficientmicronutrients, such as vitamin C. It is importantto consider these needs when determining theamount of food or cash assistance provided toadolescents and young adult male refugees.

symptoms did not improve. During subsequentmonths, more young men reported similar symp-toms. On 20 January 2018, the United NationsHigh Commissioner for Refugees (UNHCR) wasinformed and conducted clinical examinations.Signs and symptoms included lower limb painand swelling, lethargy, fatigue, gingival swellingand pain, hyperkeratotic skin changes and chestpain. Based on these clinical findings, an outbreakof micronutrient deficiency, particularly vitaminC deficiency (scurvy) was suspected. Vitamin Ctreatment was given to those affected and, in Feb-ruary 2018, UNHCR requested assistance fromCenters for Disease Control and Prevention (CDC)to carry out an investigation. is article sum-marises the findings.

Investigation and findingsTwo health specialists from CDC and UNHCRconducted an outbreak investigation from 11 to17 March 2018. A suspected scurvy case was de-fined as the occurrence of lower limb, knee jointor ankle swelling, and at least two of the fol¬low-ing: calf pain, shin pain, knee-joint pain, or gin-givitis in a person of any age. Because the SouthSudanese frequently have very dark skin, thetypical dermato¬logic symptom of petechialhaemorrhage was not included in the case defi-nition. Forty-five patients with suspected scurvywere identified and interviewed using a ques-tionnaire developed by investi¬gators to obtaininformation on symptoms and diet, with a recallperiod of six months. For a subset of 14 patients,the age structure of the household was analysed.Additional interviews were conducted with staffmembers from UNHCR, World Food Programme(WFP), the non-governmental organisation re-sponsible for healthcare in the camp, communityhealth volunteers, community leaders and food-shop owners who interacted with the patients.Dietary intake was estimated using WFP’s in-formation on provided food rations and NutVal4.1, a free soware programme for calculatingthe nutritional content of food rations.2

At the time of this investigation, all refugeesin Kakuma received food assistance, consistingof cereal, pulses, fortified corn-soy blend (CSB+)and vitamin A-fortified oil. By WFP standards,a food ration should provide 2,100 kcal perperson per day (pppd) but, aer 2015, a part ofthe cereal compo¬nent of the ration was replacedby electronic cash (e-cash) to provide dietarydiversification and choice. In 2017 and 2018,one-person households received a 500 KenyanShillings (KSh)/pppd and food ration of 900-1,400 kcal/pppd. Households of ≥2 persons re-ceived 300 KSh/pppd and a food ration of 900-1,700 kcal/pppd. e variations in the food as-sistance from 2015 onwards resulted from short-ages of commodities and funding shortfalls.Among the 45 patients with suspected scurvy,date of symptom onset was known for 44.Among these, 29 (66%) reported onset betweenAugust and November 2017.

All 45 patients with suspected scurvy wereadolescent and young adult male refugees fromSouth Sudan who had arrived in Kakuma between2012 and 2017; 33 (73%) had arrived in 2014 or

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Q: It seems these adolescent boys were theonly population group that was affected bythis outbreak. Is that correct? Regarding thecontext in which these young men wereliving, could you elaborate more on theirsocial circumstances?

e adolescent boys who were affected bythis outbreak were fleeing war. ey had nosource of income and were diligently attendingand enjoying school in the camps. is meantthey were wholly dependent on food assistanceand cash for their nutrition. As far as weknow, these young men were the only popu-lation group that was affected by this outbreak.e CDC/UNHCR investigation focusedmostly on these cases and their situation.Having an adult woman in the householdseemed to be a protective factor in this pop-ulation. Some of these boys had arrived intothe camp at 10-14 years of age, having neverlearned to cook or garden or know what ahealthy diet was.

Q: What impact did this situation have onthe boys?Scurvy had a significant personal impact onthese boys. e highlight of their day was at-tending school and playing football. e phys-ical consequences meant they could not playfootball, which had a considerable psycho-logical impact on them; some had becomedemoralised and a few expressed thoughts ofreturning back to South Sudan “to pick upweapons to fight for their own food”. Ingeneral, the condition did not heighten school

dropout if they could still walk, reflectingtheir commitment to their schooling.

Q: Regarding the findings on the CSB+vitamin C losses in preparation, how doesthis compare with other official qualitycontrol data? What do you think are theimplications of the findings regarding CSB+more broadly and what actions do youthink are needed?

Vitamin C retention was less than expectedby WFP. Based on literature, they expected a50% retention. Poor retention is not just dueto heat liability of vitamin C, but mostly oxi-dation, which leads to losses. Oxidation isaffected by preparation method – the more acooking pot of CSB is stirred, the more oxygenis introduced and the greater the loss.

We need to establish whether CSB needsto be a source of vitamin C. If the answer isyes, then we need more studies on how toprevent losses in preparation and to examineif higher levels of fortification can preventloss. If not, then we need to make sure to ac-commodate vitamin C from another source.e findings also raise concern about othervitamins – vitamin C deficiency may be aproxy for other sub-clinical deficiencies.

Q: What do you think were the keycontributing factors to this outbreak?

e adolescent boys lived together as agroup and prepared their meals together.ey ate all the CSB obtained within the first

few days of receiving it. is meant that theyhad no intake of vitamin C, as a water-solublevitamin, for the rest of the month. However,this was not the main issue. A more criticalcontributing factor to this outbreak was thecut in food assistance leading to reduced ra-tions of staple foods distributed. Cash pro-gramming was initiated to partly compensatefor less ‘in-kind’ food provision and to facilitatefood diversification, such as purchase of fruitsand vegetables. However, without adequateamounts of staple foods in the general ration,cash subsidies were used by these boys topurchase staples rather than fruit and veg-etables, as was intended.

e higher nutrient requirements of ado-lescent boys were also a critical factor. Active,growing adolescent males have a high caloricdemand; ration targets of 2,100 kcal/day basedon ‘average’ household composition are in-adequate for young men, who need closer to3,000 kcal/day. We did not look to see if theseboys were acutely malnourished, but this isalso not easy to diagnose within the Dinkapopulation, whose physique is typically leanand tall.

When household demographics are skewed,as in this case or, for example, in contextswith peace-keepers (military dominated bymales), young male migrants (as in the Eu-ropean migrant crisis), or in prisons (wherewe have also seen scurvy outbreaks), energyand nutrient estimates based on averagehouseholds are not adequate. Differences indemographics and energy and nutrient re-quirements do not just apply to men; womenmay also be disproportionately representedand have heightened needs, such as for iron,and the response should be contextualisedaccordingly.

What immediate key action would you liketo see?

We need to examine and change our wayof ‘doing business’ when it comes to nutri-tion-assistance targets. Currently, the NutVal1

programme includes adolescent boys andgirls as one group. As a priority, this shouldbe revised to distinguish boys and girls to ac-commodate their different energy and nutrientneeds and so facilitate more appropriate food-assistance planning.

Further perspectives on scurvy outbreakPostscript

Marie McGrath and Jeremy Shoham, Field Exchange editors, interviewed Mija Ververs, whoundertook the field trip with CDC to investigate the scurvy outbreak, for more insights.

1 www.nutval.net

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Refugees receiving food at Kakumarefugee camp reception center

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Research .............................................................SnapshotsAdolescent girls’ nutrition and preventionof anaemia: a school-based multisectoralcollaboration in Indonesia

In Indonesia, the national prevalenceof anaemia among females aged 15-24 years is 18.4%. Screening of juniorhigh-school students in West Java in-

dicated a prevalence of >50%. Indonesia’s2016 national programme for anaemia pre-vention and control in adolescent girls andwomen of reproductive age (WIFAS) in-

cludes a weekly iron and folic acid (IFA)supplementation of adolescent girls througha pre-existing school-health programmesupported by four ministries: Ministry ofHealth (MoH), Ministry of Education andCulture, Ministry of Religious Affairs, andMinistry of Home Affairs. A demonstrationof this project was implemented in two

districts of West Java between 2015 and 2018. is involvedthree core activities: (1) increasing awareness of andsecuring government commitment to the WIFAS projectand adolescent health in general; (2) improvement in IFAsupply through skills building of MoH staff and strength-ening of supply-chain management systems and on-the-job training for teachers, primary health facility staff anddistrict officials of each sector; (3) increasing demandand acceptability of the project through a behavior-changeintervention strategy, including a branded campaign,“healthy, beautiful and smart without anaemia”.

Modelled estimates show that the demonstration projectmay have contributed to preventing 4,071 cases of anaemiaby reaching 52,000 adolescent girls. Existing platformsand policy frameworks for action helped to catalyse mul-tisector collaboration in this context. Political commitmentfrom the highest policy-maker of each sector was key. Itwas also important to gain local and institutional com-mitment, such as from each school principal. Other driversof success were capacity-building at all levels and investmentin strengthening individual and institutional relationshipsacross sectors to help foster collaboration. Key to engagementby all stakeholders was data to drive decisions and ac-countability (and so harmonisation and collaboration ondata collection); monitoring systems; and joint responsibilityfor and ownership of shared results, outcomes and goals.e authors conclude that multisector collaborations ofthis kind require resources and coordination and shouldbe tailored to the unique needs of individual countries inorder to further reach adolescents.

1 Roche, M.L., Bury, L., Yusadiredja, I.N., Asri, E.K., Purwanti, T.S., Kusumiati, S.,Bhardwaj, A. and Izwardy, D. (2018) Adolescent girls’ nutrition and prevention of anaemia: a school-based multisectoral collaboration in Indonesia. BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4541

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Impact on child acute malnutrition of integrating apreventative nutrition package into facility-basedscreening for acute malnutrition in Burkina Faso

The impact of community-based man-agement of acute malnutrition(CMAM) is oen limited by low cov-erage of screening for acute malnu-

trition, influenced by a perceived lack of benefitsamong caregivers. A cluster-randomised con-trolled trial was undertaken to test the impactof integrating a preventive nutrition packageinto routine, facility-based monthly screeningof children under two years old in BurkinaFaso on acute malnutrition screening and treat-ment coverage and acute malnutrition incidenceand prevalence. Intervention and comparisongroups (16 health centres each) had access tostandard CMAM and facility-based well-babyconsultation services. Caregivers in the inter-vention group also received age-appropriate

monthly behaviour-change communication onhealth and nutrition and a monthly supply ofsmall-quantity, lipid-based nutrient supplements(SQ-LNS) for children over six months of age.A repeated cross-sectional study of childrenaged 17 months old (n = 2,318 at baseline and2,317 at endline two years later) was undertakento assess impacts on acute malnutrition screeningcoverage, treatment coverage and prevalence.A longitudinal study of 2,113 children enrolledsoon aer birth and followed up monthly for18 months was undertaken to assess impactson acute malnutrition screening coverage, treat-ment coverage and incidence. Results showedthat, relative to the comparison group, the in-tervention group had significantly higher monthlyacute malnutrition screening coverage (cross-

sectional study: +18 percentage points [pp],95% confidence interval [CI] 10–26, P < 0.001;longitudinal study: +23 pp, 95% CI 17–29, P <0.001). However, there were no impacts on acutemalnutrition treatment coverage, acute malnu-trition incidence or acute malnutrition prevalence.Further research is needed on remaining barriersto CMAM uptake and methods of integratingpreventative and CMAM services.

1 Becquey E, Huybregts L, Zongrone A, Le Port A, Leroy JL, Rawat R, et al. (2019) Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso. PLoS Med 16(8): e1002877. https://doi.org/10.1371/journal.pmed.1002877

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Impact on child acute malnutrition of integrating small-quantitylipid-based nutrient supplements into community-levelscreening for acute malnutrition in Mali

The impact of community-based man-agement of acute malnutrition(CMAM) is often limited by low cov-erage of screening for acute malnu-

trition. A two-arm cluster-randomised controlledtrial in 48 health centre catchment areas in theBla and San health districts in Mali aimed totest the impact of distributing small-quantity,lipid-based nutrient supplements (SQ-LNSs)at monthly screenings held by communityhealth volunteers (CHVs). Screening sessionsincluded behaviour change communication onnutrition, health and hygiene practices (bothstudy arms), and SQ-LNSs (one study arm).Impact was assessed on acute malnutritionscreening and treatment coverage and on acutemalnutrition incidence and prevalence. A re-peated cross-sectional study (n = 2,300) withbaseline and endline surveys was used to ex-amine impacts on acute malnutrition screeningand treatment coverage and prevalence. A lon-gitudinal study of children enrolled at sixmonths of age (n =1,132) and followed monthlyfor 18 months was used to assess impact onacute malnutrition screening and treatmentcoverage and incidence.

e intervention significantly increased acutemalnutrition screening coverage (cross-sectionalstudy: +40 percentage points [pp], 95% confidenceinterval [CI]: 32, 49, p < 0.001; longitudinal study:+28 pp, 95% CI: 23, 33, p < 0.001). No impact ontreatment coverage or acute malnutrition prevalencewas found. Children in the intervention arm,however, were 29% (95% CI: 8, 46; p = 0.017) lesslikely to develop a first acute malnutrition episode(incidence) and, compared to children in com-parison arm, their overall risk of acute malnutrition(longitudinal prevalence) was 30% (95% CI: 12,44; p = 0.002) lower. e intervention loweredCMAM enrolment by 10 pp (95% CI: 1.9, 18; p =0.016), an unintended negative impact likely dueto CHVs handing out preventive SQ-LNSs tocaregivers of acute malnutrition children insteadof referring them to the CMAM programme. In-corporating SQ-LNSs into monthly community-level acute malnutrition screenings and behaviourchange communication sessions was highly effectiveat improving screening coverage and reducingacute malnutrition incidence, but it did notimprove acute malnutrition prevalence or treatmentcoverage. Further research is needed on remainingbarriers to CMAM uptake.

1 Huybregts L, Le Port A, Becquey E, Zongrone A, Barba FM, Rawat R, et al. (2019) Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplementsinto community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali. PLoS Med 16(8): e1002892. https://doi.org/10.1371/journal.pmed.1002892

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Research Snapshots

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Supportive supervision to improve the quality and outcome ofoutpatient care among malnourished children in Uganda

Suboptimal quality of paediatric care hasbeen reported in resource-limited set-tings, but little evidence exists on inter-ventions to improve it. is study aimed

to test supportive supervision (SS) for improving

health status of malnourished children, qualityof case management, overall quality of care,and the absolute number of children enrolledin nutrition services through a cluster randomisedtrial in Arua district, Uganda. Six health centreswere randomised to receive SS or no intervention.SS specific to nutrition services was deliveredat a high frequency by a team of two trainedlocal staff to health centre staff at interventioncentres (phase one). SS was later extended tocommunity health workers (CHWs) (phasetwo). e primary outcome was the cure rateof children aged between 6 and 59 months en-rolled in health centres for the management ofsevere or moderate acute malnutrition. Qualityof case management was assessed by six pre-defined indicators; quality of care was assessedusing the National Nutrition Service DeliveryAssessment (NSDA) tool; and access to carewas estimated by the number of children ac-cessing health centre nutrition services.

A total of 737 children was enrolled in thestudy. In the intervention arm, the cure rate(83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI:

1.56–2.34, p=0.001), quality of care as scoredby NSDA (RR=1.57, 95% CI: 1.01–2.44, p=0.035)and correctness in complementary treatment(RR=1.52, 95% CI: 1.40–1.67, p=0.001) weresignificantly higher compared with the controlgroup. With the extension of SS to CHWs, sig-nificantly more children (38.6%) accessed carefrom intervention health centres than they hadpreviously (38.4% before extension of SS toCHWs and 62% aer; RR=1.26, 95% CI:1.11–1.44, p=0.001). e proportion of children ac-cessing care in the control group was 45% inphase one and 49% in phase two. e authorsconclude that SS significantly improved the curerate of malnourished children and the overallquality of care and providing SS to CHWs sig-nificantly increased the crude number of childrenenrolled in nutrition services. More research isneeded to confirm these results and evaluatethe cost-effectiveness of SS.

1 Lazzerini M, Wanzira H, Lochoro P, et al. Supportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda. BMJ Global Health2019;4:e001339. doi:10.1136/bmjgh-2018-001339

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An 11 months old is addmitted to a healthcentre in Kalabankoro, Mali, sufferingfrom severe acute malnutrition

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children enrolled in nutritionservices in Arua district, Uganda

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Prevention and treatment of acute malnutritionin humanitarian emergencies: a multi-organisation collaboration to increase access to synthesised evidence

Programme decision-making to preventand treat acute malnutrition in an emer-gency can be hampered by a lack of ac-cessible and relevant overviews of directly

available, robust research evidence. is paperdescribes a process whereby a multi-disciplinary,international group of specialists worked togetherto build relevant and effective collections of avail-able systematic reviews on acute malnutrition,published and disseminated as online collections,to improve access to concise, synthesised, relevantand up-to-date evidence for programming.

A group of 21volunteers and stakeholders frommultiple backgrounds collaborated between March

1 Allen, C., Jansen, J., Naude, C. et al. Prevention and treatment of acute malnutrition in humanitarian emergencies: a multi-organisation collaboration to increase access to synthesised evidence. Int J Humanitarian Action 4, 11 (2019) doi:10.1186/s41018-019-0057-8

2 Evidence Aid (2018) Evidence aid nutrition collection. Availableat: www.evidenceaid.org/prevention-and-treatment-of-acute -malnutrition-in-emergencies-and-humanitarian-crises/

3 Cochrane Special Collections. Treatment of malnutrition, available at: www.cochranelibrary.com/collections/doi/10.1002/14651858.SC000032/full; and Prevention of malnutrition, available at: www.cochranelibrary.com/collections/doi/ 10.1002/14651858.SC000031/full

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the final collections. ree collections were publishedand are publicly available: one of non-Cochranereviews published on the Evidence Aid website2

and two of Cochrane reviews; one on the treatmentof acute malnutrition and one on its prevention,published by Cochrane.3 ese collections will beupdated regularly to provide up-to-date evidenceto inform nutrition-in-emergencies decision-makersand programmers. Such collaboration and collationcould benefit other subject areas; Evidence Aid iseager to support new collections around othertopics relevant to humanitarian emergencies andcan be contacted at [email protected]

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2017 and March 2018 to review and curate collectionsof systematic reviews of interventions for the pre-vention and treatment of moderate and severeacute malnutrition (MAM and SAM) in humani-tarian emergencies. e methodology loosely fol-lowed general guidance for overviews of systematicreviews with a pre-defined question, formulatedusing the Population, Intervention, Comparison,Outcomes and Study design (PICOS) format andsearch strategies applied to multiple databases.Pairs of collaborators first screened the searchyields to identify potentially eligible reviews, aerwhich other pairs screened the list of potentiallyeligible reviews for relevance that were included in

Inpatient and outpatient treatment for acutemalnutrition in infants under six months: a qualitative study from Senegal

Treatment for children aged 6-59 monthswith acute malnutrition has shied towardsan outpatient, community-based approach,while infants under six months old are

mostly treated in hospital. In light of the large problemof malnutrition in infants under six months old inSenegal (5.4% prevalence), a descriptive study wasundertaken to describe barriers and facilitators foroutpatient and inpatient treatment of care for thisage group in a semi-urban setting. In-depth interviewsand focus group discussions with mothers of mal-nourished infants, conducted over four months (July-September 2015) in two case clinics (one inpatient,one outpatient), explored three key factors for a suc-cessful nutrition programme: access, quality of careand community engagement.

Nine facilitators and barriers emerged fromthe data. Outpatient care was perceived to bemore accessible than inpatient in terms of distanceand cost; mothers were motivated to seek supportfrom community health centres when free infantformula was available as part of care. Trust couldbe more easily generated in an outpatient settingthat mothers were already familiar with. In termsof quality of care in the outpatient setting, thecup-and-spoon relactation technique was usedeffectively but needed close supervision andbasic medical care could be offered to outpatients,provided that referral of complicated cases wasadequate. Inpatient care allowed for more intensivehealth/nutrition education due to more time forindividualised support, although this could be

1 van Immerzeel TD, Camara MD, Deme Ly I, and de Jong RJ.Inpatient and outpatient treatment for acute malnutrition in infants under 6 months; a qualitative study from Senegal. BMC Health Services Research (2019) 19:69 https://doi.org/10.1186/s12913-019-3903-x

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done in an outpatient setting. e lack of com-munity-level breastfeeding counselling and com-munity education on breastfeeding was identifiedas an important gap. In terms of community en-gagement, the community appeared to play akey role in treating malnourished infants throughits influence on health-seeking behaviour, peersupport and breastfeeding practices. e levelof support to mothers of malnourished infantsvaried widely and domestic task load of motherswas oen a barrier to infant care and breastfeeding.e authors conclude that outpatient care doesfacilitate access to treatment and the communityhas the potential to be much engaged, althoughmore attention is required for breastfeeding sup-port. An outpatient community-based treatmentapproach with an emphasis on breastfeedingshould be considered going forwards.

Efficacy of F-100, diluted F-100, and infant formulafor treatment of infants under six months withsevere acute malnutrition

Adouble-blind randomised clinical trialwas conducted between March 2012and January 2015 to assess the efficacyand safety of F-100, diluted F-100 (F-

100D), and infant formula (IF) for dietary man-agement in the rehabilitation phase of the man-agement of severe acute malnutrition (SAM) ofinfants under six months of age. Infants (n =153) were enrolled at the Nutrition RehabilitationUnit of Dhaka Hospital of the InternationalCentre for Diarrhoeal Disease Research,Bangladesh (icddr,b) in Dhaka and were randomlyassigned to any of the three diets aer stabilisation.

1 Islam, M.M., Huq, S., Hossain, M.I. et al. Eur J Nutr (2019). https://doi.org/10.1007/s00394-019-02067-5

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3.1 g/kg/d (95% CI 0.6–5.5, P = 0.015). Totalenergy intake from the study diet and breastmilkwas significantly higher in infants fed F-100 com-pared with the other two diets (P = 0.001 in eachcase). RSL was highest in infants fed F-100, butserum sodium showed no sign of elevation.Urinary specific gravity and serum sodium valueswere within normal range. Controversy aboutfeeding F-100 has concerned its renal solute loadand the possible risk of negative water balanceand hypernatraemic dehydration. As expected,the estimated renal solute load was lower thanthe potential renal solute load in all three groupsas solutes were being deposited in tissue growth.e authors conclude that F-100 can be safelyused in the rehabilitation phase for infants undersix months of age with SAM and there is no needto prepare alternative formulations.

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Two ml blood was collected on study days 1, 3,and 7 for measuring serum electrolytes, creatinineand osmolality, urine samples for specific gravityand osmolality creatinine ratio. Renal solute load(RSL) and potential RSL were calculated. Infantswere discharged when they had gained 15% oftheir admission body weight or had oedema-free weight-for-length z-score (WLZ) ≥ − 2.

Results showed that infants fed F-100 and F-100D had higher weight gain than infants whoreceived IF. e mean difference between F-100and IF was 4.6 g/kg/d (95% CI 1.5–7.6, P = 0.004).e mean difference between F-100D and IF was

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Women’s empowerment, food security andnutrition of pastoral communities in Tanzania

animal products for household food se-curity and nutrition.

A mixed-methods study examined therelationship between women’s empower-ment, household food security, and ma-ternal and child dietary diversity in pastoralcommunities in two regions of Tanzaniato understand effective pathways to en-hance maternal and child nutrition. Aquantitative survey of 373 pastoralistwomen was undertaken; indicators acrossthree domains of women’s empowerment(access to and control over resources,control and use of income, and extentand control of work time) were scoredand matched to a household food-inse-curity access scale. Qualitative surveyswere undertaken with two subsets of 176and 62 semi-sedentary, extensive pastoralistwomen to understand the gender dynamicsaffecting the women’s empowerment-foodsecurity and women’s empowerment-nu-trition security nexus.

Both methodologies showed a positivecorrelation between women’s empower-ment, their dietary diversity and that oftheir children, and therefore their nutrition

1 Galiè, A., Teufel, N., Webb Girard, A., Baltenweck, I., Dominguez-Salas, P., Price, M.J., Jones, R., Lukuyu, B.,Korir,L., Raskind, I.G. Smith, K., Yount, K.M. (2019) Women’s empowerment, food security and nutrition of pastoral communities in Tanzania. Global Food Security 23 (2019) 125–134

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A woman harvesting beans from herfarm, Dodoma region, Tanzania)

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security. Only the qualitative surveys in-dicated a positive relationship betweenwomen’s empowerment and householdfood security. A customary distinctionof gender roles was revealed betweenmen as guarantors of household food se-curity and women as in charge of nutritionsecurity; women’s perception is that thisdistinction is detrimental to achievingnutrition security. is may explain thediscrepancy in quantitative and qualitativeresults. More qualitative research is neededto understand the complex links in seden-tarising communities between women’sempowerment and food security and nu-trition, as affected by the interplay of newlivelihood arrangements, social and gendernorms and household relations, as wellas individual characteristics. e authorssuggest the adoption of an empower-ment-nutrition framework that includesnon-economic domains of empowermentand control over purchasing, sales andpreparation of animal-source food prod-ucts. Dairy projects could combine tech-nology and institutional interventions atdifferent stages to enhance women’s em-powerment and opportunities should beconsidered to enhance gender equity inrapidly sedentarising communities.

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Research Snapshots

Alternative ready-to-use therapeutic food yields less recovery than thestandard for treating acute malnutrition in children from Ghana

Only 20% of children with severeacute malnutrition (SAM) have ac-cess to ready-to-use therapeuticfood (RUTF), the cost of which

limits its accessibility. is randomised, dou-ble-blind controlled, clinical-equivalence trialcompared the effectiveness of an alternativeRUTF with standard RUTF in the home-basedtreatment of children aged 6 to 59 months withuncomplicated SAM and moderate acute mal-nutrition (MAM) in Ghana. Study participantswere recruited at 29 clinics throughout five dis-tricts in the Brong Ahafo region. AlternativeRUTF was composed of whey protein, soybeans,peanuts, sorghum, milk, sugar and vegetableoil. Standard RUTF included peanuts, milk,sugar and vegetable oil.

Analysis, conducted on an intention-to-treatbasis, revealed that of the 1,270 children treatedfor SAM or MAM, 516 of 642 (80%) receivingalternative RUTF recovered (95% CI=77% to83%) and 554 of 628 (88%) receiving standardRUTF recovered (95% confidence interval[CI]=85% to 90%). e difference in recovery

was significant at 7.7% (95% CI=3.7% to 11.7%;p=<0.001). Among the 401 children with SAM,the recovery rate was 130 of 199 (65%) with al-ternative RUTF and 156 of 202 (77%) with stan-dard RUTF (P=.01). e default rate in SAMwas 60 of 199 (30%) for alternative RUTF and41 of 202 (20%) for standard RUTF (P=0.04).Children enrolled with SAM who received al-ternative RUTF had less daily weight gain thanthose fed standard RUTF (2.4 ± 2.4 g/kg vs. 2.9± 2.6 g/kg, respectively; P<.005). Among childrenwith moderate wasting, recovery rates werelower for alternative RUTF, 386 of 443 (87%),than standard RUTF, 397 of 426 (93%) (P=0.003).e lower-cost alternative RUTF was less effectivethan standard RUTF in the treatment of SAMand MAM. Higher energy, protein and fat contentin standard RUTF and/or food intolerance toor bioactive metabolites in the alternative RUTFmay be contributing factors but, importantly,most failures in the trial were the result of de-faulting and the definitive outcomes of thosecases are unknown. e authors recommendcaution and further testing before any alternativeRUTF is used in an operational setting.

1 Kohlmann K, Callaghan-Gillespie M, Gauglitz JM, Steiner-Asiedu M, Saalia K, Edwards C, Manary MJ. Alternative ready-to-use therapeutic food yields less recovery than the standard for treating acute malnutrition in children from Ghana. Global Health: Science and Practice 2019. www.ghspjournal.org

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A child waiting for her growthmonitoring test in Ghana

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In response to environmental, social and political pressures,many of the world’s 300-600 million pastoralists areshiing to more sedentary livelihood strategies (‘seden-tarisation’), negatively affecting their food security and

maternal and child dietary intake. For example, reducedaccess to common land can reduce the ability of pastoraliststo feed their livestock and therefore threaten their reliance on

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Research Snapshots

Defining, measuring and interpreting theappropriateness of humanitarian assistance

Measuring and reporting the appro-priateness of humanitarian assis-tance is a matter of accountabilityand is critical for the assessment of

impact and value for money. A recent reviewidentified eight methods of assessing humanitarianresponse appropriateness and assessed the keyfeatures and limitations of each. is review ispart of a broader project to enhance the account-ability of humanitarian responses through devel-oping auditing approaches for real-time monitoring.e methods were found to vary considerably intheir definitions of ‘appropriateness’, provide in-sufficient guidance on measurement, be vulnerableto interpretive bias, and frequently report findingsin an ambiguous manner. ey do not allow forassessment of changes in ‘appropriateness’ of agiven response over time, nor comparison betweenresponses. A conceptual framework is proposedbased on the premise that the appropriateness ofa response or intervention is determined by theextent to which it is designed to save lives, alleviatesuffering and maintain human dignity. Figure 1shows the conceptual framework adapted to thehealth and nutrition sector.

e authors define ‘appropriate humanitarianassistance’ as a combination of (i) an intervention/

package of services that addresses objective needsand threats to the health or welfare of crisis-affected populations; (ii) a modality of deliverythat reflects the context, enhances user accept-ability and promotes sustainability where possible;and (iii) having a target beneficiary populationthat is clearly defined, sufficient in size and pri-oritised according to need. is framework in-cludes a specific set of questions relating to the

1 Abdelmagid N, Checchi F, Garry S and Warsame A. Defining, measuring and interpreting the appropriateness of humanitarian assistance. Journal of International Humanitarian Action (2019) 4:14 https://doi.org/10.1186/s41018-019-0062-y

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‘what/how/to whom’ domains of a humanitarianproject or response; a semi-quantitative scorecardto score each of the questions/domains; and abrief narrative contextualisation of the findings.A data-collection tool and operational guidanceare now being developed to test the method in anumber of ongoing health and nutrition responses.e approach is designed for self-assessment byresponse teams for early course-correction andreal-time ongoing evaluation to ultimately enhancegovernance, accountability and transparency inhumanitarian response.

Proposed conceptual framework adapted for the nutrition and healthsector Figure 1

“What”?

What is the potential or actual magnitude of excess

mortality?

What is the response’scontribution to addressing

this excess morbiditymortality?

“How”?Modality of delivery

To what extent does theresponse support the local

health system?

To what extent does theresponse address local barriers to health care?

To what extent does theresponse engage the

affected population and is accountable to it?

To what extent is the response prepared for new

emergencies/suddencontextual changes?

“For whom”?Target population

To what extent is the targetpopulation defined (by

location and size)?

To what extent is the target population prioritised

according to need?

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Analysis of trends in SMART nutrition survey datafrom South Sudan between 2004 and 2016

Despite decades of nutrition and healthinterventions, emergency levels ofglobal acute malnutrition (GAM) per-sist in former Northern Bar el Ghazal

State in South Sudan; the reasons behind the per-sistently high levels have not been explored. isstudy aimed to identify and analyse changes inpatterns of malnutrition and key factors associatedwith malnutrition in South Sudan from 2004 to2016. Anthropometric data collected from childrenunder five years of age through StandardisedMonitoring and Assessment of Relief and Transi-tions (SMART) nutrition surveys from 2004 to2016 were analysed to estimate seasonal differencesin the prevalence of GAM (weight-for-height z-score (WHZ) <-2) and severe acute malnutrition(SAM) (WHZ <-3). Risk factors for GAM wereexplored using data collected in 2014 and 2015.

Results show that, in Aweil West and North,a reduction in GAM was observed betweenSeptember 2004 (21.0%, CI 18.2-23.9) and No-

vember 2009 (16.2%, CI: 13.7-18.9). SAM preva-lence remained largely unchanged, reducing by0.9 percentage points from 3.2% (CI: 1.9-4.4)in 2004 to 2.3% (CI: 1.3-3.4) in 2009. eapparent decline in GAM likely reflects a seasonaldifference, as the five-year overall mean GAMwas 20.4% (SD: 0.403) and 17.5% (SD: 0.380) inpre- and post-harvest seasons respectively.

Data collected in 2014 and 2015 revealedthat prevalence of undernutrition (weight-for-age) and stunting (height-for-age) were higherin males compared to females (p=0.008 andp=0.001 respectively); no significant genderdifferences were found in WHZ or GAM. Im-provements were found in Aweil North in cov-erage of vitamin A supplementation (21.5% in2014 to 57.7% in 2015); coverage of measlesvaccination fell (51.6% to 41.4% during thesame period). High morbidity rates were found,with almost two thirds of children reported assick in the past two weeks (2015); however, theproportion of caregivers seeking treatment forsick children increased from 69% in 2014 to81% in 2015. In multivariable linear regression

1 Hogan et al. (2019) Analysis of trends in SMART Nutrition Survey data from South Sudan between 2004 and 2016. South Sudan Medical Journal 2019; 12(4):124-127

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modelling, not having been sick in the past twoweeks (aOR 0.78, 95% CI 0.61, 0.99, p=0.047)and not having consumed juice (possibly asso-ciated with consumption of unclean water andunhygienic juice preparation) (aOR 0.67, 95%CI 0.45, 0.99, p=0.045) were protective againstGAM aer adjusting for all potential confounders.Data are cross-sectional, so interpretationsshould be made with caution.

is study highlights the impact of instabilityon the nutritional status of a generation, withthe high prevalence of GAM and SAM remainingunchanged since 2004. Results suggest that fo-cusing on care-seeking behaviours and hygienepractices may be beneficial in this population.Results also strongly suggest that the causes ofmalnutrition in this setting should be examinedmore comprehensively and that effective pre-vention programmes are designed that addressthe underlying causes of malnutrition.

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Testing formalnutrition,South Sudan,

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Research SnapshotsHow Ebola virus disease affected nutrition in Sierra Leone: a foodvalue-chain framework to improve future response strategies

In 2014-2016 an outbreak of Ebola virusdisease (EVD) in Sierra Leone resulted in14,124 cases and 3,956 deaths. is quali-tative study sought to understand how the

outbreak impacted the nutrition sector in SierraLeone and to consider a nutrition preparednessand response framework for planning for futureoutbreaks. In-depth interviews were conductedwith key informants (n=21; government stake-holders, United Nations and non-governmentalorganisation staff) and community informants(n=21; EVD survivors, health workers and com-munity leaders) and key themes identified.

Findings show that EVD outbreak effectsand related response strategies contributed todisruptions across the multiple, interconnectedsystems comprising the food value chain foroptimal nutrition in Sierra Leone, similar todisruptions seen in large-scale earthquakes.Direct and indirect effects were experienced onagricultural production and food storage andprocessing, as well as on distribution, transport,trade and retailing. Interviews described theaggregate negative effect of this outbreak onfood security, infant and young child feedingpractices and nutrition. In particular, 21-dayquarantines to restrict population movement

placed additional economic and social burdenson people that contributed to individual andhousehold diet-related challenges. Infants andyoung children were disproportionately affectedthrough impacts on breastfeeding, complemen-tary feeding and caregiving practices; both in-directly by EVD and indirectly through marketdisruption and disease-containment measures.

Food assistance during the response (treat-ment for acute malnutrition and food basketsto improve household food security) was highlyaccepted and sharing was reported. Nutrition-sensitive interventions were not central to theinitial response, despite impact of EVD acrossthe food value chain. Instead, EVD containmentand survival took priority. Culturally appropriatesocial and behavior change communication wasa critical response component for improvinghealth, nutrition and hygiene-related behavioursthrough community engagement.

In preparation for future outbreaks of thismagnitude, a food value-chain approach mayprove useful for policy and planning, includingdeveloping improved guidelines for employingcoordinated, nutrition-specific and nutrition-sensitive approaches to address immediate andunderlying determinants of nutrition.

1 Kodish SR, Bio F, Oemcke R, Conteh J, Beauliere JM, Pyne-Bailey S, et al. (2019) A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone – A food value-chain framework for improving future response strategies. PLoS Negl Trop Dis 13(9):e0007645. https://doi.org/10.1371/journal.pntd.0007645

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Ebola virus disease and breastfeeding: time for attention

Over 2,800 cases of Ebola virus dis-ease (EVD) have been confirmedin the ongoing outbreak in theDemocratic Republic of Congo

(DRC); most cases are adults and 56% ofcases are women. Ample information is avail-able on the presence of EVD in bodily fluidssuch as blood, urine, and semen, and on theprevention of transmission from these fluids.However, information on EVD and breastmilkis limited. e current recommendation oftesting breastmilk only in mothers who areknown EVD survivors might be insufficient,because asymptomatic lactating mothers inhouseholds affected by EVD have also beenshown to have Ebola virus-positive breastmilk.In DRC, current guidance on breastfeedingissued by the Ministry of Health and supportedby the United Nations Children's Fund rec-ommends that, in EVD-affected households,mothers and infants who have symptoms butare Ebola virus blood-negative should continuebreastfeeding.

e authors of this correspondence areconcerned about these guidelines, because

Ebola virus blood negativity does not neces-sarily equal safe breastmilk. Health practitionersand policy-makers are in desperate need ofmore information on EVD and breastmilk.Systematic research is needed on EVD ap-pearance and duration in breastmilk; trans-missibility through breastmilk, taking intoaccount the effect of factors such as infantsaliva on the virus; and the provision of evi-dence-based advice for asymptomatic lactatingmothers in EVD-affected households. erepercussions of a lack of clarity on thesequestions are potentially enormous for DRC.If breastfeeding is wrongly discouraged, yearsof public health efforts to promote breastfeedingcould be lost. Conversely, if breastfeeding iswrongly encouraged, many infants could beput at risk. e authors conclude that it istime to give as much attention to Ebola virusin breastmilk as we do in semen.

1 Ververs, M. and Arya, A. (2019) Ebola virus disease and breastfeeding: time for attention. Correspondence. The Lancet, published online: August 27, 2019 http://dx.doi.org/10.1016/S0140-6736(19)32005-7

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General Food Distribution toquarantined households inPort Loko, Sierra Leone, 2015

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Democratic Republic of the Congo (DRC),Tanganyika province, May 2018

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Impact of reduced dose of ready-to-use therapeutic foods in children withuncomplicated severe acute malnutrition in Burkina Faso

Arandomised non-inferiority trial wasundertaken to investigate the efficacyof a reduced ready-to-use therapeuticfood (RUTF) dose in community-

based treatment of uncomplicated severe acutemalnutrition (SAM) in Burkina Faso. BetweenOctober 2016 and July 2018, 801 children aged6–59 months with uncomplicated SAM wereenrolled from 10 community health centres andrandomly assigned into one of two study arms:(a) a standard RUTF dose for two weeks, followedby a reduced dose thereaer (reduced); or (b) astandard RUTF dose throughout the treatment(standard). e mean weight gain velocity from

admission to discharge was 3.4 g/kg/day anddid not differ between study arms (Δ 0.0 g/kg/day;95% CI −0.4 to 0.4; p = 0.92), confirming non-inferiority (p = 0.013). No differences werefound in length of stay or recovery rate betweenarms, nor in mid-upper arm circumference(MUAC) gain velocity. However, aer two weeks,the weight gain velocity was significantly lowerin the reduced dose, with a mean of 2.3 g/kg/daycompared with 2.7 g/kg/day in the standarddose (Δ −0.4 g/kg/day; 95% CI −0.8 to −0.02; p= 0.041). e reduced RUTF dose also led to asmall but significant negative effect, 0.2 mm/week(95% CI 0.04 to 0.4; p = 0.015), on height gain

1 Kangas ST, Salpe´teur C, Nikièma V, Talley L, Ritz C, Friis H, et al.(2019) Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition: A randomised non-inferiority trial in Burkina Faso. PLoS Med 16(8): e1002887. https://doi.org/10.1371/journal.pmed.1002887

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velocity, with a mean height gain of 2.6 mm/weekwith reduced and 2.8 mm/week with standardRUTF dose. e impact was more pronouncedin children under 12 months of age (interaction,p = 0.019). e authors recommend that a re-duced-dose approach is tested in a routine pro-grammatic setting and in different food-securitycontexts before scale-up.

Individualised breastfeeding support foracutely ill, malnourished infants undersix months of age

Re-establishing exclusive breastfeeding(EBF) is the cornerstone of the 2013World Health Organization (WHO)treatment guidelines for the manage-

ment of acute malnutrition in infants under sixmonths old. However, the guidelines are incon-sistently applied, with limited evidence of out-comes in infants both in inpatient and outpatientsettings and on discharge. A recent study assessedthe feasibility of using breastfeeding peer sup-porters (BFPS) to facilitate implementation of2013 WHO guidelines among hospitalised mal-nourished infants under six months old andevaluated the outcomes (EBF, infant growth,morbidity and mortality up to six weeks post-discharge) in Kilifi County Hospital, Kenya.

Between September 2016 and January 2018,three BFPS provided individual breastfeeding

support to mothers of infants aged four weeks tofour months admitted with an illness and acutemalnutrition (mid upper‐arm circumference <11.0 cm OR weight‐for‐age z score (WAZ) < −2OR weight-for‐length z score (WLZ) < ‐2). Infants(n=51) were followed daily while in hospital,then every two weeks for six weeks aer discharge.

Most enrolled mothers had multiple breast-feeding challenges, mainly relating to technique;poor positioning and attachment were observedin 78% and 76% of the mothers, respectively. Sixper cent had no option to breastfeed. Delayedstart to breastfeeding and perceived milk in-sufficiency were reported in 34% of the mothers.Almost half (43%) of the ill, malnourished infantshad a history of small size at birth (low birthweight, premature or small for gestational age)and one third (35%) had a congenital malfor-

1 Mwangome M, Murunga S, Kahindi J, et al. Individualized breastfeeding support for acutely ill, malnourished infants under 6 months old. Matern Child Nutr. 2019; e12868. https://doi.org/10.1111/mcn.12868

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mation affecting feeding. e rate of exclusivebreastfeeding was 55% on admission and 81% atdischarge. At discharge, 67% of infants had at-tained the WHO recommended weight velocityof >5 g/kg/day for three consecutive days onbreastmilk alone. Re-establishing EBF requiredtime beyond medical recovery; extending inpatientadmission to achieve feeding targets risked cross-infection. Gains in WLZ and WAZ were generallynot sustained beyond two weeks aer discharge.

e authors conclude that BFPS operatedeffectively in an inpatient setting and increasedrates of exclusive breastfeeding at discharge.However, lack of sustained anthropometric gainpost-discharge suggests the need for continuedactive intervention. Future studies need toexplore integration of such support under ‘real-life’ health-service conditions and strategies forstructured breastfeeding support on dischargeto improve growth and ensure survival amongrecovering infants.

Research Snapshots

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Conflict of interest in nutrition research

All scientists have an academic conflictof interest (COI) in that the impactof their research, their ability to attractresearch funding, and perhaps keep

their jobs, depend on their having researchsuccess. Most discussion about COI focuses onfunding received from industry. e food industryhas steadily increased its investment in externallytargeted research; academics are drawn to suchfunds as they are less arduous to apply for, oenoffer a greater chance of being funded, and canlead to long-term funding collaborations. All in-dustries work toward their own profit and thefood industry is no exception. As a group ofeditors, the authors reflect on how to progress

the outcomes of industry-funded research thatmay lead to healthy debate within the nutritioncommunity. In their view, a paper with a COIshould be published if it has been internally andexternally peer reviewed and meets the journal’sstandards. When a paper is received with a clearlydeclared COI that has an interesting hypothesisand that addresses an area of current debate orhopes to confirm the clinical benefits of a nutri-tional product (and that passes ethics and writingquality standards), the authors will categorise itas one of the following: (1) financed by industrywith a clear declaration that the industry wasnot involved in the study hypothesis/ design, ex-ecution, analysis or interpretation; (2) sponsored

by industry with a clear declaration that industrywas involved in the above, with industry involve-ment clearly outlined; (3) funded and conductedby industry with no external partners. Papers incategories (1) and (2 ) will need to demonstratethe transparence of industry funding, academicindependence and public access to raw data.Once published, category (1) papers will appearas standard and categories (2) and (3) will appearunder the subject category ‘Industry Research’.is new subject category will signal papers witha strong but declared COI. e reader can thenmake a judgement on the veracity of the findingsand the overall message of that paper.

1 Soares, M.J., Müller, M.J., Boeing, H., Maffeis, C., Misrsa, A., Muscogiuri, G., Muthayya, S., Newsholmes, P., Wolever, T., andZhu, S. (2019). Conflict of interest in nutrition research: aneditorial perspective. European Journal of Clinical Nutrition (2019)73:1213–1215 https://doi.org/10.1038/s41430-019-0488-8

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Association of early interventions with birth outcome and childlinear growth in low-income and middle-income countries

The first 1,000 days of life represent acritical window for child development.Pregnancy and the exclusive breast-feeding (EBF) (0-6 months) and com-

plementary feeding (CF) periods have differentgrowth requirements, so separate considerationsfor intervention strategies are needed. e pur-pose of this study was to determine the associationof interventions with birth and linear growthoutcomes based on randomised clinical trials(RCTs) of interventions under the domains ofnutrition; deworming; maternal education; andwater, sanitation and hygiene (WASH) providedto pregnant women, infants aged 0-6 monthsand children aged 6-24 months conducted inlow and middle-income countries (LMICs) usingBayesian network meta-analyses. Random-effectsmeta-analyses were performed for each lifeperiod and odds ratios were compared onpreterm birth and mean differences on birth

weight for pregnancy, length-for-age (LAZ) forEBF, and height-for-age (HAZ) for CF.

Among 302,061 participants in 169 RCTs,several nutritional interventions were found thatdemonstrated greater association with improvedbirth and growth outcomes compared with stan-dard care. For instance, compared with standardcare, maternal supplements of multiple micronu-trients during EBF showed reduced odds forpreterm birth (OR, 0.54; 95%CrI, 0.27-0.97) andimproved mean birth weight (MeanDiff, 0.08kg; 95%CrI, 0.00-0.17 kg) but not LAZ (MeanDiff,−0.02; 95%CrI, −0.18 to 0.14). Supplementinginfants and children with multiple micronutrientsshowed improved LAZ (MeanDiff, 0.20; 95%CrI,0.03-0.35) and HAZ (MeanDiff, 0.14; 95%CrI,0.02-0.25). Interventions provided to pregnantwomen generally demonstrated greater associa-tions with improved outcomes than interventionsprovided to infants and children at later periods.

1 Park, J.J.H., Lan Fang, M., Harari, O., Dron, L., Siden, E.G., Majzoub, R; Jeziorska, V., Thorlund, K., Mills, E., Bhutta, Z. (2019). Association of Early Interventions With Birth Outcomesand Child Linear Growth in Low-Income and Middle-Income Countries: Bayesian Network Meta-analyses of Randomized Clinical Trials. JAMA Network Open. 2019;2(7):e197871. doi:10.1001/jamanetworkopen.2019.7871

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Findings highlight the importance of inter-vening early to improve birth outcomes andcounter childhood stunting. Findings also revealthat nutritional interventions, micronutrientsand food supplements generally showed greaterassociations with improved outcomes than in-terventions from other domains. Despite thenumerous clinical trials that have already beenconducted, more research targeting less exploredareas, such as maternal education and WASH,appears to be needed. Research is also neededthat combines interventions from multiple do-mains and tests their effectiveness as a package.

Practical pathways to integrate nutrition and water, sanitationand hygiene

Interviews were undertaken in Cambodia,Ethiopia and Madagascar and resultsanalysed alongside research and experienceof multiple agencies to highlight common

entry points for governments and developmentpartners to take integrated action on water, san-itation and hygiene (WASH) nutrition. Resultshighlighted the need to target WASH interventionsto undernutrition hotspots (‘convergence’ or ‘co-

location’); promote the integration of key hygienebehaviours in nutrition interventions; prioritisemothers, newborns and young children as targetsfor WASH interventions; deliver a minimumpackage of health, nutrition and WASH servicesand messaging; strengthen capacity and resourcingof service-delivery platforms and frontline healthworkers; and ensure regular vertical and horizontalcoordination meetings between nutrition stake-

1 WaterAid and Action Against Hunger (2019). Practical pathways to integrate nutrition and water, sanitation and hygiene. Available at washmatters.wateraid.org/practical-pathwaysnutrition-wash

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holders from local to national levels. Seven path-ways to the success of integration efforts areidentified (summarised in Box 1) and illustratedby country examples.

Pathways to success Box 11. Leadership: Secure the highest-level leadership, from the prime minister or president, to drive cross-ministerial coordination and hold line ministries to account for integration of WASH and nutrition.

2. Policies: First, ensure national and regional development plans take a multisector approach to integrating nutrition and WASH interventions, aiming to improve child nutrition. Second, ensure specific policies for nutrition and WASH are coordinated and cross-refer to one another.

3. Financing and strong government systems: Fully finance national WASH and nutrition plans, with clearly defined financing strategies across ministries that support better coordination.

4. Data: Governments and donors must prioritise investments in data systems to enable effective targeting and prioritisation, and reliable monitoring.

5. Sub-national coordination: Replicate strong national coordination mechanisms at sub-national level, ensuring 360-degree accountability.

6. Knowledge sharing: Local authorities, civil society organisations, non- governmental organisations and donors should prioritise documenting and sharing knowledge and experience from integrated WASH-nutrition projects to support governments to adopt and scale up models that work.

7. Accountability: Ensure transparency and accountability: this is key to driving multisector approaches.

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The WASH benefits and SHINE trials: interpretation of WASHintervention effects on linear growth and diarrhoea

Globally, stunting is the most prevalentform of child undernutrition and isonly modestly responsive to dietaryinterventions. Numerous observa-

tional studies have shown that water quality,sanitation, and handwashing (WASH) in a house-hold are strongly associated with linear growthof children living in the same household, whichmay be partially mediated through diarrhoea,but primarily through environmental entericdysfunction. ree randomised efficacy trials(SHINE) were undertaken to test improvedhousehold-level WASH with and without im-proved infant and young child feeding (IYCF)on child stunting and diarrhoea in Bangladesh,Kenya, and Zimbabwe. SHINE was a two-by-two factorial trial with four groups: IYCF (coun-selling on complementary feeding and provisionof small-quantity, lipid-paste-nutrient supple-ment); WASH (combined sanitation, water chlo-

rination and handwashing with soap); IYCFcombined with WASH; and standard care. In alltrials, the IYCF intervention modestly but sig-nificantly increased mean length-for-age (LAZ)by 0.13-0.25 (about one eighth of the deficit ofthe average child aged 18-24 months). A significantrelative reduction in diarrhoea of 31-40% wasobserved in the water-chlorination interventionunder WASH Bangladesh only. In all three trials,the WASH interventions had no effect on lineargrowth, and providing WASH concurrently withIYCF had no additional benefit on linear growthcompared with providing IYCF alone.

ese findings are inconsistent with existingand oen-cited observational evidence. Furtheranalysis suggests baseline sanitation was a strongrisk for stunting. However, the relationship be-tween household WASH indicators and childlinear growth may be confounded. e effecton diarrhoea in Bangladesh is likely due to the

1 Pickering, A.J., Null, C., Winch, P.J., Mangwadu, G., Arnold, B.F.,Prendergast, A.J. et al (2019) The WASH benefits and SHINEtrials: interpretation of WASH intervention effects on lineargrowth and diarrhoea. Lancet Glob Health 2019; 7: e1139–46

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regular visits to participating household (sixtimes per month), compared to monthly inKenya and Zimbabwe. Such intense contact isnot possible at scale. e authors conclude thatthese trials were not effective enough in reducingthe faecal-oral transmission of pathogens toresult in linear growth and optimal health, withchildren having high rates of enteric infection.Future research should explore interventionsthat are radically more effective in reducingfaecal contamination in the domestic environment(‘transformative WASH’) and, irrespective ofintervention, strengthened support is requiredfor governance systems of financing, operations,monitoring, evaluation, and regulation.

Soya, maize and sorghum-based ready-to-usetherapeutic food with amino acid for treatmentof severe acute malnutrition

Development of more cost-effectiveready-to-use therapeutic food(RUTF) for the treatment of severeacute malnutrition (SAM) is a global

public-health priority. To date, previous lower-cost recipes have been less effective than thestandard peanut and milk (PM)-based RUTF,particularly in children aged less than 24 months.is study aimed to compare the efficacy of thePM-RUTF to a milk-free soya, maize, andsorghum (FSMS) RUTF enriched with crystallineamino acids without cow milk powder, and amilk, soya, maize and sorghum (MSMS) RUTFcontaining 9.3% skim cow milk powder, bothof which provide a substantially lower cost al-ternative. A non-blinded, three-arm, parallel

group, simple randomised controlled trial wasundertaken in 21 clusters of three health districtsin central Malawi. Between September 2015and June 2016, a total of 22,790 children werescreened. Of these, 2,277 were diagnosed withSAM and 1,347 randomly assigned to either theFSMS-RUTF (n=454), the MSM-RUTF (n=435),or the PM-RUTF (n=458) study groups. Another48 children were excluded from the study aerrandomisation (because consent was withdrawnor medical complications became apparent),aer which 1,299 were finally included (795aged 6-23 months and 504 aged 24-59 months).ose children with SAM who did not meetstudy criteria2 received routine treatment frompre-existing outpatient therapeutic services.

1 Bahwere, P., Akomo, P., Mwale, M., Murakami, H., Banda, C., Kathumba, S., Banda, Chimwemwe., Jere, S., Sadler, K. and Collins, S. (2017). Soya, maize, and sorghum-based ready-to-use therapeutic food with amino acid is as efficacious as the standard milk and peanut paste-based formulation for the treatment of severe acute malnutrition in children: a non- inferiority individually randomized controlled efficacy clinicaltrial in Malawi. Am J Clin Nutr 2017;106:1100–12.

2 Based on home distance, age >59 months, mother pregnant,weight-for-height <-3 but MUAC ≥115mm and others.

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In intention-to-treat analyses, FSMS-RUTFshowed noninferiority for recovery rates inchildren aged 24-59 months (Δ: 21.9%; 95%CI: 29.5%, 5.6%) and 6-23 months (Δ: 20.2%;95% CI: 27.5%, 7.1%) compared with PM-RUTF. MSMS-RUTF also showed noninferiorityfor recovery rates in children aged 24-59 months(Δ: 0.0%; 95% CI: 27.3%, 7.4%) and 6-23 months(Δ: 0.6%; 95% CI: 24.3%, 5.5%). Noninferiorityin recovery rates was also observed in per-pro-tocol analyses. For length of stay in the pro-gramme (time to cure), both FSMS-RUTF inchildren aged 24-59 months (Δ: 2.8 d; 95% CI:20.8, 6.5 d) and 6-23 months (Δ: 3.4 d; 95% CI:21.2, 8.0 d) and MSMS-RUTF in children aged24-59 months (Δ: 0.2 d; 95% CI: 23.1, 3.6 d)and 6-23 months (Δ: 1.2 d; 95% CI: 23.4, 5.8 d)were not inferior to PM-RUTF. FSMS-RUTFwas also significantly better than PM-RUTF atincreasing haemoglobin and body iron storesin anaemic children, with mean haemoglobinincreases of 2.1 (95% CI:1.6, 2.6) and 1.3 (95%CI: 0.9, 1.8) and mean body iron store increasesof 2.0 (95% CI: 0.8, 3.3) and 0.1 (95% CI: 21.1,1.3) for FSMS-RUTF and PM-RUTF, respectively.e authors conclude that FSMS-RUTF withoutmilk is efficacious in the treatment of SAM inchildren aged 6-23 and 24-59 months and isbetter at correcting iron deficiency anaemiathan PM-RUTF.

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Understanding how Rwanda created anenabling environment for improvementsin nutrition

Rwanda has made substantial progressin reducing malnutrition, with reduc-tions in stunting and anaemia of 14and 15 percentage points respectively

between 2005 and 2015. However, stunting re-duction has been uneven across the country andprevalence remains very high at 38%. To facilitatefurther progress, a ‘stories of change’ study wasconducted to identify drivers of stunting andanaemia reduction and potential barriers andfacilitators to future progress in Rwanda. Quali-tative methods included semi-structured inter-views with 90 key stakeholders in nutrition, and40 focus-group discussions with communitymembers in five districts that experienced re-duction in stunting and five that did not. Quan-titative data from Demographic and Health Sur-veys (2005, 2010 and 2015) were also analysed.

Key drivers of change based on the qualitativedata were: leadership, peace and security anddecentralisation of government; political com-mitment to nutrition and multi-sector program-ming, facilitated by national policy (in particular

the National Food and Nutrition Policy 2013-2018) and nutrition coordination mechanisms;and increased provision of community-level,nutrition-related services and programmes, es-pecially in health and agriculture (e.g. nutritioncounselling, antenatal care, kitchen-garden pro-grammes). Quantitative data revealed that factorsthat contributed most to reduced stunting wererelated to maternal health, including quality ofprenatal visits; proportion of women giving birthat a health facility; and the number of children awoman had. Household wealth, parental educationand insurance coverage were also important.

Districts without reduced stunting had weakerhorizontal and vertical coherence of policy andprogramming; less robust, multi-sector and in-tegrated monitoring and evaluation for nutrition;and decreased food availability at communitylevel. For further improvements, Rwanda mustkeep up the momentum of positive change andfurther strengthen existing plans, systems andapproaches. Remaining challenges must also beaddressed, including those around financial

1 Iruhiriye, Elyse; Olney, Deanna K.; Ramani, Gayathri V.; Heckert, Jessica; Niyongira, Emmanuel; and Frongillo, Edward A. 2019. Stories of Change: Rwanda: Understanding how Rwanda created an enabling environment for improvements in nutrition and the challenges that remain. Stories of Change Rwanda Program Brief 1. Washington, DC: International Food Policy Research Institute (IFPRI). https://doi.org/10.2499/p15738coll2.133378

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constraints; gaps in policy; institutional, hori-zontal and vertical coherence and monitoringand evaluation for nutrition; and community-level issues such as poverty, food security, genderrelations and health, nutrition, and water, sani-tation and hygiene practices.

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Soya, maize and sorghum ready-to-use therapeutic foods (RUTF)are more effective in correcting anaemia and iron deficiencythan standard RUTF

The prevalence of anaemia and iron de-ficiency (ID) among children with severeacute malnutrition (SAM) and theircorrection during nutritional rehabili-

tation are not well documented. A randomisedcontrolled trial was undertaken in central Malawiamong children with SAM age 6-59 months(n=389) to assess anaemia and ID prevalence andtheir predictors at the start of SAM treatment,and the efficacy of their treatment and effect ongut health of two novel ready-to-use therapeuticfoods (RUTF) prepared from soybean, maize and

sorghum (SMS) with (MSMS-RUTF) or withoutadded milk (FSMS-RUTF) compared to those ofthe standard formulation prepared from peanutand milk (PM-RUTF). All the RUTFs were de-signed to meet the World Health Organisation(WHO) recommendations for RUTF mineral andvitamin levels with the exception of iron and zinc.Iron, zinc and vitamin C levels in FSMS-RUTFand MSMS-RUTF were increased to attain aphytic acid / iron molar ratio, ascorbic acid / ironweight ratio and zinc / iron weight ratio of < 2.5,3.0– 16.0 and 0.8–3.5, respectively to enhanceiron and zinc absorption.

A total of 386 children were surveyed on ad-mission (227 of whom were under 24 monthsof age and 165 over 24 months); 266 of whomwere also assessed at discharge. At admission,the prevalence (%(95%CI)) of anaemia was48.9(41.4–56.5)%, while that of ID and IDAwere 55.7(48.6–62.5)% and 34.3(28.2–41.0)%when using soluble transferrin receptor (sTfR)criterion and 29.1(24.4–34.4)% and 28.9(23.7–34.9)% when using body iron stores (BIS) crite-rion, respectively. Results, presented in Table 1,show a linear trend in the prevalence of anaemiaand iron-deficiency anaemia related to the milkcontent of the RUTF, with the prevalence lowest

1 Akomo, P., Bahwere, P., Murakami, H., Banda, C., Maganga, E., Kathumba, S., Sadler, K. and Collins, C. (2019) Soya, maize and sorghum ready-to-use therapeutic foods are more effective in correcting anaemia and iron deficiency than the standard ready-to-use therapeutic food: randomized controlled trial. BMC Public Health 19:806

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in the FSMS-RUTF and highest in the PM-RUTF. is trend was seen in both those withand without anaemia at admission. A similartrend was observed when comparing haemo-globin change between admission and discharge.SMS-RUTF was also associated with the highestincrease in BIS among the iron-depleted at ad-mission (6.2mg/kg (3.7-8.6) for FSMS-RUTF;3.2mg/kg (0.8-5.6) for MSMS-RUTF; and2.2mg/kg (0.2-4.3) for PM-RUTF) (p=0.045).Compared to PM-RUTF, FSMS-RUTF had thehighest adjusted recovery rate (OR (95%CI) =0.3 (0.2–0.5) with p < 0.001 for FSMS-RUTFand 0.6 (0.3–1.0) with p = 0.068 for MSMS-RUTF). No effect of iron content on risk of ironoverload or gut inflammation was observed.is study found that anaemia including IDA iscommon among children with SAM. e authorsconclude that FSMS-RUTF with a higher levelof iron and no cows milk is more efficacious intreating anaemia and correcting BIS in thisgroup of children than standard RUTF.

N %(95%CI) p-value

Prevalence of anaemia at discharge

FSMS-RUTF 83 12.0(6.9-20.3) p=0.023

MSMS-RUTF 77 18.2(11.9-26.8)

PM-RUTF 106 24.5(15.8-35.9)

Prevalence of IDA at dischargeFSMS-RUTF 63 7.9(3.4-17.3) p=0.028

MSMS-RUTF 46 10.9(4.8-22.6)

PM-RUTF 83 20.5(10.7-35.5)

Table 1 Prevalence of anaemia andiron deficiency anaemia(IDA) on discharge (n=266)*

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By Alice Burrell

Alice Burrell is a public healthnutritionist with five years ofexperience working in thenutrition sector in multiplecountries, mainly on infantand young child feeding in

emergency (IYCF-E) programming. Alicepreviously worked for Save the Children’shumanitarian response team as a nutritionadvisor, where she worked in the Rohingyaresponse. She now works with GOAL as the‘management of at risk mothers and infantsunder six months’ (MAMI) advisor.

The author would like to acknowledge the Savethe Children Bangladesh nutrition team,especially those working on the Rohingyaresponse for their dedication and hard work indelivering the support discussed in this article.She would like to thank the IYCF technicalworking group in Cox’s Bazaar for advocating forbetter support for infants and initiating importantrelated initiatives and discussions. The authoralso wishes to thank Caroline Wilkinson, UnitedNations High Commission for Refugees (UNHCR)for her review of this article and AlessandroIellamo, IYCF Advisor at Save the Children UK, forhis technical guidance and support.

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

Location: Bangladesh What we know: Non-breastfed infants require timely identification, protectionand support in emergencies.

What this article adds: A 2017 SMART survey of refugee camps in Cox’s Bazaarrevealed low levels of exclusive breastfeeding in infants under six months, with1.4 – 2.3% never having been breastfed. Save the Children International (SCI)efforts to support non-breastfed infants through wet nursing and relactation(including piloting home-based supplementary suckling support for two infants)as part of a comprehensive package of infant and young child feeding inemergency interventions were challenged by a lack of relevant operationalguidance, capacity and practical limitations. For those who chose to or had toadopt artificial feeding as a last resort, a safe, sustained supply of breastmilksubstitutes (BMS) in line with international recommendations was not available;SCI and United Nations High Commission for Refugees (UNHCR) proposals toaddress this were not validated by the Nutrition Sector. SCI reduced risks toaffected infants through provision of safer BMS kits, counselling and close followup. Interim operational guidance on the management of non-breastfed infantshas been developed by SCI, UNHCR and UNICEF for the Rohingya responsebut is not yet endorsed by government; there is still no safe BMS programmingfor the population. Guidance, tools, capacity, resources and mechanisms for thesafe supply of BMS and effective support for wet nursing and re-lactation inemergencies are urgently needed to translate international recommendationsinto practice to support this vulnerable group.

BackgroundRecommended infant and young child feeding(IYCF) practices greatly benefit the health ofchildren and their mothers. Breastfeedingcould save the lives of an estimated 823,000children under five years and 20,000 womenannually (Victora et al, 2016). In emergencies,disrupted access to healthcare; food; water,sanitation and hygiene (WASH) facilities anda lack of privacy to breastfeed can compromiseIYCF practices. Additionally, heightened stresslevels, traumatic experiences, disrupted supportnetworks and increased time required fordaily tasks can negatively impact mothers’mental health, care and breastfeeding practices.Sub-optimal IYCF practices put young childrenat risk of acute malnutrition, stunting and

micronutrient deficiencies, with the youngestbeing the most vulnerable. erefore, pro-tecting, promoting and supporting recom-mended IYCF practices and minimising as-sociated risks around feeding and care arecrucial to child survival, nutrition and devel-opment in emergency contexts.

IYCF interventions in both emergency anddevelopment settings should align with keypolicy guidance, such as the Global Strategyfor Infant and Young Child Feeding (WHOand UNICEF, 2003); the International Codeof Marketing of Breastmilk Substitutes (WHO,1981) and subsequent relevant World HealthAssembly (WHA) Resolutions (“the Code”);and the Operational Guidance on IYCF in

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Mothers gather at a Mother Baby Area for IYCFsupport, Cox's Bazar, Bangladesh, 2019

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Emergencies (OG-IFE), endorsed by the WHA(IFE Core Group, 2017). ese documents pro-vide key guidance and recommendations aroundthe support, promotion and protection of IYCFfor all children and their mothers.

Recent emergencies, such as the Syrian crisis(Mboya, 2014) and European migrant crisis(Modigell, Fernandes and Gayford, 2016) havehighlighted the needs of non-breastfed infantsin emergencies. e World Health Organization(WHO)/UNICEF Global Strategy for Infant andYoung Child Feeding emphasises that not beingbreastfeed for the first six months of life is arisk factor for malnutrition, illness and mortality.In emergencies, non-breastfed infants requiretimely identification and specialised support.e OG-IFE reaffirms this principle, highlightingmandated United Nations (UN) roles (UNICEF/UNHCR) for the protection and support ofnon-breastfed infants, including ensuring ap-propriate supplies of breastmilk substitutes(BMS) and associated support services. At anagency level, this is reflected in UNICEF’s CoreCommitment to Children in Humanitarian Ac-tion (2010)1 and Standard Operating Procedures(SOPs) on the handling of breastmilk substitutes,developed by both UNHCR (2015) and UNICEF(2018, updated pending 2019).

e Rohingya response saw significant chal-lenges and shortfalls in the protection andsupport of non-breastfed infants, which arecritical to examine and address and are sharedin this article.

The Rohingya crisisIn August 2017, intense violence in RakhineState Myanmar led Rohingya people to flee toneighbouring Bangladesh. As of 12 December2018, 908,000 Rohingya people were residingin makeshi settlements and camps in Cox’sBazar, Bangladesh. Over 700,000 of these hadarrived since the 25 August 2017 (IOM, 2018).e population was and remains highly de-pendent on humanitarian aid and, due to expo-sure to traumatic events, many remain in needof medical and mental health/psychosocial sup-port. e potential outbreak of contagious dis-eases given the low health status of the population,severely crowded conditions in the settlements,and poor water and sanitation are serious con-cerns. e estimated proportion of childrenunder five years and pregnant and lactatingwomen (PLW) is 29% and 10% respectively. Asof October 30 2017 there was an estimated totalof 8,129 infants less than six months old amongthose displaced (RRRC-UNHCR, 2017).

Nutrition coordinatione humanitarian response is led and coordinatedby the Government of Bangladesh. Followingthe influx, the Refugee Relief and RepatriationCommissioner (RRRC), under the Ministry ofDisaster Management and Relief (MDMR), wasmandated to provide operational coordinationfor all refugees/Forcibly Displaced MyanmarNationals (FDMNs).2 For humanitarian agencies,strategic guidance and national-level governmentengagement is provided by the Strategic Executive

Group (SEG) in Dhaka, co-chaired by the ResidentCoordinator, International Organisation for Mi-gration (IOM) and UNHCR. At district level,the Senior Coordinator leads the Inter-SectorCoordination Group (ISCG), composed of the-matic Sector and Working Group Coordinatorsrepresenting the humanitarian community.

e nutrition response in Cox’s Bazar is ledby the Nutrition Sector, chaired by the Ministryof Health and Family Welfare (MoHFW) in col-laboration with UNICEF. e response plan fo-cused on treatment and prevention of acutemalnutrition with specific interventions includingcommunity-based management of acute mal-nutrition (CMAM) for children aged 6-59 monthsand PLW, IYCF in emergencies (IYCF-E)3 in-cluding one-to-one and group counselling andcommunity-based management of at risk mothersand infants under six months old (C-MAMI).4

Assessment of needResults of SMART surveys in October and No-vember 2017 in Kutupalong, Makeshi andNayapara camps raised serious concerns. Preva-lence of global acute malnutrition (GAM) wasfound to be at crisis levels at 24.3%, 19.3% and14.3% respectively, with severe acute malnutrition(SAM) prevalence at 7.5%, 3.0% and 1.3% re-spectively (AAH, 2017). Results also showedworrying IYCF practices with 17.9%, 43.9% and27.8% of infants under six months old in the re-spective camps not exclusively breastfed andbetween 1.4% and 2.3% of children aged 0-23months across all camps never breastfed (an es-timated total of 167 infants). In addition, a verylow proportion of children aged 6-23 monthswere receiving a minimum acceptable diet(MAD) (8.8%, 6.4%, and 15.7% respectively).

Follow up SMART surveys conducted in Apriland May 2018 indicated a marked improvementin GAM in Makeshi camp from 19.3% to 12.0%,with less improvement in Nayapara camp from14.3% to 13.6% (AAH, 2018). e survey wasnot repeated in Kutupalong camp. However, IYCFpractices showed no improvement; in Makeshicamp the proportion of non-breastfed infants

1 https://www.unicef.org/publications/files/CCC_042010.pdf2 The Government of Bangladesh refers to the Rohingya as

“Forcibly Displaced Myanmar Nationals” (FDMN). The UN system refers to this population as ”Rohingya refugees” in line with the applicable international framework for protection and solutions, as well as the resulting accountabilities for the countries of origin and asylum in addition to the international community as a whole. These terms refer to the same population.

3 IYCF focuses on improving practices, whereas IYCF-E focuseson doing no harm, minimising risks and protecting practices, and may require artificial feeding support that is not usually a component of routine IYCF programmes.

4 C-MAMI is an approach to identify and manage at risk mothers and infants under six months in the community who are nutritionally vulnerable. The C-MAMI Tool can be accessed at https://www.ennonline.net/c-mami

5 The community based management of at risk mothers and infants under six months (C-MAMI) tool was developed to inform case management of this age group. www.ennonline.net/c-mami

Household counselling session onhygiene of the Supplementary

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increased from 1.4% to 3.4% and exclusive breast-feeding reduced from 56.1% to 50.0%. When ap-plied to population numbers, this indicates a sig-nificant number of children needing identification,management and support. In addition to thoseinfants never breastfed, there were likely additionalinfants under six months whose caregivers hadstopped breastfeeding prior to six months; thesenon-breastfed infants are not captured in thesurvey results.

Save the Children’s nutritionresponseSave the Children (SCI) nutrition response in-volved establishing Nutrition Centres with anOutpatient erapeutic Feeding Programme(OTP) for acutely malnourished children aged6-59 months and Mother Baby Areas (MBAs)for IYCF-E support; IYCF-E corners in targetedSupplementary Feeding Programmes (TSFPs)and Blanket Supplementary Feeding Programmes(BSFPs); and piloting the C-MAMI tool5 to caterfor infants aged less than six months at nutritionalrisk in select sites. SCI also responded with in-terventions in health; education; child protection;WASH; shelter; food security and livelihoods.

IYCF-E responseSCI was a key agency in the IYCF-E response,leading implementation of the IYCF Framework

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Field Article

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with UNHCR6 to support multiple sectors tocreate an infant and young child friendly envi-ronment and facilitate optimal IYCF in thisemergency.

SCI also led the development of the initialIYCF- E response plan and supported all NutritionSector IYCF-E initiatives, including coordinationand technical leadership and chairing the IYCFtechnical working group (TWG) for an assignedperiod. SCI led a quality-monitoring initiative,providing IYCF-E supervisors to the collectiveto facilitate supportive supervision, training andother capacity building initiatives. SCI also sup-ported the Nutrition Sector to ensure that allstakeholders considered IYCF-E and prioritisedthe needs of infants and young children acrossthe response.

SCI established Mother Baby Areas (MBAs)with trained IYCF-E counsellors to provideIYCF-E assessment, counselling and group ses-sions and a private space to breastfeed. Supportfor non-breastfed infants was provided on aone-to-one basis, usually at the household level,given the relatively low caseload and sensitivitiesaround the demonstration of the safe preparationof infant formula. MBAs were established withinNutrition Centres, which also housed OTPsand, in some locations, a C-MAMI programme(Kueter et al, 2018). Nutrition centres werelocated next to SCIs health clinics where possibleto facilitate easy referrals and linkages betweenthe various services.

IYCF-E supervisors and counsellors were re-cruited locally and trained on IYCF-E counsellingover two days, including on wet nursing, relacta-tion, cup feeding and risks of formula use (withsupervisors given an additional day’s training onMBAs and supervision). On-the-job coachingon counselling for BMS use was provided ascases arose, rather than through formal training,due to sensitivities around the topic. IYCF-Ecounsellors conducted rapid IYCF assessmentsfor all identified caregivers with children undertwo years old; if a feeding issue was identifiedthey then conducted a full IYCF assessment anddeveloped a counselling care plan. Caregivers ofchildren under two years old were mainly identifiedthrough community outreach activities by SCI’scounsellors and community mobilisers. Healthand nutrition facilities and protection teams alsoreferred caregivers of children under two yearsold with feeding difficulties to the MBA.

Challenges managing non-breastfed infantsSerious challenges were encountered in themanagement of non-breastfed infants due tolimited guidance on the support of wet nursingand relactation in emergency settings and thelack of agreed and coherent policy and imple-mentation plans on the support of non-breastfedinfants less than six months old with artificialfeeding when wet nursing and relactation werenot feasible.

Wet nursingThere is a paucity of documented experiences

on the support for wet nursing in emergencysituations (Teshome, 2019). Experiences docu-mented by UNHCR in 2008 found wet nursingto be acceptable in the Rohingya population(Sfeir, 2008). Challenges experienced by SCI inthe Rohingya response included identifying wetnurses if unavailable among close relatives; re-location of wet nurses; acceptance by the wetnurse’s family and expectation of incentives;poor access to nutritious and adequate foods forlactating women; practicality of the arrangementsbetween infant carers and wet nurses to supportexclusive breastfeeding; and preference for useof BMS when it was accessible to the family.

RelactationSCI could not source guidance on the opera-tionalisation of relactation relevant for refugeecamps and settlements in Cox’s Bazar. Availableguidelines focused on relactation during inpatientcare (ACF International, 2012), but this wasoen impossible for caregivers in this contextdue to high opportunity costs and multiple chil-dren to care for. Additionally, SCI did notsupport inpatient facilities and MBAs were anunsuitable place to conduct the SupplementarySuckling Technique (SST) due to sensitivitiesaround the use of infant formula and risks ofdiscouraging other caregivers from breastfeeding.Lastly, considering the limited geographicalscope of SCI’s programme and dispersion ofidentified cases of non-breastfed infants (<1%of infants under six months old assessed bySCI, over 10 operational areas, were not breastfed)it was not operationally viable to create a separateestablishment for this purpose within each camp.

Given these considerations, SCI piloted home-based SST support for two infants whose motherswere willing to attempt relactation and where itwas considered the most sustainable, safestoption. Specific challenges that arose in sup-porting these two cases were limited guidanceon reducing the supplement once breastmilkproduction began; maintaining caregiver moti-vation for re-lactation; keeping good hygiene ofequipment within poor household hygiene andenvironment; lack of team capacity to conductregular household support visits; and lack ofhousehold capacity to support SST. It was also

6 www.unhcr.org/publications/operations/5c0643d74/infant-young-child-feeding-refugee-situations-multi-sectoral-framework.html

7 There was an effort to collect an estimate of non-breastfed infants through the IYCF TWG, however agencies experienced challenges in collecting this data from the field teams and some data received was inaccurate and required follow up.

A grandmother is taught how to cup feed her granddaughter afterthe mother passed away after a wet nurse was found but moved

out of the camp, Cox's Bazar, Bangladesh, 2019

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difficult to provide home-based support to re-ferred infants residing in camps where SCI wasnot operational.

BMS programmingMajor challenges were encountered when non-breastfed infants began to be identified and wetnursing and/or relactation was either ineffective,inappropriate or not accepted. Most non-breastfedinfants were detected either by the child protectioncase management team, the UNHCR protectionteam and medical teams in health facilities, orwere among those infants referred by SCI com-munity mobilisers to the C-MAMI site or MBAfor assessment. From the start of the response,SCI engaged the Nutrition Sector and partnersto seek support to initiate a safe BMS supplyprogramme in full compliance with nationallaws, regulations and recommendations. An initialjoint proposal from SCI and UNHCR to providethe necessary support to families and a supply ofBMS and associated materials for the smallnumber of non-breastfed infants identified wasnever validated through the Nutrition Sector.

In Bangladesh, breastfeeding is strongly sup-ported both through cultural practices andofficial legislation, such as the Bangladesh Act2013 and the national IYCF strategy (IPHN,DGHS, MoHFW and GoB, 2007). Current na-tional regulations recognise that a minority ofinfants may need BMS support, but no guidanceand directions are provided on the operational-isation of this support in a humanitarian context.At the same time, the Nutrition Sector’s experienceand capacity needed strengthening in theseareas. ere was also a lack of accurate data onthe caseload of non-breastfed infants,7 whichmade it difficult for agencies responsible todecide if they would financially support thesupply of BMS and accompanying materials forsafer preparation in the context of the response.

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Given these factors, no supply chain for anappropriate BMS for the response (such as pro-viding cash or vouchers to purchase BMS) wasprovided or made available to families of non-breastfed infants for whom BMS was indicated.While SCI had the resources, there was no gov-ernment or UN approval to source infant formulaand the necessary UN supply chain was not es-tablished. When families chose or needed touse BMS as a last resort, SCI reduced risks byproviding a safer BMS kit (thermos flask, prepa-ration utensils, feeding cup, and washing mate-rials); counselling on safe and appropriate typeand use of BMS; close follow up with homevisits; and information to the family on risksassociated with not breastfeeding and usingBMS, especially in an emergency context.

Attempts to address barriers –policy and guidancee situation reveals gaps and barriers frompolicy and regulatory level down to programmelevel that prevent a prompt and effective responseand continues to compromise the protection ofvulnerable infants. Dialogue with partners andauthorities prompted the development and pro-posal of an interim Operational Guidance forthe non-breastfed infant for the Rohingya re-sponse. is process began in December 2017,led by SCI with the support of other partneragencies, including UNICEF and UNHCR, andentailed several rounds of review. Sections wereincluded on identification, referral, management

(including wet-nursing, relactation and BMSprovision and support for safe use) and technicalcapacity building. e guidance was presentedto the IYCF-E TWG for endorsement, the CivilSurgeon of Cox’s Bazar for approval, and theNutrition Sector. Reviewers requested moredetails, data and better clarity of roles and re-sponsibilities. In June 2018, the finalised interimguidance was presented to the national NutritionCluster, presided over by the Institute of PublicHealth within the Ministry of Health. e guid-ance was neither rejected nor approved and, attime of writing, no further progress has beenmade. e Government simultaneously developedand finalised national IYCF-E guidelines forBangladesh, which also remains under review.Both the interim Operational Guidance and na-tional IYCF-E guidance are critical for currentand future responses but are, as yet, unavailable.

Conclusionse experiences documented here highlight afailure to translate global guidance into practice.Concrete guidance and coherent regulations areneeded that allow for timely and safe interventionsto protect, promote and support recommendedand safe IYCF practices for all infants and youngchildren affected by an emergency. However, thecurrent lack of operational guidance for managingthe non-breastfed infant in emergencies with wetnursing or relactation means that humanitarianorganisations do not have essential tools theyneed to manage the most vulnerable infants.

ReferencesACF International (2012) Guidelines for the integratedmanagement of severe acute malnutrition: in- and out-patient treatment.

Action Against Hunger (2017) Emergency NutritionAssessment: Cox’s Bazar, Bangladesh.

Action Against Hunger (2018) Emergency NutritionAssessment Final Report.

IFE Core Group (2017) Operational guidance on infantfeeding in emergencies version 3.0. Available from:www.ennonline.net/operationalguidance-v3-2017

International Organisation for Migration (IOM) (2018)Needs and Population Monitoring (NPM) Site Assessment:Round 9, Cox’s Bazaar.

IPHN; DGHS; MoHFW; GoB (2007) National Strategy forinfant and young child feeding (IYCF). Institute of PublicHealth and Nutrition (IPHN).

Kueter, Anne-Marie; Burrell, Alice; Butler, Sarah; Sarwar,Mostofa; Rahaman, Habibur (2018). Piloting the C-MAMIapproach in the Rohingya response in Bangladesh. FieldExchange issue 51. www.ennonline.net/fex/58/pilotcmamiapproachbangladesh

Mboya, Suzanne (2014) Artificial feeding in emergencies:experiences from the ongoing Syrian crisis. Field Exchangeissue 48. www.ennonline.net/fex/48/artificialfeeding

Modigell, Isabelle; Fernandes, Christine; Gayford, Megan(2016) Save the Children’s IYCF-E Rapid Response inCroatia. Field Exchange issue 52, page 106.www.ennonline.net/fex/52/rapidresponseincroatia

Sfeir, Yara (2008). Wet nursing for refugee orphans inBangladesh. Field Exchange issue 25.

Teshome, S. (2019) A review of wet nursing experiences,motivations, facilitators and barriers. Available from:www.ennonline.net/wetnursingreview

UNHCR (2015) Infant and young child feeding practices:standard operating procedures for the handling ofbreastmilk substitutes (BMS) in refugee situations for children0-23 months. www.ennonline.net/iycfsopbmsrefugee

UNICEF (2018) UNICEF Standard Operating Procedure onthe procurement and use of breastmilk substitutes inhumanitarian settings.UNHCR (2017) RRRC-UNHCR Family Counting Analysis.

Victora, C.G. et al (2016). Breastfeeding in the 21stcentury: epidemiology, mechanisms and lifelong effect.The Lancet 475-490.

WHO & UNICEF (2003). Global Strategy for Infant andYoung Child Feeding. Available from:www.who.int/nutrition/topics/global_strategy/en/

WHO (1981) The International Code of Marketing ofBreastmilk Substitutes and subsequent WHA resolutions(“The Code”).

Household counselling session on the Supplementary SucklingTechnique, Cox’s Bazar refugee camp, Bangladesh, 2018

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While it is important to ensure that allmothers are enabled to breastfeed or thatinfants can receive breastmilk feeding as asafe alternative, there is sometimes a need forthe provision of a BMS, as recognised by in-ternational guidance. Agency and country-level protocols, guidance and tools are neededto ensure that skills, capacity and resourcesare in place at the national level to managethe feeding of these infants as needs arise.

Current systems are inadequate for supportingthe operationalisation of BMS programmes.ere are no clearly defined mechanisms toaccess safe BMS and necessary equipment inthe humanitarian sector and a pipeline for theseproducts does not exist; hence humanitarianagencies have no standardised and systematicway to manage non-breastfed infants for whomBMS is indicated. International leadership byUN agencies is not always aligned from head-quarters to country levels on this issue. Advocacyand sensitisation must therefore continue toensure that national and regional-level officeshave a common understanding and vision ofmandated responsibilities for the managementof non-breastfed infants among the key hu-manitarian nutrition response interventions.

Mechanisms for BMS support need to befurther developed at national level to ensuretimely and responsive availability in an emer-gency setting when required. Training moduleson safe BMS programming should be developedand adapted to different contexts and scenarios,learning from best practices globally. Protocolsand guidance for procurement, transportation,logistics, stocking, distribution, targeting andutilisation may be partially available, but needto be updated to reflect learnings and bestpractices and translated to more user-friendlytools for field practitioners. IYCF-E core indi-cators are available to assess the need for safeBMS programming, but are rarely used. Moreadvocacy and sensitisation on how to accuratelycollect and use such data is required.

At time of writing there is still no safe BMSprogramming in place in Cox’s Bazar for theinfants who need it.

For more information, contact: Alice Burrell,email: [email protected]

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InternationalMedical Corpsstrengthensnutrition alertand surveillancesystems in South Sudan By Muhammad Ali Jatoi, Deepak Kumar,Dugsiye Ahmed and Iris Bollemeijer

Muhammad Ali Jatoi is theSenior Nutrition SurveillanceManager at InternationalMedical Corps (IMC) SouthSudan, where he managessurveillance and is responsible

for the coordination and representation of IMC inthe Nutrition Information Working Group (NIWG)and Nutrition Cluster with regard to assessmentsand surveys.

Deepak Kumar is a rovingnutritionist for IMC SouthSudan. He has extensiveexperience in conductingoperational research, surveysand assessments.

Dugsiye Ahmed is a nutritioncoordinator and head of thenutrition department in IMCSouth Sudan. He is responsiblefor the overall performance ofall nutrition programming and

provides technical support to the surveillancesection.

Iris Bollemeijer is a nutritionadvisor for IMC for northAfrica, east Africa, Asia andEurope. She provides remoteand in-country technicalsupport for the design and

implementation of IMC’s nutrition programmes.

The authors would like to acknowledge thefollowing agencies who supported theprogramme described in this article: Ministry ofHealth South Sudan, NIWG South Sudan, theNutrition Cluster South Sudan, the Office of U.S.Foreign Disaster Assistance (OFDA) and theUnited Nations Children’s Fund (UNICEF). Inaddition, the authors would like to thank ClaraLong (Media and Communications Officer at IMC)for her support in writing the article and SamuelMbuto for his dedication and efforts inestablishing the surveillance system, as well ashis support in writing this article.

Background South Sudan is currently facing a period ofsevere food insecurity. Approximately 5.24million people (of an estimated populationof 11 million) were projected to be severelyfood insecure in the first quarter of 2019, ofwhom 36,000 were estimated to be at risk offamine.1 While the situation is no longer de-teriorating significantly, the country remainsin the grip of a serious humanitarian crisis.Nearly 4.5 million people have been displaced,including approximately 2.5 million to neigh-bouring countries.

Maternal and child malnutrition is a sig-nificant public health as well as a social andeconomic problem in South Sudan. An esti-mated 17.1% of children aged 6-59 monthsare stunted, 10.6% are moderately acutelymalnourished and 2.7% are severely acutelymalnourished.2 A complex web of multi-sector factors contribute to this burden, in-cluding poor maternal and childcare practices(especially sub-optimal infant and young

child feeding (IYCF) practices), high prevalenceof low birth weight, inadequate dietary intake,food insecurity, unsafe water and poor sani-tation, inadequate health services, high preva-lence of morbidity, low levels of educationand socio-economic challenges. ere are se-vere challenges in addressing the burdenarising from inadequate health services, pooraccess to health and nutrition services due tolong travel distances, and displacement dueto insecurity and higher food prices.

International Medical Corps (IMC) hasbeen working in South Sudan since 2011 andin southern Sudan since the mid-1990s. eorganisation currently operates in five of thecountry’s 32 states, providing healthcare, psy-chological support, nutrition services and gen-der-based violence prevention. e nutritionprogramme provides services to internallydisplaced people (IDPs), refugees and host

Location: South Sudan What we know: Nutrition surveillance is needed to provide timely, reliable datato monitor population nutrition status and inform programme interventionsand decision-making.

What this article adds: In 2015 International Medical Corps (IMC) establisheda Nutrition Alert and Surveillance Strengthening (NASS) team to support theFood Security and Nutrition Monitoring System (FSNMS), the primary nationalinformation system, and Integrated Food Security Phase Classification (IPC).Priority areas are determined by the Nutrition Information Working Group(NIWG), under the leadership of the Nutrition Cluster. By January 2019, 52multiple-type surveys had been conducted in IMC operational and non-operational areas to inform IPC analysis and programme interventions. Theteam also provided technical support and capacity-building to government andother partners (training 1,182 individuals). Lessons learned include the need forthorough planning and preparation pre-survey; good communication andcoordination within and outside the organisation; investment in team capacity-building and supervision for collection of high-quality data; and necessity for amulti-sector approach in data analysis. The 2019-2021 strategy includes plans tofurther build the capacity of the IMC surveillance team; mobilise funds for acentralised, online surveillance data hub; increase support for country-widesurveys; and introduce cost-recovery for surveys in IMC non-operational areas.

1 Integrated Food Security Phase Classification (IPC), September 2018.

2 Food Security and Nutrition Monitoring System (FSNMS) Round 22 report published in December 2018.

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People of Uror County, Pieri, South Sudan, 2019

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communities in three states, including MalakalCounty of Upper Nile State (Malakal Protectionof Civilian (POC) site; Malakal town and Mabanrefugee camps) (Integrated Phase Classification(IPC) Phase 4); Nyal-Panyijar County in UnityState (IPC Phase 4); and Juba County POCs inthe Central Equatoria region (IPC Phase 3).

Nutrition-surveillance systemneedse government-United Nations (UN) FoodSecurity and Nutrition Monitoring System (FS-NMS) is currently the only nationwide nutri-tion-surveillance system in the country. Non-governmental organisation (NGO)-implementedlocation-specific SMART surveys are also regu-larly undertaken. e Nutrition InformationWorking Group (NIWG), under the leadershipof the Nutrition Cluster, identifies priority areasfor surveys to fill gaps in knowledge to informthe IPC and FSNMS to strengthen the nationalinformation system and identifies responsiblepartners to carry them out.

Until 2015, NGO and FSNMS surveys andassessments were normally carried out by externalconsultants, who oen lacked a thorough un-derstanding of the context. Surveys were oennot completed on time due to the lengthy processof consultant recruitment and visa applicationand were rushed as consultants’ visas were gen-erally restricted to one month. ese factorsoen compromised the quality of survey dataand meant that partner staff were le to defendthe results during NIWG validation. Conse-quently, some surveys were rejected and valuableresources wasted.

With the escalation of conflict during 2015in Upper Nile, Lake and Unity States and wors-ening trade situation in the country overall, ac-curate monitoring of nutrition status, nutritioncoverage and childcare practices became essentialto ensure that interventions were guided by

valid and timely information. Nutrition datawas also needed to accurately determine foodsecurity and nutrition phase classification ofthe country aer 2014, when the IPC was intro-duced. In response, IMC implemented a newnutrition-surveillance initiative in 2015 to supportwider surveillance needs and demands.

IMC’s surveillance strengtheningIMC’s Nutrition Alert and Surveillance Strength-ening (NASS) team was established in August2015 to undertake nutrition surveys and as-sessments to provide robust information toinform the design and implementation of ap-propriate nutrition interventions in South Sudan.e team comprises international and nationalstaff, including two surveillance managers, twosenior surveillance officers and four nutrition-surveillance officers. When needed, validatedlocal enumerators are also hired on an ad hocbasis from an IMC database of 1,200 members;the majority of whom have already been con-tracted and have undertaken several surveysfor IMC. is widespread team enables multiplenutrition surveys to be carried out simultaneously.

Surveys undertaken by IMC e majority of surveys conducted by the sur-veillance team to date have been SMART surveys.However, the team has increased its technicalcapacity to conduct coverage assessments(SQUEAC); IYCF assessments; knowledge, at-titude and practice (KAP) surveys; and barrieranalyses (BA). Surveys are conducted in IMCoperational sites and in counties with nutritionemergencies identified as priority areas for in-formation by the NIWG of the Nutrition Cluster,government, or partners. So far, the NIWG hasrequested IMC to conduct 16 SMART surveysand four emergency assessments (two rapid-re-sponse mechanism (RRM) assessments and twoinitial rapid-needs assessments (IRNA)) in areaswhere IMC is not operational. In October 2018,the NIWG formally identified three partners

(IMC, Save the Children and Action AgainstHunger) to be responsible for nutrition surveysand assessments in South Sudan based on theirexperience, including quality of data, timelyprovision of results, cost-effectiveness and overallorganisational capacity.

IMC has conducted the most surveys to dateamong all partners and has been selected tocarry out the vast majority planned for 2019.e team has also participated in the reviewand validation of multiple surveys conductedby other Nutrition Cluster partners and hasprovided feedback to enable the effective analysisof data. Partners with limited or no capacity toconduct surveys or assessments also asked IMCfor support in carrying out surveys of theirown; previously these organisations hired con-sultants to conduct surveys but lacked in-housecapacity to validate them.

IMC has established relationships with keystakeholders such as the Ministry of Health(MoH), the Nutrition Cluster, relevant UN agen-cies and other partners and shares updated andreliable information with them as needed. AllIMC surveys have been validated by the NIWGand have been found to be of good quality andto reflect the situation of the area assessed. IMCsurveys are regarded in South Sudan as a trustedsource of information, and data are oen sharedin national and international forums.

Survey process Whether conducted for IMC or partners, thesurvey process is similar. e surveillance teamdevelops a survey protocol according to inter-nationally recognised methodologies (whethera SMART, SQUEAC, KAP, IYCF or BA survey),which is then validated by the NIWG. On ap-proval, enumerators are trained by senior sur-veillance officers on the specific questionnaires,tools and sampling frame. During the data col-lection period, surveillance officers discuss resultsand any challenges with the enumerators daily.e data is digitally collected through sowaresolutions such as ODK or KOBO using tabletsto support accuracy and speed. Surveillancemanagers analyse the data in Juba, aer whicha dra report is prepared and submitted to theNIWG within two weeks for review and valida-tion. NIWG meetings are held on a monthlybasis and the validation process takes a maximumof two weeks. e final report is then submittedto the NIWG for dissemination within the Nu-trition Cluster (the County Health Director,State Ministry of Health, MoH and IMC), aswell as to relevant donors.

Costs, funding and capacity e average cost of a survey ranges from USD9,000to USD12,000 in IMC operational areas andfrom USD15,000 to USD20,000 in non-IMC op-erational areas. Costs are directly related toaccess and available services in geographicalareas. For instance, if a county has no functionalmarket, all supplies must be carried from Jubato the survey area, which escalates costs.

From 2015 to 2018, IMC’s NASS receivedfunding from the Office of U.S. Foreign Disaster

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Assistance (OFDA) and the United NationsChildren’s Fund (UNICEF), but since 2019 theteam has been solely funded by USAID and istherefore currently in need of funding assistance.A new partnership agreement with UNICEF iscurrently being discussed and IMC will continueconducting nutrition surveys/assessments toensure adequate availability of information. isinformation will be vital in decision-makingand to increase nutrition-service interventions.e MoH is currently working to introduceDistrict Health Information Soware 2 (DHIS2)3

in South Sudan; this will capture the resultsfrom these assessments and will make the in-formation more easily available to partners foruse in decision-making and programme design.

NASS team challenges andlessons learnedSouth Sudan is a country with many challenges,making it crucial to plan for multiple scenarios.Operations can be severely affected by the pre-vailing security and political situation and inmany parts of the country the situation is fluid.e surveillance team takes appropriate pre-cautionary measures during planning and im-plementation stages to deal with such challenges.However, situations can easily change duringdata-collection periods. Delays are also common(for example, in procurements and simplearrangements on the ground, particularly inIMC non-operational areas). ere is also a lackof accurate population data in the country. emost recent census was undertaken in 2008 andno census is currently planned. is makes case-load projections difficult, ultimately resultingin over- or underestimation and over- or un-derutilisation of financial resources.

Gradually and with experience, the surveil-lance team has learnt to overcome challenges toavoid delays and ensure quality surveys. Lessonslearned by the surveillance team include:

Planning and preparationIn the South Sudan context it is necessary tostart planning and consulting partners long beforethe survey takes place to mitigate risks and avoidunnecessary delays. All available options shouldbe considered to enable smooth logistics arrange-ments and the MoH, NIWG and all partners onthe ground should be consulted at planning stageto provide the necessary approvals and guidance.It is also important to remember that on-the-ground partners and stakeholders can provide

additional support, such as accommodation andcommunication services. A clear, concise andconcrete survey protocol should be prepared wellin advance, specifying clear inclusion and exclusioncriteria, sample size, sampling frame, methodologyand sample selection.

Coordination within and outside theorganisationBefore proceeding to the field, all relevant per-missions should be secured from the authorities.e team should also coordinate with on-the-ground partners or field logistics to understandthe availability of items in local markets to savecosts. Sensitising on-the-ground partners and lo-gistics and finance teams in the organisation tothe plan will help to overcome major challenges atlater stages and will help them to understand theimportance of the activity and its impact: successdepends on inter-organisation coordination.

Capacity-building and supportivesupervisionIn the field, a team of technical supervisorsmust be prepared and empowered to take deci-sions on operational matters and to tackle tech-nical issues in the field during data collection.e objective of these assessments is to collecthigh-quality data. is will require investmentin quality training of enumerators and teamleaders, coupled with a standardisation test anda practical field test, close and supportive su-pervision from the team leaders/supervisors,daily meetings before field work to discussquality and address field challenges, daily dataentry and regular plausibility checks.

Involving village leaders and representativesduring data collection for extended support andtraining the data collectors in behavioural changewill build a positive image of the organisationin the community.

Data analysis and report writingA multi-dimensional perspective is neededduring data analysis as nutrition is a multi-sector discipline requiring multiple, co-relatedindicators. Once the data analysis is complete itis essential to present it to the multi-sectorstakeholders for the preliminary results to bevalidated before draing the final report.

Achievements to date From 2015 to January 2019, the team conducted52 surveys, including 36 SMART surveys (19 inIMC operational areas and 17 in non-IMC op-

3 DHIS2 is the flexible, web-based open-source information system www.hisp.org/services/dhis-2/

4 Three SQUEAC assessments; four IYCF assessments; one barrier analysis; two community assessments; three health and nutrition KAP, two IRNA and two RRM surveys in areas where the organisation is currently not operating).

Number of children with severe acute malnutrition age 6 to 59 monthstargeted and reached in South Sudan, 2014-2018Figure 1

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erational areas).4 In addition, IMC has providedtechnical support to partners with limited nu-trition-survey capacity (specially SMART-surveycapacity). IMC has also improved the in-housecapacity of government and NGO personnel toconduct SMART surveys and other relevant nu-trition assessments. In total, since 2015, IMChas trained 1,182 individuals from different part-ners, including national and international NGOs,County Health Departments (CHD), state MoHsand national MoH. e information collectedin these surveys has been used for IPC analysis,advocacy and to inform programme interventions.

In-country support has also been providedto other IMC missions. For example, supportwas given to the Somalia mission to strengthenstaff capacity to conduct a SMART survey. isalso built the capacity of national South Sudanstaff by giving them international experience.

Next stepsIMC is keen to continue the success of the NASSteam and aims to expand its reach, capacity andimpact by taking the following actions, accordingto the IMC Nutrition Strategy 2019-2021: • Advocacy to establish inter-sector (nutrition; health; gender-based violence; and water, sanitation and hygiene (WASH)) assessment tools to integrate multi-sector indicators within surveys.• Further build the capacity of IMC staff to develop data collection tools, digitalise data and use data-analysis soware.• Continue to utilise the South Sudan surveillance team to support other IMC country missions to establish similar mechanisms. • Mobilise funds to establish a centralised, online nutrition-surveillance data hub at IMC Juba office with open access to all relevant stakeholders, including the Nutrition Cluster and NIWG• Incorporate nutrition-surveillance team costs into existing and upcoming grants to build system sustainability.• Strengthen the liaison with the Nutrition Cluster and NIWG to support countrywide surveys, such as the FSNMS, IRNA and RRM, among others. • Continue providing vital inputs to IPC analysis as a potential partner of the Relief Organization for South Sudan (ROSS), the Government and the UN Food and Agri- culture Organization.• At the request of the Nutrition Cluster, introduce a cost-recovery mechanism for surveys conducted in areas IMC non-operational areas to improve sustainability and enhance partner ownership and thereby enhance cooperation and improve outcomes.

For more information, please contact Muham-mad Ali Jatoi at [email protected]

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Special focus on GTAMGlobal Technical Mechanism forNutrition (GTAM)

The Global Technical Assistance Mechanismfor Nutrition (GTAM) is a soon-to-be launchedcommon global mechanism, endorsed byover 40 Global Nutrition Cluster (GNC)

partners. It is being established to provide nutritiontechnical assistance to support quality programmingfor people affected by humanitarian emergencies. Thestory of how the GTAM has evolved is described indetail in the first article in this special section.

What is the status of GTAM now? GTAM remains inthe ‘build’ stage. Progress has been hamperedsomewhat by delays in launching the online platform.This is currently being resolved ready for onlinelaunch in 2020.In the meantime, the focus during2019 has been to agree and document ways ofworking through standard operating procedures andprinciples of engagement with Global TechnicalWorking Groups (GTWGs) on key topic areas. Thesegroups are in various stages of development: thosethat have been integrated into existing forums (suchas the Infant Feeding in Emergencies Core Group1)have naturally progressed faster, while others are inearly-establishment phase. A baseline technical needsassessment has also been carried out, including areview of technical discussions posted on en-net

(ENN’s online technical forum; www.en-net.org).Findings are summarised in articles in this section andprovide insight into the technical gaps that will beprioritised in the workplans of each GTWG.

Work was also undertaken in 2019 to define waysof working with existing mechanisms, such as theGNC Technical Helpdesk, United Nations Children’sFund (UNICEF) HQ, en-net and the Technical RapidResponse Team (Tech RRT). The continuedcommitment of the GTAM Core Team (UNICEF, WorldVision, ENN) to work with others, use existingplatforms and gain broad ownership has meant thatthe journey to this point has taken time. However, wehope that this will serve GTAM well in the long termby providing a stronger mechanism that will providesystematic, predictable, timely and coordinatednutrition technical assistance, true to its aim.

This special section is the fulfilment of part ofENN’s commitment to provide knowledge-management expertise to the GTAM.2 Here, wedocument the journey so far – why the GTAM iscoming into being, what technical priorities it willaddress, and how. We will continue to update youperiodically as the story evolves.

1 www.ennonline.net/ifecoregroup2 Information shared here has drawn on the Global Technical Mechanism for Nutrition (GTAM): Quarterly Digest, April to July 2019, compiled by ENN.

Quarterly Digests will be available on the GTAM platform once launched.

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Location: Global

What we know: There is a longstanding demand for predictable,accessible technical assistance on nutrition in emergencies (NiE) forcountry practitioners.

What this article adds: The Global Technical Assistance Mechanism forNutrition (GTAM) is a global mechanism endorsed by over 40 GlobalNutrition Cluster (GNC) partners which is being built to facilitateprovision of timely, predictable NiE technical assistance at country level.The GTAM core team (GTAM-CT) comprises UNICEF (lead), World VisionInternational (co-lead), the Technical Rapid Response Team (Tech RRT),the GNC Coordination Team, GNC Technical Helpdesk and ENN(knowledge management). Leveraging what already exists whereverpossible, efforts centre around three ‘pillars’ to fill identified gaps: (1)provision of technical advice to support implementation of normativeguidance (in collaboration with ENN’s online platform en-net); (2)development of consensus-driven interim guidance where there is none(through existing or new Global Thematic Working Groups (GTWGs) andthe World Health Organization); (3) provision of specialised technicalexpertise to countries (in collaboration with the existing Tech RRT).Numerous processes and discussions have influenced theconceptualisation and setting up of the mechanism over several years,enabling broad participation and ownership by the GNC collective.Current priorities are finalising practical details for implementationphase, developing a strategy to sustain the initiative, and formalisinglinks and ways of working with existing bodies.

Isabelle Modigell is the Project Managerfor Global Technical AssistanceMechanism for Nutrition (GTAM)knowledge management at EmergencyNutrition Network (ENN). She is aconsultant with a public health

background and over six years of experience working in avariety of humanitarian settings during all stages of

emergency response.

Tanya Khara is a Technical Director at ENN.She is a public health nutritionist with 20years’ experience in humanitarian anddevelopment programmes, policy andresearch. Tanya is the lead for ENN’s role

as knowledge management partner for the GTAM.

The authors would like to sincerely thank and acknowledgethose who were interviewed for the purposes of this article,including Josephine Ippe (Global Nutrition Cluster (GNC))and former GNC Nutrition in Emergencies (NiE) TechnicalTask Force members Leisel Talley (Centers for DiseaseControl and Prevention), Erin Boyd (United States Office forDisaster Assistance), Carmel Dolan (ENN), Megan Gayford(Save the Children), Colleen Emary (World VisionInternational), Ruth Situma (United Nations Children’s Fund(UNICEF), Zita Weise Prinzo (World Health Organization) andBritta Schumacher (World Food Programme). Additionalthanks to Colleen Emary, Diane Holland (UNICEF) and AndiKendle (Technical Rapid Response Team) for reviewing thisarticle.

This article shares the findings of several studies and reports(referenced herein) and is framed around interviewsconducted by ENN to capture learning to date on the processof developing the GTAM. The views expressed here are those ofthe authors themselves and do not necessarily represent theviews of UNICEF or other organisations.

By Isabelle Modigell and Tanya Khara

Global Technical AssistanceMechanism for Nutrition(GTAM): The story so far

The Global Technical Assistance Mecha-nism for Nutrition (GTAM) is a commonglobal mechanism endorsed by over 40Global Nutrition Cluster (GNC)1 partners

to provide systematic, predictable, timely andcoordinated nutrition technical assistance inorder to meet the nutrition rights and needs ofpeople affected by emergencies. As the GTAM’sbuild launched this year, we take a look in thisarticle at how and why it came to be, with thehelp of some of the people who have beeninvolved in the journey so far.

Origins of the GTAMThe conception of the GTAM can be pinpointedto the GNC annual meeting in 2015. Discussionsat this meeting highlighted issues around oper-ational ‘grey zones’ (technical areas of nutrition inemergencies (NiE) for which there is no norma-tive guidance) and limitations in technicaloperational capacity, which at the time arose inemergencies in the Philippines, Ukraine andSyria. Consequently, a decision was taken toreassess and more clearly define the GNC’s tech-nical role. Space previously existed at the globallevel to identify and grapple with technical issuesin the form of the NiE working group of theUnited Nations Standing Committee on Nutrition

(UNSCN). However, this group ceased in 2008and, although the GNC became operationalaround the same time, there was a lack of clarityon the GNC’s technical role compared to its clearmandate with respect to coordination and infor-mation management. In its early years, the GNCprovided some technical support, in particularthrough technically-oriented working groups,and actively advocated for the re-establishmentof a technical space, although unsuccessfully.However, a governance review in 2013 recom-mended that the GNC turn its focus firmlytowards its core functions of coordination andinformation management (Gostelow, 2013).Josephine Ippe, former GNC Coordinator, statedin interview,

“I knew even then that when the governancereview talked about the GNC, it was referring to theCoordination Team (GNC-CT), not the collective.You can’t talk about the collective not having atechnical role; it’s impossible when what you areimplementing is technical.”

Unsurprisingly therefore, just two years later,it was widely agreed that, while the provision oftechnical support was outside the scope andcapacity of the GNC-CT, the GNC as a community

does have a role in the provision of technical sup-port, and that a collective agreement was neededon exactly what that role should be. Two papers(Le Cuziat and Frize, 2015; Richardson andVervers, 2015) were subsequently commissionedby the GNC-CT to evaluate the support providedby the GNC to national coordination platforms,the GNC’s collective role in providing technicalsupport and how best this role could be sup-ported. Specific gap were highlighted by bothpapers; one of which concluded that:

“The NiE sector is missing an overarching tech-nical platform which can provide strategic directionon how to prioritise and address technical capacitygaps at country level.” (Le Cuziat and Frize, 2015).

Specific gaps identified by the papers andsubsequent discussions with GNC partnersrelated to insufficient on-the-ground expertise totranslate existing guidance into practice; a lack ofpredictable processes to address technical areaswhere no normative guidance exists; and anabsence of leadership and coordination for theprovision of NiE technical expertise to countries.

1 The Global Nutrition Cluster (GNC) is a partnership of inter-national non-governmental organisations (NGOs), the Red Cross and Red Crescent Movement, United Nations (UN) organisations, and donors and individuals

Field article Special focus on GTAM



2016 2017 2018 2019

GNC members recognised that, in today’s rap-idly changing humanitarian environment,responders are increasingly facing emergingissues for which there is no normative guidance,or for which existing guidance must be adaptedto a new context. The growing complexity ofemergencies means that clarity and coherence isessential. Britta Schumacher, World Food Pro-gramme (WFP) and former Task Force member,stated:

“It’s the exceptional circumstances that generatelots of questions; they are the instances where prac-titioners get stuck, when there is no evidence orexperience available, and guidance is needed.”

The frustrations felt by practitioners on theground who “needed guidance yesterday” hadoften been shared in GNC meetings and calls. Forexample, the 2014 Ebola virus disease (EVD) out-break required clarity on the nutritional care ofEVD-infected patients2 and on breastfeeding inthe context of EVD,3 highlighted on EmergencyNutrition Network (ENN)’s en-net forum.Although, in this high-profile instance, willingpartners (World Health Organization (WHO),ENN, UNICEF and others) quickly came togetherto produce rapid interim (and subsequent WHOnormative) guidance, a systematic mechanismwas lacking that could track and tackle emergingand unresolved technical issues. GNC partnersfelt that an overarching mechanism couldremove the need for the (often slow) process offorming new structures to tackle each emergingchallenge and increase confidence in outputsdeveloped through a clear, transparent and pre-dictable process.

Partners also recognised the existence oflongstanding, unresolved issues discussed bythe international community for many years(the weight-for-height versus mid-upper armcircumference (MUAC) debate is an oft-quoted

example). It was felt that a global mechanismcould bring together practitioners, donors, aca-demics and other key stakeholders to arrive atconsensus-driven conclusions on such issueswith an accepted level of legitimacy. Stakehold-ers also noted the need for support in thedissemination and communication of newguidance. Britta Schumacher shared her previ-ous experience of developing guidance oncommunity-based management of acute mal-nutrition (CMAM) programming in exceptionalcircumstances:

“We were a bit uncertain as to how we woulddisseminate it, who would accept it, how to com-municate it and how to have it validated. The GTAMcould have developed and communicated suchinterim guidance and led the dialogue on how to goabout it.”

Another issue identified was that guidancedocuments and technical materials are currentlyscattered across various partners, without easycommon access. This has resulted in duplicationof guidance, inefficiencies (time and resources),limited reach, a lack of technical coherence and,ultimately, impact. A former Task Force memberexplained, “We have all lost so much time lookingfor the right tool or rewriting things.” A commonand accessible repository for guidance and tech-nical material with a knowledge-managementmechanism to highlight inconsistencies and sign-post people to the different resources availablewas another gap identified that it was felt anoverarching platform could address.

By 2015, the ad hoc nature of initiatives provid-ing technical support resulted in disconnectedresources, unclear processes, duplications of effort,over-reliance on personal networks (rather thanhaving access to the expert best suited to the jobat hand) and (the bottom line) an inadequateresponse to country needs. “There were several ini-

tiatives doing really good work, but we knew thatif there was something to bring them together, wecould be more effective,” said Colleen Emary.4

In response to the need for technical expert-ise, the Technical Rapid Response Team (TechRRT) was established by a consortium of GNCpartners in 2015. This aimed to improve the over-all availability of NiE specialists during large-scaleemergencies by deploying centrally recruited,skilled technical advisers in response to country-level requests. By June 2019, the Tech RRT hadprovided technical surge capacity through 50deployments in response to 61 requests.5 Theuptake of the Tech RRT highlights the demand forspecialist technical expertise at field level. Theactual need is likely under-represented in thesefigures, given the limited awareness of the serviceby actors on the ground, its focus on a smallnumber of technical areas, and the limited capac-ity of the small, busy Tech RRT team.

Development of the GTAMThe recommendations made by the 2015 papersfuelled the GNC NiE Technical Task Force,6 chairedby the UNICEF and the Centers for Disease Con-

2 www.en-net.org/question/1460.aspx3 www.en-net.org/question/1445.aspx4 Former Task Force Member and current GTAM-CT Member,

World Vision International.5 Read a collection of field articles on the experiences of the

Tech-RRT in Field Exchange 56 special issue on Global Nutrition Cluster coordination. Download from: www.ennonline.net/fex/56/en

6 The Task Force was co-chaired by UNICEF (Diane Holland and subsequently Ruth Situma) and the CDC (Leisel Talley.) Members included the GNC (Josephine Ippe), World Vision (Colleen Emary), ACF (Jose Luis Alvarez, Anne Dominique Israel and Danka Pantchova), Tech RRT / IMC (Geraldine Le Cuziat), UNHCR (Caroline Wilkinson), Save the Children (Nicki Connell and Megan Gayford), HelpAge (Juma Khudonazarov), Samaritans Purse (Julie Tanaka) and OFDA (Erin Boyd).

7 2019 Needs Assessment Report: www.ennonline.net/resource/baselinetechnicalneeds2019

• Decision to reassess GNC technical role • Review of GNC technical role (Le Cuziat and Frize – Save the Children USA)

• Formation of NiE Technical Task Force• Consultation with other sectors (by Samaritan's Purse) and initiatives• SWOT analysis of different models

• GNC endorsement of technical support definitions• GNC endorsement of Model• Guiding principles agreed• TORs and operationalisation requirements reviewed (GNC partners)• UNICEF funding commitment (2018 - 2021 Strategic Plan)

• WVI nominated as co-lead• ENN identified as Knowledge Management Partner• Transition from Task Force to GTAM -Core Team• en-net review (Tech RRT)• country TWG review (GNC) • Documentation of interim guidance development process (Tech RRT)• Mapping of existing resources (Tech RRT)• Workplan development

• Engagement of technical expertise pillar• Engagement/ formation of GTWGs• Technical priority gaps defined in Baseline Technical Needs Assessment Report• Consultant roster recruitment • IT system development started

2015

Figure 1 Critical processes and milestones in the development of the GTAM7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50



trol and Prevention (CDC), tasked with identifyingways that GNC partners could organise them-selves to address technical operational gaps.From 2015 to 2018, the Task Force led on a seriesof processes that culminated in the birth of theGTAM (Figure 1).

A fundamental first step for the Task Force wasto outline the problem it had been created toaddress. Definitions of technical roles were con-sequently outlined and endorsed by partners in2017. An analysis of models (based on a reviewof other clusters’ experiences) was undertakenand one subsequently endorsed by the GNC. Itwas eventually agreed that the scope of work forthe technical mechanism would be to providetechnical advice, consensus-driven guidance andspecialised technical expertise, now referred toas the “three pillars of the GTAM” (Figure 2). Thisinformed the subsequent operationalisation ofthe mechanism, including decisions about whoshould be involved.

Several critical conversations influenced theconceptualisation of the GTAM. Discussions tookplace on governance and leadership of the mech-anism, particularly around the need to strike theright balance between providing leadership andmaintaining a collaborative spirit to capitalise onthe GNC’s collective and widespread expertise. In2018, responsibility for further developing themechanism transitioned to a wider GTAM CoreTeam (GTAM-CT).8 In response to partners’ con-cerns that the process felt too ‘United Nations(UN)-centric’ at times and based on past positiveexperiences of shared leadership models, thedecision was made for a nominated non-govern-mental organisation (NGO) to co-lead the GTAMalongside the nominated UN agency. Following areview of nominations against set criteria by the

GNC Strategic Advisory Group (SAG), World VisionInternational (WVI) was selected as the NGO co-lead for a two-year term. UNICEF was nominatedto continue as the UN co-lead in line with itsaccountabilities as Cluster Lead Agency.9 Inresponse to a call from partners to engage exist-ing service providers, ENN was brought into theGTAM-CT to oversee knowledge managementand monitoring of the mechanism. The Tech-RRT,as an existing provider of technical expertise anden-net, ENN’s online platform for technical sup-port (www.en-net.org), were embedded withinthe GTAM. Given the demonstrated achievementsof the Tech RRT,10 a desire existed to build on itsexperience of supplying technical expertise,whilst overcoming some of its previous capacitylimitations. By uniting many more GNC partnersunder a common approach, it is anticipated thatcountry needs will be matched with availablecapacity more effectively. Zita Weise-Prinzo, WHOand former Task Force member stated:

“The important thing was to involve existing ini-tiatives from the beginning and see how theiradded value could be pulled into this work. I thinkthat was done in a good way.”

Global Thematic Working Groups (GTWGs)were (or are in the process of being) established,using existing multi-agency groups where possi-ble (such as the Infant Feeding in Emergencies(IFE) Core Group11), to bring together expertstakeholders in specific areas to answer technicalquestions and provide consensus-drivenresponses where guidance is insufficient orunclear (interim guidance). It is anticipated thatthis approach will enable a transparent and con-sultative process, resulting in high-quality andunbiased technical support that carries sufficientweight and is responsive to the needs of the

sector as a whole, rather than individual agencypriorities. As the GTAM is not, however, a norma-tive agency, it was recognised that, where newrecommendations are required (rather than guid-ance on implementation or adaptation), a moreformal WHO interim or comprehensive guidanceprocess may be needed. A ‘triage protocol’ wastherefore developed to help decide where gapissues are best addressed (GTAM or WHO), for trialon a case-by-case basis. Zita Wise-Prinzo fromWHO stated:

“Although questions remain, it is more impor-tant to get this process going and learn by doing toimprove the mechanism.”

Care has been taken to ensure that the GTAMand GTWGs do not duplicate existing global-levelstructures and that GTAM activity does notundermine or encroach on country and regional-level capacities and responsibilities. This has beenachieved through engagement with existingexpert groups, the development of a clear termsof reference (TOR) for the GTAM and its GTWGs,and identification of appropriate contact pointsfor GTAM users (en-net, UNICEF HQ, the GNCtechnical helpdesk, Tech-RRT and WVI) to enablea good flow of information and avoid gatekeep-ing. Zita Wise Prinzo stated:

The three pillars of the GTAM Figure 2

8 The GTAM Core Team is co-led by UNICEF (Ruth Situma) and World Vision (Juliane Gross and Colleen Emary). Members include the GNC Coordination Team (Josephine Ippe and Anna Ziolkovska), the GNC Technical Helpdesk (Yara Sfeir), the Tech RRT (Andi Kendle) and ENN (Tanya Khara and Isabelle Modigell).

9 UNICEF (2014) Evaluation of UNICEF’s Cluster Lead Agency Role in Humanitarian Action (CLARE).

10 Allen, B. (2018) External Evaluation of the Technical Rapid Response Team. Tech RRT and USAID and Field Exchangeissue 56 on Nutrition Cluster Coordination pages 62-75.

11 Infant Feeding in Emergencies (IFE) Core Group www.ennonline.net/ifecoregroup

Provide feedback to questions fromindividuals working in countries

experiencing emergencies within ashort timeframe, particularly whererelevanf normative guidance exists

and is available.

Identify urgent needs for interim operationalguidance and facilitata the process of developing

such guidance, based on consensus amongexperts, enabling a timely response to nutrition-

related emergencies.

Support provision of specific technicalexpertise required by a country to deliverresults for nutrition. Technical expertise

support may be in the form of deploymentof human resources remote support of

technical staff or capacity building.

PILLAR 1: PROVIDE TECHNICAL

ADVICE

PILLAR 2: FACILITATE CONSENSUS

DRIVEN GUIDANCE

PILLAR 3: PROVIDE SPECIALIZEDTECHNICAL EXPERTISE

51



“I think this is the first time that there is anattempt to formalise the process and look at it in amore holistic way; not only technical gaps, but alsohow to give technical assistance. It’s more practical,more strategic and more systematic.”

Strengths and challenges of theprocessWork has also gone on behind the scenes to gen-erate buy-in among GNC partners and beyond.Interviewees identified UNICEF’s tangibledemonstration of its commitment through dedi-cated both staff time and funding as well as theparticipative and inclusive process as keyenabling factors for buy-in; cluster partners havebeen included in discussions at every stage andconcerns, needs and feedback have been activelysought and listened to. Other feedback, however,suggests that stakeholder mapping was a missedstep in the process, which limited the composi-tion of the Task Force to individuals who attendedthe 2015 GNC meeting. Due to its voluntarynature, it was also felt that the Task Force wasbiased towards those who had sufficient role flex-ibility and interest. Megan Gayford, Save theChildren and former Task Force member, stated:

“If the process had optimal resourcing from theoutset, a cost-recovery basis for task force members’time – where their organisations required this – mayhave facilitated a more holistic and diverse repre-sentation.”

An initial lack of clarity on the scope of theend product and the large amount of preparatorywork required prior to the mechanism’s launchalso made it difficult to manage expectations andmaintain confidence in what often appeared tobe a slow process. Ruth Situma, former Task Forcemember and GTAM co-lead until 2019, said:

“Because you’re building as you go, there isuncertainty. How will it work? How will it affectme, my institution, my donors, our operations?Some want certainty before buying in.”

Understanding needs and concerns, obtaininginputs from those working in emergencies, build-ing trust and buy-in and the collectiveconceptualisation of an entity of this magnitudeall require time. Nevertheless, the process maywell have been slowed down by a lack of dedi-cated resources for several years. The allocation offunding (which resulted from the inclusion of

GTAM in UNICEF’s 2018-2021 Strategic Plan) andUNICEF staff time to lead the GTAM’s develop-ment were identified in interviews as criticalaccelerators to the GTAM’s progress from 2018onwards. However, others interviewed regardedthe long period of time taken for the commitmentof this funding as a constraint that further slowedthe process and questioned the value of attempt-ing to move forward before base resources weresecured – resources that could have included stafftime from a broader range of agencies. An over-reliance on infrequent GNC meetings to advancediscussions and build consensus was identified asanother barrier, with the changing compositionof participants over the years requiring previousdecisions and discussions to be revisited.

Despite these challenges, presentations at the2019 GNC Annual Meeting revealed the signifi-cant progress that has been made. Althoughmany identify Ruth Situma as the driving forcebehind this progress, she acknowledges thatmuch of where the GTAM is today is thanks toinputs by country coordination teams and tech-nical partners over the course of six GNCmeetings. As she stated;

“We have come this far because of the supportof different stakeholders at country, regional andglobal levels.”

Current priorities The GTAM now finds itself in the critical phase ofworking out the practical details of the mecha-nism and moving into the phase ofimplementation, getting it fully up and runningin line with GTAM guiding principles, as collec-tively conceptualised and endorsed by the GNCCollective (See Box 1). A strategy to ensure theGTAM’s sustainability, both in terms of agencycommitments and financial resources, is beingdefined. This includes the development of acommon resource mobilisation strategy to securecore funding for multiple agencies and allow costrecovery for others, based on the learning of thepast years. Efforts continue to strengthen con-nections with existing GTWGs outside the GTAMand formal linkages with key UN agencies. Nico-las Joannic of WFP stated in interview;

“I see that WFP would have a great role to playin the GTWGs on CMAM, IFE, assessments and nutri-tion-sensitive programming.”

Looking forward We asked interviewees what the big picture isthat is being worked towards. Erin Boyd, UnitedStates Office for Disaster Assistance (OFDA) andformer Task Force member, explained:

“The GTAM is a platform through which peoplecan access different types of technical capacity,whether it’s guidelines, policies, under- standingrecent evidence, or actual hands-on support that’sneeded.”

Leisel Talley of CDC and a former Task Forcemember added:

“It’s a consortium of partners that can providevarious forms of assistance to other partners or enti-ties, a consolidated place to request assistance andaddress broader technical issues.”

Ruth Situma described the GTAM as:

“A public good that is available to respond to theneeds of countries.”

The GTAM’s visionaries are also keen toemphasise that the GTAM aims to serve. MeganGayford stated:

“It’s a global service mechanism. We have a clearproblem in the complexity of the system in whichwe work, so the GTAM should be looking to solvethat problem by making what’s needed accessibleand that process efficient.”

Colleen Emary added:

“It’s a mechanism that is going to be responsiveto the user…we are working under the ethos thatwe are service providers and those requesting serv-ices are clients.”

And the bottom line? Erin Boyd said:

“I see it very much as a platform that will havean actionable role in helping agencies to betterprogramme NiE. Just as it has become easier forNutrition Cluster Coordinators to contact theGNC Helpdesk and figure out what they’re ableto do, I hope it will become easier for practition-ers too.”

Colleen Emary concluded that the GTAM “hasthe potential to bring together the emergency-response community and improve the way we’reworking.”

For more information, contact: Diane Holland [email protected] or Juliane Gross at [email protected]

Read a one-page brief on GTAM athttps://www.ennonline.net/resource/gtamfor-nutrition

References Gostelow, L. (2013) Global Nutrition Cluster GovernanceReview Report. GNC.

Le Cuziat, G. and Frize, J. (2015) Position of the GNC onProviding Technical Support to Country Clusters. Save theChildren USA, GNC and UNICEF.

Richardson, L. and Ververs, M. (2015) Evaluation of thesupport provided by the GNC to National CoordinationPlatforms. GNC and UNICEF.

GTAM guiding principles Box 1• Maximising existing technical resources at country, regional and global level and avoid duplication of efforts.• Serving both the nutrition sector as a whole as well as individual agencies, with the best interest of the affected population at the heart of work, regardless of agency motivations.• Tackling technical issues in a timely, coordinated and collaborative way to enable quality and effective nutrition response in humanitarian crisis.• Facilitating consensus on Nutrition in Emergencies (NiE) related guidance/best practices and enable global networks supporting countries to speak with ‘one voice’ to avoid confusion of practitioners.• Addressing nutrition technical gaps that are most important and most feasible for the GTAM to impact.• Acting to facilitate, coordinate and catalyse filling of technical guidance gaps, but not to execute the development of guidance itself.• Ensuring official guidance is evidence-based, and all other guidance (e.g. interim) may be based on best practice and experience.

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Location: Global

What we know: A common Global Technical Assistance Mechanism (GTAM) hasbeen developed to address technical gaps in nutrition in emergencies (NiE).

What this article adds: A baseline needs assessment was carried out between 2018and 2019 to identify priority thematic areas, and technical gaps within them, toinform the GTAM workplan. Methods included a review of posts on en-net (ENN’sonline technical forum); surveys of Nutrition Cluster Coordinators and CountryTechnical Working Group members; and key informant interviews. Findings werereviewed and synthesised at the 2019 Global Nutrition Cluster (GNC) annual meetingand by a GNC partner survey. Key technical priorities were identified in the followingpriority areas: nutrition assessment; community-based management of acutemalnutrition (CMAM); and infant and young child feeding in emergencies. The GTAMcoordination team will work with Global Thematic Working Groups (GTWGs) underGTAM to identify appropriate actions in response to each technical priority. Theseactions will form the basis of the initial workplan and direction of the GTAM andGTWGs, which will be reviewed regularly in response to emerging needs.

Baseline technical needs assessment for theGlobal Technical Assistance Mechanism forNutrition (GTAM)

In 2016, the Global Nutrition Cluster (GNC)initiated a technical task force to propose amechanism for addressing technical gaps innutrition programming in humanitarian con-

texts. The concept of the Global TechnicalAssistance Mechanism for Nutrition (GTAM) wasdeveloped and endorsed during the 2017 GNCannual meeting and subsequently developed.2

The three main functions of the GTAM are to: 1)provide technical advice; 2) facilitate consensus-driven guidance; and 3) provide specialised

technical expertise. To design an effective serviceresponsive to country-level needs and informthe GTAM workplan, a baseline technical needsassessment explored the key technical gapswhere advice is sought by nutrition-in-emergen-cies (NiE) practitioners and priorities by thematicarea.

Mixed methods were used between 2018 and2019, including a review of posts on en-net(ENN’s online technical forum, www.en-net.org);3

a survey of Nutrition Cluster Coordinators (n=5);

an online survey of GNC Country Technical Work-ing Group (CTWG) members (n=33); and keyinformant interviews (n=22). Results were col-lated and shared at the 2019 GNC annualmeeting, where working groups reviewed find-ings and identified technical priorities and nextsteps. Priorities were further refined by a GNCpartner survey in 2019 to determine final techni-cal priority areas.

Findings reveal that the three priority techni-cal areas are: assessment; community-basedmanagement of acute malnutrition (CMAM); andinfant and young child feeding in emergencies(IYCF-E). Within these areas, the key technical pri-orities identified are summarised in Box 1.

These will inform the initial workplan anddirection for the GTAM and the Global ThematicWorking Groups (GTWGs) under GTAM. A systemto ensure ongoing monitoring of issues andquestions coming into the GTAM mechanism willbe put in place to ensure that GTAM is agileenough to respond to any changing and emerg-ing needs not reflected in the baseline.

Planned next steps are to share the identifiedtechnical priority gaps with relevant GTWGs toexamine identify best way forward4, obtain feed-back from Nutrition Cluster Coordinators onwhether the suggestions will provide practicalsolutions to the country-level technical needs;and identify who is best placed to take actionsforward. More straightforward actions will likelybe addressed by the GTAM Coordination Team(GTAM-CT), while more complex issues, wherecurrent guidance is unclear or non-existent, willbe carried out by specialised GTWGs and theirnetworks (for example; within academia). It is rec-ommended that agreed actions are included incosted GTWG workplans.

Moving forward, channelling technical ques-tions that cannot be answered at country levelinto a central entry point for technical support(i.e. the GTAM) offers the opportunity for the reg-ular and systematic analysis of challenges facedby a broad range of NiE practitioners.

For more information, please contact IsabelleModigell at [email protected]

Technical NiE priorities identified in the GTAM baseline needs assessmentBox 1Assessment: • Influence of body shape on anthropometric status; • How to undertake sampling in pastoral areas; • Estimating dietary intake among households eating from a common plate;• Estimating feeding practices in children older than two years.

CMAM:• Alternative moderate acute malnutrition (MAM) management; • Clear guidelines on what to do in the absence of a therapeutic product; • Clarity/guidance on simplified protocols/combined protocols/expanded criteria using ready-to- use therapeutic food (RUTF)/ready-to-use supplementary food (RUSF) for the management of severe acute malnutrition (SAM) and MAM; • Better integration of SAM screening for infants under six months of age for community volunteers; • How to best calculate the SAM and MAM caseload? (What is the correct incidence correlation factor to be used?)

IYCF-E:• Clear guidance on monitoring and evaluation for IYCF-E; • Strong global guidance on the management of non-breastfed infants in emergencies using ready- to-use infant formula (RUIF); • Impact of cash-based programmes on IYCF practices; • Direct impact of IYCF programmes on stunting and wasting; • Review of current guidance on IYCF Corners and mother-and-baby areas (MBAs) to streamline and widely disseminate.

1 GTAM (2019) Baseline technical needs assessment. Availablefrom: www.ennonline.net/resource/baselinetechnicalneeds2019

2 See article in this issue of Field Exchange ‘Global Technical Assistance Mechanism for Nutrition (GTAM): The story so far’.

3 Results of the en-net review are shared in the accompanyingarticle in this issue of Field Exchange, ‘A review of technical discussion on en-net: Recurring questions and gaps experi-enced by programmers’.

4 A process that has already been undertaken with the Infant Feeding in Emergencies Core Group for the priorities highlighted under IYCF-E.

Summary of review1

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Scott Logue has beenAssessment Adviser to the Technical RapidResponse Team (Tech RRT) since 2015. Hehas been deployed to

multiple humanitarian contexts to supportNutrition Clusters/ Sectors and AssessmentWorking Groups and has provided remotesupport on nutrition assessment to individualorganisations and coordination mechanisms.

Michele Goergen holds anMSc in Clinical Nutrition fromNew York University and is aregistered dietitian. She hasover eight years’ experienceworking on nutrition

programmes. Michele previously served as theTech RRT Adviser for community-basedmanagement of acute malnutrition and infantfeeding in emergencies.

Isabelle Modigell is aconsultant with a backgroundin public health and over sixyears’ experience in a varietyof humanitarian settingsduring all stages of

emergency response. She is currently EmergencyNutrition Network (ENN) Project Manager forknowledge management of the Global TechnicalAssistance Mechanism (GTAM).

Andi Kendle has been theProgramme Director of theTech RRT since September2016. She has over 15 yearsof experience inhumanitarian assistance and

development contexts, working in nutrition,food security and livelihoods, and childprotection.

Tamsin Walter has beenENN’s en-net moderatorsince en-net was launched in2009.

Marie McGrath is a TechnicalDirector at ENN andoversees the en-netplatform.

The authors acknowledge the contributionsand support of Ruth Situma of the UnitedNations Children’s Fund (UNICEF) and TanyaKhara, ENN Technical Director (GTAMknowledge management lead) in this review.

By Scott Logue, Michele Goergen,Isabelle Modigell, Andi Kendle,Tamsin Walters and Marie McGrath

Location: Global

What we know: There is demand for timely and systematic nutrition technicalsupport to countries during emergencies. en-net is an online technical moderatedplatform established in 2009 to help address this.

What this article adds: A Global Technical Assistance Mechanism for Nutrition (GTAM)will be launched in 2019 to meet country-level technical needs; where possibleleveraging technical support that already exists. A review of issues discussed on fouren-net thematic areas (infant and young child feeding interventions; prevention andtreatment of severe acute malnutrition; prevention and treatment of moderate acutemalnutrition (MAM); and assessment and surveillance1) was synthesised and analysedfor themes and gaps to inform GTAM priorities and ways of working. The mostpopular thematic area was assessment and surveillance; the least activity was seen onMAM. A broad range of challenges was identified for each forum area that may reflectevidence or guidance gaps or poor awareness, application and accessibility of whatis available. en-net technical discourse is a rich, ongoing resource for the GTAM.Recommendations support the planned integration of en-net within themechanism and advise future en-net/GTAM collaboration to better addressunresolved technical questions and technical discord, strengthen knowledgemanagement, and increase country-level engagement in responses.

Background For the past few years, Global Nutrition Cluster(GNC) partners have sought to identify a solutionto the gap in provision of timely and systematicnutrition technical support to countries duringemergencies. A GNC Task Force was formed in2016 to address this and, following extensiveconsultation, the concept of the Global TechnicalAssistance Mechanism for Nutrition (GTAM)emerged. This was subsequently endorsed in aGNC meeting in 2017 and will be launched in2019. The GTAM’s main functions are to providetechnical advice, facilitate consensus-drivenguidance, and improve access to technical ex-pertise to address unresolved technical issuesonce country and regional capacities are ex-hausted. It will seek to leverage existing technicalsupport mechanisms wherever possible.

To take stock of issues commonly faced bypractitioners working in emergencies and soinform GTAM priority technical areas, a review ofthe four most commonly used technical forumson the Emergency Nutrition Network (ENN)-hostedonline technical forum, en-net2, was undertakenby the Technical Rapid Response Team (Tech RRT3)between June and October 2018, overseen byENN and UNICEF. This is one of several reviewsconducted by the GTAM in preparation for itslaunch (GTAM, 2019). This article provides anoverview of the findings of this review.

Objectives and methodology The aim of the review was to synthesise discus-sion on en-net to identify key learning and gapsin guidance and evidence/research, as viewedby programmers. Specific objectives addressedwere to:

1. Review and classify content of the en-net thematic categories by technical theme;2. Analyse the content of en-net forum ex changes, pulling together discussions which complement each other, address a common theme and which may build a body of experience around a topic;3. Determine the degree to which technical questions have been addressed.

Four thematic areas were reviewed: infant andyoung child feeding (IYCF) interventions; pre-vention and treatment of moderate acute mal-nutrition (MAM); prevention and treatment ofsevere acute malnutrition (SAM); and assessmentand surveillance. Questions posted from 2009onwards were exported into Excel, categorisedby sub-theme and type of post, and analysedin terms of the number of replies, whether adefinitive answer was provided (classified as‘fully’ or ‘partially’ answered) and whether therewas consensus or disagreement. As the reviewspans almost nine years, apparent gaps in earlierposts may have been resolved since the questionwas posted. The approach to data analysis wasadapted per theme due to the varying natureof questions and responses by forum. Forumareas were reviewed according to the Tech RRT’sdesk-based (non-deployment) availability.

1 The ‘assessment’ thematic area on en-net has since been renamed ‘assessment and surveillance’

2 www.en-net.org and www.fr.en-net.org 3 The Tech RRT is an emergency response mechanism formed

in 2015, led by International Medical Corps in a consortiumwith Save the Children and Action Against Hunger, that aims to improve the quality and scale of nutrition humani-tarian responses. It is funded by USAID/OFDA, Irish Aid and SIDA and works in close collaboration with the GNC and UNICEF Program Division and is part of the GTAM.

A review of technical discussion on en-net:Recurring questions and gaps experiencedby programmers

Research Special focus on GTAM


Research

4 https://smartmethodology.org/5 www.en-net.org/question/1445.aspx

Special focus on GTAM

Percentage ofquestions posted2010-2018 bythematic areareviewed

Figure 1

Assessment andsurveillance, 37%

IYCF, 20%

MAM, 10%

SAM, 33%

Number of new questions overtime posted 2010-2018 bythematic area reviewed

Figure 270

60

50

40

30

20

10

0

Num

ber o

f pos

ts

2010 2011 2012 2013 2014 2015 2016 2017

IYCF MAM SAM Assessment and surveillance

IYCFinterventions

Prevention andtreatment of MAM

Prevention andtreatment of SAM

Assessment andsurveillance

Dates analysed February 2009to June 2018

February 2009 toOct 2018

February 2009 toSeptember 2018

Feb 2009 to June2018

Total no. of questions 149 143 316 376

Total no. of replies 614 558 1,063 1,704

Total no. of views 394,816 400,526 823,610 996,268

Table 1 en-net activity by thematic area

Breastfeeding support: A common topic (20% of questions) centred on the need for appropriateadvice for women with low milk supply concerns, beyond advice on “frequent suckling”. While awealth of global knowledge and guidance exists, it has not necessarily been adapted toemergency realities (e.g. limited resources, client access and counsellor capacity). There werealso discussions around wet nursing and relactation in emergencies, where operationalguidance with practical suggestions on intervention design and clear protocols are lacking.

Support for non-breastfed infants: Multiple questions were raised around the sourcing andstock management of ready-to-use infant formula (RUIF), on upholding the International Codeof Marketing of Breast-milk Substitutes (the Code)6 while supplying breast-milk substitutes(BMS), and how to appropriately handle intercepted donations or expired products. Discussionson supporting non-breastfed infants indicate a lack of clarity in how to put the recommendationsof Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) into practicein particular situations or contexts.7

Monitoring and reporting Code violations in emergencies: Discussion reflected a lack ofclear global channels for reporting Code violations during an emergency, as well as a lack ofclarity on specific actions to take in-country to prevent and act on Code violations.

Cultural reasons or barriers leading to inappropriate breastfeeding practices and how toaddress these during emergencies: This also appeared to be a knowledge gap; evidence andcase studies seemed to be lacking that link IYCF to behaviour change and that examine what isfeasible to achieve in various stages of an emergency response.

The difference between IYCF corners and mother-baby areas (MBAs)/baby-friendly spaces:Several guidance documents exist on MBAs but are based on individual agencies’ programmedesigns and harmonisation is lacking. Confusion exists with regard to differences in terminology,functions and minimum requirements.

Mother-to-mother support groups and care group models: Global guidance on theimplementation of these models exists; however, questions remain around the differences betweenthem and how to effectively lead support group discussions beyond simply providing messaging.

Monitoring and evaluation (M&E) of Infant and Young Child Feeding in Emergencies (IYCF-E)programmes: Continued challenges were on assessing the outcomes and impact of IYCF-Einterventions (tools, indicators, appropriateness of survey methodologies) and training. SeeTable 5 for IYCF-E questions in the assessment forum.

Complementary Feeding: Questions raised on en-net (on cooking demonstrations and impactof kitchen gardens) were addressed, but a consolidated body of evidence and experiencesavailable to easily refer to appears to be lacking.

Direct impact of IYCF interventions on the reduction of stunting and wasting: Questions onimpact were not answered, which may be due to a lack of existing or easily available collatedevidence.

Table 2 Key programming challenges discussed on IYCF interventionsen-net forum

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Findings A total of 984 questions were analysed that generated3,939 replies and 2,570,220 views between 2009 and2018. Overall activity by theme is summarised in Table 1.‘Assessment and surveillance’ was the most commonlyused forum (40% posts, 2009 -2018, 42 posts/year), fol-lowed by the ‘prevention and treatment of SAM’ forum(37% of posts, 34/year); see Figure 1. As shown in Figure2, questions related to assessment and surveillance roseover time (from 26 in 2010 to 40 in 2017), with peaks in2012 (57) and 2015 (59). The 2012 peak involved numerousquestions related to mid-upper arm circumference (MUAC)that coincided with the 2012 launch of the SMARTwebsite.4 Questions related to SAM rose from 17 in 2010to 35 in 2017. Questions on MAM peaked at 26 in 2011,which coincided with the introduction of Supercerealsin 2010 (Annan, Web and Brown, 2014) (almost half thequestions on the MAM forum in 2011 were on treatment),then gradually declined to 11 in 2017. The number ofquestions on IYCF remained relatively low between 2010and 2014 but rose from 2014 onwards, with issues arisingfrom the European refugee crisis (there was also a lot ofactivity around Ebola programming in West Africa duringthis period, but this was only generated from two ques-tions). While the IYCF and MAM forums attracted equivalentnumbers of questions and replies, the IYCF forum attractedmany more ‘views’. Although there were fewer questionsposted in some months, this is not necessarily indicativeof a lack of activity as lively debate is often generated inthe form of replies to individual questions and ‘old’ dis-cussions continue to attract views over time.

Infant and young child feedinginterventionsThe IYCF forum was well used and most questions wereadequately answered (74% fully and 6% partially). Com-mon question topics included: breastfeeding issues;management of non-breastfed infants; support for moth-ers; monitoring and evaluation for IYCF interventions;effective interventions to address or prevent stunting;dietary diversity; and complementary feeding practices.A discussion thread on IYCF in the context of the Ebolavirus in 20145 generated 78 replies and 18,225 viewsand catalysed rapid, consensus-based interim guidanceon this topic and subsequent World Health Organization(WHO) guidance (WHO, 2016). Several posts (n = 6) ex-posed potentially harmful IYCF practices in the media orin partner reports. When these involved reports by anon-governmental organisation (NGO) or United Nations(UN) agency, the IYCF community moved to communicatedirectly with them to resolve the issue. It appears thatmainstream media/news outlets were not contacted di-rectly. Key IYCF programming challenges reflected inen-net discussions are summarised in Table 2.

Prevention and Treatment of MAM Questions on the MAM forum were commonly relatedto a specific treatment/approach (29%) (e.g. Can Plumpy’-Sup be used for blanket supplementary feeding (BSFP) inthe absence of Plumpy’Doz?) or involved a request for aspecific document or guideline (28%). Discussions relatingto admission and discharge criteria in special circumstanceswere also common (17%); for example, using MUAC-only for admission and discharge (see Figure 3). The ma-jority (72.4%) of questions were successfully answered(17.3% were not resolved, 10.4% partially resolved). Dis-agreement was detected in 6% (n = 7) of questions.


Technical gaps most commonly fell underthe sub-themes of ‘enrolment’ (n=7) and‘specific treatment/special cases’ (n=6). Themain programming challenges discussedare summarised in Table 3.

Prevention and Treatment of SAMThe most popular question themes wereon programme implementation and moni-toring (38%) and products used to treatSAM (23%). Under these themes, the mostcommon questions were on MUAC (cut-offpoints and MUAC-only admission and dis-charge) and incompatibly between SAMand MAM programmes (such as limited co-location of SAM and MAM programmesand ineffective referral systems betweenprogrammes). There was also a significantnumber of questions on stock procurementand shortages. Clinical questions on specifictreatment protocols and questions on re-search methodology or requests for back-ground information to inform research madeup 11% and 5% of technical questions re-spectively. Questions raised regarding com-munity-based management of infants undersix months old prompted the developmentof a dedicated en-net forum on managementof at-risk mothers and infants less than sixmonths old (MAMI). Prominent issues withinthe SAM forum area are listed in Table 4.

Assessment and surveillanceThe assessment and surveillance forum wasthe most frequently used forum, with severalposts generating significant debate. Half ofthe discussions were specific to surveys andhow to put guidance into practice. Aroundone third of questions (29.2 %; n=110) weregeneral questions or discussions related toassessment, while 20.7% (n=78) were generalsurvey questions (see Figure 4).

The most common themes discussedwere anthropometric indicators (42.4%), as-sessment methodology/type of assessment(35%), and statistical tests, formulas, dataand thresholds (27.9%). Prominent and re-curring discussions have included whenand how to use and interpret the variousanthropometric indicators (MUAC, weight-for-height z-score (WHZ), weight-for-age z-

Expected caseload for targeted supplementary feedingprogramme (TSFP) recipients: Discussions raised the needfor a standardised template to take account of factors such asestimated change in population, coverage and prevalence inorder to estimate caseloads and forecast supply needs.

Exit types: Discord was detected on definitions andtimelines for different exit types from a MAM programme.

Use of nutritional products for the prevention of MAM:The issue was whether there is a place for products in theprevention of MAM and if so, how, for how long and whetherthey should be reserved for humanitarian responses and/orspecific groups of vulnerable persons. Discussions suggestedthe need for more evidence and clear guidance.

Changes in MUAC during supplementary feeding: In thecase of MUAC-only admissions, questions were raised onhow MUAC evolves over the course of MAM treatment tohelp benchmark progress and recovery of children.

Admission of pregnant and lactating women (PLW) withMAM: Discussion highlighted that pregnant women withMAM are often not admitted into treatment programmesduring their first trimester of pregnancy, a critical phase offoetal development.

Table 3 Key programming challengesdiscussed on MAM en-net forum

Topics of questionson the MAM en-netdiscussion forum

Figure 3

Calculation Cooking/homemade food Enrolment Doc/Guidance RequestTreatment Other

32%

31%

18%

6%11%

2%

MUAC: MUAC measurements were a common topic,including discussions on cut-off points and MUAC-onlyadmission and discharge criteria. Calls were made for moresharing of evidence and experiences and the need for clearguidance on protocols for MUAC-only programming.

Programming where SAM and MAM treatment are notboth in place: Discussions included the use of expandedcriteria for therapeutic treatment in emergencies andcombined protocols, such as MAM and SAM managementusing one protocol and product. Users sought practicalrecommendations on these new approaches and protocolsfor when MAM or SAM treatment are not in place.8

Coverage: Practitioners regularly report difficulties inachieving levels of coverage to adhere to SPHERE standards,raising challenges related to programme quality andimplementation.

Stock shortages of therapeutic products: Questionsregarding appropriate responses to stock shortages instabilisation centres (SCs), outpatient therapeutic programmes(OTPs) and supplementary feeding programmes (SFPs) werecommon, as well as questions on modified treatmentprotocols, rations and reporting. Specific questions includedhow to treat malnourished pregnant women in the absence ofcorn-soy blend (CSB), what to do in the absence of therapeuticmilks (stabilisation centres), and guidance on longer supply ofready-to-use therapeutic food (RUTF) in poorly accessible areas.

Procurement of therapeutic products based on caseloadestimation: While procurement tools for various countriesand programmes were shared on en-net, many questionsremained around calculating the number of people affectedby malnutrition for programme planning purposes. The needfor a global procurement tool for all products was also raised.

Community-based management of acute malnutrition(CMAM) transition strategies: There was disagreement indiscussions around how to handle closure of NGO-supportedCMAM programmes (exit strategies).

Local production of therapeutic products for use in out-patient care: Several posts were made on this topic, withshared examples and recipes from India and Bangladesh; how-ever, there is no global guidance on local production of RUTF.

SAM and cholera treatment guidance: While this is an area ofattention and guidance development, appropriate nutritionalcare of cholera patients who are acutely malnourishedcontinues to present significant challenges for practitioners.

Table 4 Key programming challengesdiscussed on SAM en-net forum

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score (WAZ) and MUAC-for-age); the prosand cons of knowledge, attitude and practice(KAP) surveys; how to achieve a samplelarge enough to examine IYCF indicatorswhen conducting a nutrition/ SMART survey;and how to evaluate programme impact(see Table 5). Additional questions coveredincluded ones on software-based analysis,assessment in pastoralist populations, urbansettings, nutrition surveillance, and assess-ment of adults and older people.

The vast majority (88%) of questionswere successfully answered; 7% were notsuccessfully answered and 5% only partiallyanswered. Gaps in knowledge or guidancemost commonly identified were those underthe themes ‘different types/methodology ofassessment’ (n=14) and ‘planning, sampling,questionnaire/indicators and analysis’ (n=12).

Recommendations andpotential links with the GTAMThis analysis provides a valuable snapshotof technical challenges faced by practitionersin frontline nutrition programming. Questionson en-net often relate to issues where nofirm guidance exists, where assistance isneeded to translate or adapt existing guidanceinto practice or a specific context, or wherethere is a lack of awareness of what global/country-level guidance exists. Answers fromen-net peers/moderators may provide prac-tical illustrations of what is happening else-where or a steer that is based on respondents’knowledge or the opinion of the technicalexpert moderating that area.9 It was beyondthe scope of this review to comprehensivelydetermine which of the outstanding/recurringquestions on en-net are true evidence orguidance gaps and which reflect poor aware-ness/application/accessibility of what is avail-able. However, the findings have identifiedkey technical areas that warrant more scrutinyand insights into future ways of working foren-net and the GTAM.

Handling unresolved technicalquestionsA key challenge identified in this review ishow to handle unresolved technical questions,both within en-net and, looking ahead, viathe GTAM. Within en-net, questions are onlyescalated to technical moderators whenthere is contention or lack of resolution or ifthe question is critical or urgent. This is tomake the most of the limited time that thesecommitted individuals have. In general, unan-


6 www.who.int/nutrition/publications/code_english.pdf7 Since the en-net review took place, a paper has been

published, Considerations regarding the use of infantformula products in IFE programmes (Gribble & Fernandes, 2018), which could be used as a starting point.

8 A dedicated forum on simplified approaches to acute malnutrition that includes combined SAM/ MAM treatment approaches was launched on en-net in July 2019.

9 It is important to note that more straightforward questions to en-net are handled ‘offline’ by the en-net moderator to retain the online forum for discourse regarding challenging issues benefiting from peer and technical expert inputs.


swered or unresolved questions may be due topoorly phrased questions, lack of moderator availability,inability by users/moderators to answer the question,low relevance to other users, no need for a response(e.g. announcement), and/or users being less willingto reply to anonymous users (e.g. 41% of questionson the MAM forum). There may also be wider influ-ences. For example, the prevention and treatmentof MAM forum was the most underused thematicarea on en-net and 17% of posts had no reply. Thismay reflect the lack of attention to and evidence onMAM programming more generally in the nutritionsector (Shoham and McGrath, 2019), or possibly alack of moderator capacity on this particular forum.

Moving ahead, we propose that en-net questionsthat have not received a reply within a definedtimeframe are systematically flagged to technicalmoderators for review and response. Where mod-erators or the en-net community are unable toprovide an answer (definitive or otherwise) or mod-erators judge that further consultation and consen-sus-gathering on an issue would be beneficial, theGTAM may play a role through its interaction withglobal thematic working groups to formulate a re-sponse. The IYCF in the context of Ebola experienceshared earlier is a good example of a working modelfor such escalation in order to develop consensus-driven guidance in collaboration with an expertgroup and country stakeholders.

While technical debates on en-net and experi-ence and knowledge of forum moderators arehighly valued, outstanding technical disagreementor uncertainty may confuse and not serve the im-mediate practical needs of programmers. To helpaddress this, we suggest that ENN and the GTAMcollaborate to summarise difficult discussions, iden-tify gaps in knowledge and guidance, and provideinterim direction to programmers where needed.

Knowledge managementA wealth of advice, knowledge and experiencesare shared on en-net. Users often use the searchfunction to find previous discussions pertainingto the technical issues they are interested in. Whenfirst established, it was anticipated that questionswhen answered would be ‘closed’; in practice,topics often remain current, are revisited and henceall discussion threads remain ‘live’. The GTAM coulduse en-net as an open-resource on an ongoingbasis to identify key technical issues facing pro-grammers and synthesise learning from them. TheGTAM could also use en-net to identify potentialcountry case studies to examine technical challengesin more depth and facilitate cross-country learning.

Strengthening country networks andconnectionsThe GTAM should only be used once countryand regional capacities have been exhausted.en-net is used as a means to locate country-specific resources. For example, several Francoph-one and country-specific materials were providedin response to a request from the DemocraticRepublic of Congo for training materials.10 Thereis a potential role for the GTAM to play in strength-ening this inter- and intra-country-level networkingby directing country-specific questions to appro-priate in-country contacts; this should help widenthe en-net user base and the geographical spreadof users. In other instances, country-specific ques-tions are posed on en-net specifically becausequestions could not be answered in-country. Anexample of this is a request for assistance in in-terpreting the International Code of Marketingof Breast-milk Substitutes (the Code) in Bangladesh,where definitions are not aligned with globalstandards. In such cases, the GTAM could facilitatetechnical advice and expertise through (for ex-ample) escalating the issue to experts on theCode. An important area for ongoing examinationby the GTAM will be how to determine if countryand regional avenues have been explored and ifthere are gaps in technical assistance availableat this level; whether due to evidence gaps orshortfalls in regional/country capacity. This raisesthe bigger question as to the role of GTAM andexisting mechanisms in compensating for capacityshortfalls in the immediate and longer term.

Next stepsen-net is a well-used resource and has becomethe ‘go-to’ place for rapid, practical technical sup-port. These findings substantiate the decision tointegrate en-net within the GTAM service platform.Looking ahead, the authors recommend that theGTAM continues to monitor en-net to identifypotential gaps and inconsistencies in knowledgeand guidance and to help determine key chal-lenges facing programmers.

Findings of this review should be triangulatedwith other reviews and existing knowledge andguidance to confirm whether a technical gaptruly exists and to help inform initial priorities asthe GTAM prepares to start providing technicaladvice, producing consensus-driven guidanceand linking experts with implementers to ensurecritical gaps are filled.

For more information, contact: Tamsin Walters,en-net moderator, [email protected]

Deciding on which measures or combinationof measures (MUAC and WHZ to use forprogramme admission and discharge: Therewere many questions on en-net debatingwhich method is best used for determiningacute malnutrition, particularly the influencethat body shape has on these measures.

Inclusion of infants 0-5 months old innutrition surveys: There is lack of clarity onwhen infants age 0-5 months should beincluded in surveys and methodological/practical implications.

Assessing nutritional status of pre-adolescents and adolescents: Discussionsreflected a lack of consensus on the mostappropriate anthropometric indicators toassess school-age children and adolescents.

Assessing nutrition status of PLW: Discussionsdebated the most appropriate approach to assessnutritional status and admit PLW into treatmentprogrammes, given divergent measurementapproaches and their interpretation (e.g. differentcountries use different MUAC cut-offs).

Inclusion of IYCF indicators in SMARTsurveys: Practitioners carrying out SMARTsurveys found it difficult to determine whichadditional IYCF indicators can be includedwhile maintaining a sufficiently high degree ofprecision to inform programme decisions.

KAP surveys: Ten discussions were generatedaround this topic, particularly around the needfor clarity on when it is appropriate to conducta KAP survey (objectives) and how to do so(questions on sample-size calculations (n=4)and how to combine with SMARTmethodology). This indicates that availableguidance may not be sufficiently detailed orpractical and the need for indicators andstandardised questions for various sectors.

Advanced analyses on nutrition surveys:Examples included issues on stratifying clusters,cross-tabulations when analysing nutritionsurveys and how to implement weight factorfor survey results. Frequent requests for SMARTsurvey training were also noted.

Sampling frames where population-sizeinformation is unavailable: While the SMARTmethodology provides guidance, manyquestions were raised about sampling anddetermining population size in contexts wherethere is no reliable population-size data.

Flags (extreme values): Discussions reflecteda lack of consensus around what flags shouldbe used for analysis of MUAC data, due to thelack of a MUAC reference population.

Gender considerations in measuringmalnutrition: An unresolved debate remainson en-net on the apparent higher prevalenceof undernutrition in boys, including whetherthe WHO Child Growth Standards themselvespreferentially identify boys.

Measuring feeding practices and dietquality of children over two years of age:Questions remain on which indicators areappropriate (and in which contexts) fordetermining feeding practices and diet qualityfor children over two years of age (minimumacceptable diet (MAD) indicator focused onchildren under two years old).

Table 5 Key programmingchallenges discussed onassessment andsurveillance en-net forum

Challenging questions onthe assessment andsurveillance forum

Figure 4

Survey specificquestion, 50%

Generalquestion, 29%

Non-surveyspecificquestion, 21%


10 www.en-net.org/question/3629.aspx

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ReferencesAnnan, A., Web, P., and Brown, R. (2014) CMAM forum briefon MAM. www.ennonline.net/attachments/2289/MAM-management-CMAM-Forum-Technical-Brief-Sept-2014.pdf

GTAM (2019) Baseline Technical Needs Assessment Reportwww.ennonline.net/resource/baselinetechnicalneeds2019

Shoham, J. and McGrath, M. (2019) Editorial perspectiveon the continuum of care for children with acutemalnutrition. Field Exchange issue 60, July 2019. p2.www.ennonline.net/fex/60/extendededitorial

World Health Organisation (2016) Clinical care forsurvivors of Ebola virus disease. Interim guidance. WHO.11 April 2016. www.who.int/csr/resources/publications/ebola/ guidance-survivors/en

Mahmoud Bozo is a WorldHealth Organization (WHO)Nutrition Technical Officer forSyria. He has extensiveexperience in malnutritiondetection and management.

Hala Khudari is a WHOTechnical Officer for theEastern MediterraneanRegional Office, Cairo. Hala isa nutritionist with extensiveexperience in managing and

coordinating health and nutrition emergencyprogrammes in Syria and supporting otheremergency contexts in the region.

Mutasem Mohammad is aHealth InformationManagement Officer for WHOSyria. Mutasem is in charge ofstrengthening healthinformation systems,

assessments, data management and analysis forevidence-based planning and response.

The authors would like to acknowledgeElizabeth Hoff, WHO representative; Dr AyoubAl-Jawaldeh, Nutrition Regional Adviser; andAyman Al-Mobayed, Global InformationSystems Officer for their support to thisprogramme and in the writing of this article.

57


By Mahmoud Bozo, Hala Khudari andMutasem Mohammad

Scale-up ofmalnutritionscreening bythe WorldHealthOrganizationin Syria

Location: Syria What we know: Nutrition surveillance is a valuable means to identify cases ofmalnutrition, facilitate timely treatment, monitor caseloads and so plan services.

What this article adds: A pilot nutrition surveillance system (NSS) was establishedby the World Health Organization (WHO) and Ministry of Health (MoH) in 2014in Syria, based on existing growth-monitoring services at 115 health facilities. Thesystem was expanded to screen children at 802 health centres by 2018. Identifiedcases are referred for community-based management (86 centres) or tostabilisation centres (23) as appropriate; surveillance data informs district andnational planning. From 2017, health-worker training and computerised reportingsystems improved data collection and reporting quality. In 2018, of 928,000children screened, 1.8% were moderately malnourished and 0.6% severelymalnourished (0.1% complicated). System reach was expanded through mobilehealth teams to conflict-affected populations, non-governmental organisations andprivate doctors. Prevalence of global acute malnutrition (GAM) (12%) and stunting(30%) was considerably higher than national average among those identified viamobile screening. Capacity to manage complicated and uncomplicated acutemalnutrition was increased through coordinated WHO, United Nations Children’sFund and World Food Programme support. Nationally, GAM prevalence declinedfrom 2015 (5.25%) to 2018 (2.4%). This was due to stabilisation of the situationand continued humanitarian support to meet basic needs, supported by early casedetection and referral; more effective community-based management of acutemalnutrition services; and infant and young child feeding interventions. Besiegedpopulations remain highly vulnerable. Plans are to increase NSS coverage and tointegrate into the national health information system.

BackgroundEight years of protracted crisis in Syria has hadan immense negative impact on the living con-ditions of the population. Violence, interruptionof services and forced displacement have com-promised access to basic commodities and serv-ices, including food, livelihoods, safe drinkingwater, sanitation, education, shelter and healthcare.is has increased the population’s vulnerabilityto poverty, food insecurity, poor dietary diversityand disease. is, coupled with inadequate infant,young child and maternal feeing practices andgeographical and gender inequalities, has greatlyheightened the risk of malnutrition in childrenunder five years of age.

Impact of the crisis on the healthsystem Health service delivery in Syria has been heavilydisrupted as a result of the crisis and attackshave le health centres damaged and, in somecases, non-functional, significantly reducing theavailability of essential health services to affectedpopulations. By the end of 2018, out of 1,811public health centres assessed, only 68% werereported to be functioning (46% fully and 22%partially) and, out of 11 public hospitals, 76%were reported to be functioning (52% fully and24% partially). irty-one per cent of healthcentres were reported damaged (7% fully and24% partially), as well as 45% of hospitals (11%fully and 34% partially) (HeRAMS 2018a; HeR-AMS 2018b). Figure 1 shows the location offunctioning and non-functioning health centers

and hospitals across the country, which showshighly vulnerable and hard to reach or besiegedareas with limited health services. is situationhas been exacerbated by the fact that 50% ofhealth workers have either fled from Syria or tosafer locations within the country. Health workersare concentrated in areas considered safer (largelyin the central governorates) with reduced avail-ability of skilled health workers in vulnerableareas in the northeast, northwest and southernparts of the country (Figures 2 and 3).

Responding to the emergingneed of malnutritionAccording to the Syrian Family Health Survey(2009), the nutrition situation of children underfive years of age was already poor pre-crisis (23%stunted, 9.3% wasted and 10.3% underweight).Only 42.6% of infants under six months oldwere exclusively breastfed and only 42.2% ofnewborns were introduced to breastfeedingwithin the first hour of birth (WHO/MoH, 2009).Micronutrient deficiencies were also commonpre-crisis, including prevalent anaemia (29.2%,MoH, 2011), vitamin A deficiency (8.7%, MoH1998) and iodine deficiency (12.9%, MoH, 1998)amongst under-fives. Neonatal mortality rates,infant mortality rates and under-five mortalityrates stood at 12.9/1000, 17.9/1000 and 1.4/1000respectively. Pre-crisis, severe acute malnutrition(SAM) was managed in paediatric departmentsin some main referral hospitals. Community-based management of acute malnutrition(CMAM) services have since been established

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Proportion of medical doctors in public health centres per governoratein 2017 and 2018 Figure 2

Proportion of medical doctors in public hospitals per governorate in2017 and 2018Figure 3

2017 2018

to cater for increased crisis-related burden. Sup-plementary feeding programmes (SFPs) and out-patient therapeutic feeding programmes (OTPs)are now co-located in 86 centres across thecountry, managed by the World Food Programme(WFP) and the United Nations Children’s Fund(UNICEF), respectively. Twenty-three stabilisationcentres (SCs) for complicated SAM cases arebased in public hospitals, supported by the WorldHealth Organization (WHO).

Development of a nutritionsurveillance system (NSS) Prior to the conflict, a national NSS reported

cases of acute and chronic malnutrition amongchildren under five years old visiting health fa-cilities for routine immunisations (targeting allchildren under five years – an estimated 2.7million children). is service was intended toprovide parents with information on their child’sgrowth through routine monitoring. Aer theonset of the crisis, concerns regarding increasedrisk of malnutrition and poor case detection ledto a pilot surveillance system in 2014, buildingon existing growth-monitoring services at 115health facilities. is was later transformed intoan emergency nutrition NSS which, by 2018,covered 802 health centres (WHO Syria Annual

Distribution of public health facilities per governorate in Syria, 2018 Figure 1

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report, 2018). e purpose of the NSS is todetect children with acute malnutrition forreferral to management services at treatmentcentres. Global acute malnutrition (GAM) andother nutrition data are collected from publichealth centres and collated into national consol-idated reports to inform evidence-based planning,forecast needs and evaluate programme impact.As children who attend centralised and decen-tralised health centres in multiple governoratesfor routine immunisations are monitored (exceptfor inaccessible areas such as Idleb and parts ofrural areas of Deir-ez-Zor and Raqqa), GAMrates through surveillance data are consideredfairly representative of the country as a whole.Service coverage rates are not currently measured.

Pilot NSS system e pilot initiative began in early 2014, in col-laboration with the Ministry of Health (MoH),United Nations (UN) agencies and national non-governmental organisations (NGOs). e agreedlogical approach was to adapt the existing NSSbased on growth monitoring in selected healthcentres in 12 governorates. Adaptations includedrevised reporting and monitoring tools andtraining for health workers. e pilot governorateswere selected using two criteria: (i) conflict-im-pacted areas (Daraa, Homs, Aleppo, rural Dam-ascus, Idlib, Quneitera and Deir-ez-Zor); and (ii)densely populated areas with high numbers ofinternally displaced persons (IDPs) (Damascus,Tartous, Latakia, Hama and Sweida). In theselected health centres, coverage rates of nutritionsurveillance, capacity of human resources, avail-ability of physical space and equipment needswere assessed and gaps filled. Nutrition surveillancewas also restarted in the highly conflict-affectedgovernorate of Ar-Raqqa through the coordinatedefforts of WHO field staff. Many constraints werereported by selected health centres during thepilot period, including lack of human resources,space, equipment and telecommunication-re-porting utilities. ese obstacles were especiallyevident in the case of Deir-ez-Zor, a significantlyunder-staffed and under-resourced area of thecountry. Despite these challenges, by the end of2014, 115 health centres were integrated into thepilot NSS, covering 50,000 beneficiaries.

Countrywide NSS system – data andmethods Following the success of the pilot, the systemwas expanded to additional health facilities from2015 onwards until, by the end of 2018, 802health centres were included, screening a totalof 928,000 children during 2018 (Figure 4). Ofthese children, 40% were aged under six months;16.5% 6-12 months; 19% 12-24 months; and25% 24-59 months. All children who attendedthe clinic were included in screening, includingthose who attended for immunisations andthose seeing treatment for sickness. e NSScollects data on weight and height (to assesswasting and stunting), oedema, mid-upper armcircumference and on exclusive breastfeeding(maternal report). Cases of moderate acute mal-nutrition (MAM) are referred to SFPs, uncom-plicated SAM to OTPs and complicated casesof SAM to SCs. WHO has worked closely with

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the MoH, UNICEF and WFP (co-members ofthe Nutrition Cluster) to strengthen communi-cation channels between different levels of careto ensure quality referral services. In 2018, 848complicated cases were referred to SCs and 905cases admitted; this suggests that the referralsystem is working.

Data was initially entered manually on pa-per-based registries, submitted monthly by health

centres to district level for collation and submissionto Damascus. However, data quality was limitedby human errors and a cumbersome (delayed)process. To address this, from 2017, monitoring,reinforced trainings, user-friendly Excel spread-sheets and computerised reporting were imple-mented at district and central levels. Reportingformats were improved further in 2018 to differ-entiate between new and returning cases in orderto strengthen the quality of data, treatment and

Map of nutrition surveillance centres, 2018 Figure 4

Infographic presenting data from the NSS, 2018 Figure 5

follow-up. Since mid-2017, infographics such asthose presented in Figure 5 are published on aregular basis to aid communication.

Engaging NGOs and the privatesectorIn areas where health services were severely dis-rupted, additional partners were needed to un-dertake nutrition screening. As a result, surveillancetraining was expanded to local NGOs able toperform screening in Homs, Aleppo, Hama, Has-sakeh, and Raqqa in areas receiving large influxesof IDPs. Training was also provided to 30 privatedoctors in 2016 and 175 doctors in 2018 in eightgovernorates (Damascus, rural Damascus, Homs,Aleppo, Latakia, Tartous, Sweida, and Hama) incollaboration with the Paediatric Society. InAleppo alone, 878 children were screened byprivate doctors in 2018. Of these, one was foundto have complicated SAM, 12 uncomplicatedSAM and 54 MAM. All cases were referred tothe public health system for treatment.

Reaching the most vulnerablewith nutrition screening In situations such as the East Ghouta evacuation,the Raqqa offensive, or the latest displacementfrom Hajin and Baghouz in Deir-ez-Zor, hun-dreds of thousands of people who had beensuffering from long-term food insecurity withlimited access to health services, water and hy-giene, arrived in informal settlements or campsneeding urgent support. Among them, childrenunder five years old were at particularly high

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# of children screened

400

350

300

250

200

150

100

50

0

Number of nutritionsurveillance centres inSyria, 2014-2018

Figure 6

Number of childrenscreened in nutritionsurveillance centres,2014-2018

Figure 7

Number of health centres with integrated NSS2014-2018 by governorateFigure 8 GAM prevalence identified through surveillance

by governorate, 2015-2018Figure 9

risk of malnutrition. In response, mobile teamswere established, made up of NGO or MoHstaff or trained members of the local community,to rapidly screen all children on arrival andrefer identified cases of malnutrition for man-agement. A total of 46 mobile teams have beensupported by WHO to rapidly screen over128,000 children in 2018, including in East Gh-outa, (70,000 children) Aleppo (4,500 children),Hassakeh (7,000 children), Daraa (26000 chil-dren), Quneitera (10,000) and Homs (10,000children). WHO worked closely with UNICEFto share identified cases and UNICEF deployedmobile teams to provide CMAM services, withcomplicated SAM cases referred to the nearestSC. Among those screened, GAM prevalencewas 12% (1% SAM and 11% MAM) and 30% ofchildren were identified as stunted (higher thanthe national average of 2.4% in 2018).

Analysis of NSS expansion andGAM trends Between 2014 and 2018, the number of nutritionsurveillance centres expanded from 115 to 802,growing by approximately 200 health centres peryear across the country (Figure 6) and increasingthe number of children screened (Figure 7). In2018, among 928,000 children screened, the preva-lence of GAM was 2.4% (MAM 1.8%, SAM 0.6%and complicated SAM 0.1%); these cases were re-ferred to SFP, OTP and SCs for treatment.

Since 2015, several approaches have beenused to expand the NSS and associated treatmentservices, including:1. Geographical expansion through an increased number of facilities integrating nutrition surveillance to increase geographical coverage of screening. 2. Capacity-building of health workers in selected health facilities on nutrition screening to increase the number of qualified health workers to undertake this activity.3. Increased availability of nutrition supplies in health centres and hospitals providing nutrition services.4. Increased monitoring and supervision of work established at facility level to help improve quality of care and nutrition services.

An improved security situation in some locationssince 2015 (which increased access to facilities bybeneficiaries, health workers and supporting agen-cies) has also facilitated surveillance and treatment.Figure 8 shows the increase in the number ofhealth centres with integrated nutrition surveillanceover time. By the end of 2018, the NSS was im-plemented in all governorates with the exceptionof Idlib, which was inaccessible from 2015, andDeir-ez-Zor, which was under ISIS control andinaccessible between 2015 and 2017.

e main aim of the surveillance expansionwas to ensure early detection and treatment ofacute malnutrition cases. Figures 9 and 10 showthat overall GAM prevalence remained withinmoderate limits and reduced over time from5.25% in 2015 to 2.4% in 2018 (928,000 screened);SMART surveys found 2.5% GAM in 2015 and1.7% GAM in 2019. Governorates such as Dam-ascus, rural Damascus, Homs, Hama, Latakia

2014 2015 2016 2017 2018

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928000

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2015 2016 2017 2018 GAM prevalence

and Tartous all showed reductions in GAMrates from 2015 to 2018, which can be explainedby the stabilisation of the situation in theseareas and continued humanitarian support tomeet basic needs. Spikes that can be seen inAleppo, Daraa and Hassakeh correlate to acuteemergency situations, such as the evacuation inAleppo at end of 2016, escalation of violence inDaraa mid-2018 and the massive displacementof people in Raqqa and Deir-ez-Zor to Hassakehin mid-to-late 2018. As people moved fromlong-term besiegement or fled from violence tosafer or more accessible areas, screening improvedand the reporting of malnourished childrenconsequently increased. In the cases of Hassakeh,Ar-Raqqa and Deir-ez-Zor that were under ISIScontrol prior to 2017, NSS did not expand asplanned until later (2018-2019), when moreNSS centres were activated.

Factors that likely contributed to the reductionof GAM in certain governorates include the im-plementation of the NSS system enabling earlydetection and referral; raised awareness amongmothers of child health and malnutrition; stronginfant and young child feeding interventions athealth centre and community level by variousnutrition partners; the improved food securitysituation; close management of SAM and MAMcases within the CMAM system, with follow-upat health centres and hospitals; improved securitysituation; and better living conditions.

Development of treatmentservices for acute malnutritionComplicated case management Prior to the crisis, the MoH took the lead onmost nutrition-related initiatives and WHOprovided technical guidance on growth moni-toring and infant and young child feeding ini-tiatives (e.g. the International Code of Marketingof Breastmilk Substitutes and the Baby-friendlyhospital initiative). During the crisis, WHOtook the lead in both nutrition surveillance andmanagement of complicated SAM together withthe MoH, NGOs and health partners. To managecomplicated SAM, from 2014, WHO supportedthe establishment of 10 SCs within the paediatricdepartments of main public hospitals; additionalSCs were established in private hospitals andimplemented by NGOs where public services

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Mor

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were too badly damaged or inaccessible (Figure11). WHO supported SCs with capacity-buildingof the health workforce (training 350 health inSAM management protocols to date); providingmedicines, medical supplies and equipment fortreatment of complicated SAM (e.g. anthropo-metric equipment, antibiotics, minerals, vitaminsand F100, F75 formulas); and providing technicalsupport for treatment protocols and reporting.Referral rates demonstrate strong complemen-tarity of programmes; by 2017 all cases of com-plicated SAM referred to SCs were admitted,compared to 60% of cases in 2015. Furthermore,with continued capacity-building and support,programme implementation and quality hasimproved, reflected in reduced mean length ofstay at hospital from 12 to approximately 6 daysand reduced mortality from 9% to 2.2% in fouryears (Figures 12 and 13). is demonstrateshigh efficiency and quality of service.

Uncomplicated case managementUNICEF and WFP have supported public healthcentres to provide outpatient nutrition services

to manage uncomplicated SAM and MAM casesusing the CMAM approach. Outpatient centreshave expanded over time across the countryand there is good complementarity between theNSS and inpatient and outpatient programmes,with referrals regularly happening between them.

Co-planning of servicesSurveillance data, together with SMART surveydata, are heavily relied on to estimate annualtargets and caseloads to support WHO, UNICEFand WFP acute malnutrition programming. Im-plementation and linkages between SFPs, OTPsand SCs are managed by nutrition officers inMoH who have oversight of MoH activities atdifferent levels and who play an important rolein planning for expansion and deciding wherenew services are needed.

ConclusionsTransforming the existing growth-monitoringsystem into an NSS has had tremendous valuein the timely detection and management ofacute malnutrition in Syria. A strong networkof trained health workers has been establishedand health facilities have been equipped toprovide quality services for screening and casemanagement. is has complemented interven-tions supported by UNICEF and WFP and haspaved the way to strengthen CMAM interven-tions. Data provided by the NSS has enabledMoH, WHO, UNICEF and WFP to plan anddesign appropriate interventions and has providedvital information for country-level planning;for example, for the annual humanitarian needsoverview and the humanitarian response plan,which are used to advocate for funds for theemergency response. NSS data has revealed areduction in GAM rates since 2015; a trendconsistent with SMART survey data. is suggestsan improvement in the overall nutrition situationin the country and points to the benefits ofquick referral, timely management of acute mal-nutrition cases identified, and complementaryservice provision. However, besieged populations

GAM prevalenceidentified throughsurveillance in Syria2015-2018

Figure 10

Mean length of stay inSCs, 2015-2018Figure 12

Mortality rate amongcomplicated SAM casesat SCs, 2015-2018 (basedon a total of 905 casesover the period)

Figure 13

Location of SCs in Syria, October 2018 Figure 11

ReferencesHeRAMS Annual Report-January-December 2018a - PublicHospitals in Syrian Arab Republic. http://applications.emro.who.int/docs/syr/CoPub_HeRAMS_annual_rep_public_Hospitals_2019_EN.pdf?ua=1

HeRAMS Annual Report- January-December 2018b -PublicHealth Centres in Syrian Arab Republic. http://applications.emro.who.int/docs/syr/CoPub_HeRAMS_annual_rep_public_health_2019_en.pdf?ua=1

Ministry of Health, Nutrition surveillance system report,Syria, 2011.

Ministry of Health, Vitamin A deficiency Study, MoH, 1998

WHO/MOH. Syrian Family Health Survey, Syria, 2009

6

5

4

3

2

1

0

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remain highly vulnerable; mobile services proveda successful approach to cater immediately forthose displaced from inaccessible areas and se-curing humanitarian access remains a priorityconcern.

Future plans for the NSS are to increasescreening coverage. Based on the immunisationtarget of 2.77 million children under five yearsold, just one third are currently screened foracute malnutrition, so there is room to gofurther. Other ambitions of WHO and MoHare to integrate surveillance services into allfunctional health centres and improve coverageof children in health facilities already withinthe NSS. Integrating NSS into health informationsystem online platforms is also required to movehealth facilities from paper-based systems tofurther improve quality and timeliness of data.Moreover, with the slow shi to early recoveryin parts of the country, the expectation is forthe system to move towards routine growthmonitoring (while continuing to report on acutemalnutrition to inform the services still provided)with a renewed focus on stunting and other on-going nutrition concerns, such as micronutrientdeficiencies.

For more information please contact MahmoudBozo at [email protected] [email protected]

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Field Article


By Ahmad Nawid Qarizada, Maureen L. Gallagher, Abdul Qadir Baqakhiland Michele Goergen

Ahmad Nawid Qarizada is a NutritionSpecialist for the United NationsChildren’s Fund (UNICEF) Afghanistan.He is a medical doctor with a post-graduate Diploma in Nutrition, aMaster’s degree in Public Health and

over eight years’ experience in public health nutrition withgovernment, non-governmental organisations and UNICEF.

Maureen L. Gallagher is the Chief ofNutrition for UNICEF Afghanistan. Sheis a public health specialist with over15 years’ experience in nutritionprogramming in several countries inAfrica and Asia.

Abdul Qadir Baqakhil is NutritionProgramme Manager for Agency forAssistance and Development ofAfghanistan (AADA). He holds aMaster’s degree in Public Health and a diploma in Public Health Nutrition.

Michele Goergen is a nutrition-in-emergencies consultant with theUNICEF South Asia Regional Office. She has an MSc in Clinical Nutritionand is a registered dietitian andspecialist in the design and

implementation of community-based management ofacute malnutrition and infant and young child feeding inemergency programmes.

UNICEF Afghanistan is grateful to the Agency forAssistance and Development of Afghanistan (AADA) andthe Provincial Public Health Directorate (PPHD) of Faryabprovince for their support in implementation ofintegrated mobile health and nutrition teams in Faryabprovince.

The findings, interpretations and conclusions in this articleare those of the authors. They do not necessarily representthe views of UNICEF, its executive directors or the countriesthey represent and should not be attributed to them.

Integratingnutrition servicesinto mobile healthteams: Bringing comprehensiveservices to anunderservedpopulation inAfghanistan

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Location: Afghanistan What we know: Distance between remote communities and fixed healthfacilities in hard-to-reach areas can greatly impede service developmentand coverage.

What this article adds: Mobile health teams (MHTs) were rolled out by theUnited Nations Children’s Fund with a local partner in 2018 to implementthe Ministry of Public Health basic package of health services (BPHS) inremote/hard-to-reach communities in Faryab province. Four MHTsprovided monthly antenatal care, postnatal care, immunisation, nutritioneducation and management of uncomplicated severe acute malnutrition(SAM) at agreed delivery points between February and December 2018,covering a population of 66,590. BPHS coverage increased by 10%; 19,187children aged 6-59 months were screened for malnutrition, of whom 1,586SAM children were successfully treated (94% cured, 4% defaulted and 1%died). MHTs were successful in improving coverage and service demandbut are unsustainable in the longer term due to cost. The programme wasextended for six months while capacity of government health sub-centreswas built to provide services to the same communities.

Background Afghanistan has struggled with protractedconflict for over three decades and is proneto recurrent natural disasters. Currently,13.5 million people are estimated to befacing emergency levels of food insecurity(levels three and four of the IntegratedPhase Classification.1 Afghanistan has oneof the highest rates of stunting of childrenunder five years old in the world at 37%,2

and an alarming level of under-five wastingat 9.5%.3 Only half of Afghan infants areexclusively breastfed during the first sixmonths of life and only 16% of Afghanchildren aged 6-24 months receive a min-imum acceptable diet that includes theright variety of food in the quantity neededfor their age.

Remarkable improvements have beenmade in Afghanistan’s health system in thepast decade. Coverage of health serviceshas increased from 60% in 2015 to 90% in2019; child mortality has decreased from257/1,000 in 2003 to 55/1,000 in 2015; andmaternal mortality has decreased from1,600/100,000 to 600/100,000. However,Afghanistan still faces considerable challenges.

Rural populations pay around nine timesmore for a one-way trip to a health facilitythan urban populations. Nutrition servicesremain limited and healthcare providerslack training to assess and offer counsellingand treatment services for the managementof malnutrition. Mothers and children livingin remote and conflict-affected areas oendo not access the Ministry of Public Health(MoPH) basic package of health services(BPHS) (Table 1), which is reflected in verylow coverage of antenatal care, postnatalcare, immunisation and nutrition servicesin these areas (all under 50%).4

Remarkable improvements have beenmade in Afghanistan’s health system in thepast decade. Coverage of health services hasincreased from 60% in 2015 to 90% in 2019;5child mortality has decreased from 257/1,0001 Afghanistan Country Overview, ACAPS

www.acaps.org/country/afghanistan/crisis/complex-crisis

2 Afghanistan Health Survey, 20183 Afghanistan National Nutrition Survey, 20134 UNICEF Afghanistan:

www.unicef.org/afghanistan/nutrition5 Coverage estimate based on the population being

within two hours of walking distance to the closest health facility.

AA

DA

Joint monitoring visit at MHT service delivery point by AADAM&E officer and UNICEF health extender, Do Abe village,

Qyasar District, Faryab Province, Afghanistan, 2019

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in 2003 to 55/1,000 in 2015; and maternal mortalityhas decreased from 1,600/100,000 to 600/100,000.However, Afghanistan still faces considerablechallenges. Rural populations pay around ninetimes more for a one-way trip to a health facilitythan urban populations. Nutrition services remainlimited and healthcare providers lack training toassess and offer counselling and treatment servicesfor the management of malnutrition. Mothersand children living in remote and conflict-affectedareas oen do not access the Ministry of PublicHealth (MoPH) basic package of health services(BPHS) (Table 1), which is reflected in very lowcoverage of antenatal care, postnatal care, immu-nisation and nutrition services in these areas (allunder 50%).

Intervention approachMobile health teams (MHTs) provide a vehicleto bring care closer to the homes of underservedpopulations living far from fixed health facilitiesand sensitise communities to health and nutritionservices. In an effort to address outstandingchallenges and to scale up the provision of theBPHS, an integrated model of mobile teams(health and nutrition) was piloted in four districtsof Faryab province, northern region, Afghanistan(Figure 1). e pilot programme was imple-mented and funded by the United Nations Chil-dren’s Fund (UNICEF) in 2018 as part of abroader emergency nutrition programme, in

partnership with the Agency for Assistance andDevelopment of Afghanistan (AADA), a non-profit, independent, registered national organi-sation with expertise in implementingAfghanistan’s BPHS and essential package ofhospital services.

e goal of the project was to reduce maternaland child mortality among the most vulnerable,underserved and highest-risk communities inFaryab province by increasing access to integratedhealth and nutrition services. Faryab provincewas chosen due to its remoteness and the seriouschallenges that parts of its population face interms of access to services. Functional healthfacilities do exist in Faryab; however, due topopulation distribution in very remote areas,the facilities are inaccessible to a portion of thepopulation.

e MoPH approved two types of MHT tobe integrated into the BPHS: reproductive, ma-ternal and newborn child health (RMNCH)MHTs and ‘all-age’ MHTs. RMNCH MHTs targetpregnant women and children under five yearsof age to provide reproductive, maternal andnewborn child health and acute malnutritionservices. ‘All-age’ MHTs provide the same services,but have additional components for adults, in-cluding mental health services, management ofcommunicable and non-communicable diseases,

and trauma care.6 Four RMNCH mobile teamswere established in Faryab province that aimedto cover around 20,000 people each. e MHTsare comprised of four health workers: a midwife;a vaccinator for the expanded programme onimmunisation (EPI) and polio eradication ini-tiative; a nurse or doctor to provide integratedmanagement of neonatal and childhood illness(IMNCI) to children under five years old; and anutrition counsellor. e nutrition counsellorsupports the delivery of nutrition services, suchas maternal and infant young child nutrition(MIYCN) counselling; iron-folic acid (IFA) sup-plementation for pregnant and lactating women(PLW); growth monitoring; uncomplicated severeacute malnutrition (SAM)/moderate acute mal-nutrition (MAM) case management accordingto the national community-based managementof acute malnutrition (CMAM) protocols; vitaminA supplementation; and deworming. ComplicatedSAM cases are referred to one of the two inpatientservice units in the province; although, giventhe remoteness of the location, it is estimatedthat only 50% of referred cases reach inpatientservices.

For this pilot project, MHTs visited designatedservice delivery points (SDP) on a monthlybasis between February and December 2018.SDPs were identified in a mapping workshopwith local government, community leaders andimplementing partners, and are located at villagelevel in areas at least 10km from the nearestfixed health facility. Community groups (healthshuras) were established in each SDP area, madeup of six members representing the local popu-lation. MHTs regularly engaged with these com-munity groups, who provided assistance to staff,including accommodation and security, andhelpful feedback on the performance of MHTsto improve service delivery. e groups alsohelped to sensitise their communities to theservices that the MHTs provide and supportedMHT health-awareness activities concerning,for example, timely health-seeking behaviours,child health, safe drinking water and personalhygiene. To address the issue of treatment in-tervals in the context of CMAM, a mini nutritionteam consisting of a small vehicle, a nutritioncounsellor and supplies visits each SDP every

6 The Government has since unified the approach so that all MHTs in Afghanistan provide all-age services (including RRMNCH services).

Location of Faryabprovince, northernregion, Afghanistan

Figure 1Maternal and newborn care Antenatal care; delivery care; postpartum care; care of the newborn

Child health and immunisation Expanded Programme on Immunisation (EPI); Integrated Managementof Childhood Illness (IMCI)

Public nutrition Prevention of malnutrition; assessment of malnutrition

Communicable diseasetreatment and control

Control of tuberculosis; control of malaria; prevention of HIV and AIDS

Mental health Mental health education and awareness; case identification, diagnosisand treatment

Disability and physicalrehabilitation services

Disability awareness, prevention and education; provision of physicalrehabilitation services; case identification, referral and follow-up

Regular supply of essential drugs Listing of all essential drugs needed

Table 1 Seven elements of the MoPH basic package of health services(BPHS) in Afghanistan and their components

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Almar MHT team members, Khoshbay village, AlmarDistrict, Faryab Province, Afghanistan, 2019

Field Article

64


two weeks to ensure continuation of SAM casemanagement between MHT monthly visits.

All mobile teams operating in Afghanistanare registered in the Health Management Infor-mation System (HMIS) of the MoPH and provideregular reports to the HMIS for health servicesand to the online nutrition database for nutritionservices. MHTs enter daily indicators into theBPHS record system and receive monthly sup-portive supervision from a BPHS coordinator.MHT staff were initially recruited and trainedby the implementing non-governmental organ-isation (NGO) AADA using national certifiedmaster trainers. MHT staff also receive annualrefresher trainings.

Results Estimated baseline coverage of health servicesat the start of the project was around 70%. Inthe past year, HMIS shows that coverage of theBPHS in the four districts covered by MHTshas increased by 10-15% (2018). Districts withMHTs have roughly 10% more coverage thanthose without.

Over the pilot period a total of 66,590 peoplewere reached with health and nutrition services;over half (57%) of whom were children underfive years old. Active screening was not conductedby the MHTs due to the security situation andrough terrain. However, community sensitisationthrough the established community groups en-abled passive screening of 19,187 children underfive years old. Of these, 1,586 children aged 6-59 months were identified as having uncompli-cated SAM (610 male and 967 female) and ad-mitted to the MHT outpatient treatment pro-gramme (OTP). is surpassed the target caseloadof 831 SAM children. Of these cases, six wereidentified as having SAM with medical compli-cations and referred to the nearest inpatienttreatment facility. By the end of the programme,94% of the children who entered OTP treatmenthad been cured, 4% defaulted and 1% died.

During screening 2,451 children were identifiedas having MAM; however, there were no MAMservices in Faryab province. To fill this gap,MHTs provided nutrition counselling and monthlyfollow-up growth monitoring to MAM children.Infant and young children feeding (IYCF) coun-selling and nutrition education reached 4,529caregivers of children aged 0-23 months.

Other services provided by the MHTs alsoproved successful. A total of 2,070 children aged0-11 months (82% of the project target) and1,035 children aged 12-23 months were immu-nised with pentavalent-3;7 1,931 children receivedthe first measles vaccine; 1,194 children receivedthe second measles vaccine; and dewormingtablets were provided to 3,858 children aged24-59 months. Reproductive health serviceswere provided to many women who otherwisewould not have had access to these services. Atotal of 3,486 women registered for the first an-tenatal clinic (ANC) visit; 1,737 for the secondvisit; and 1926 for subsequent visits. is translatesto 89% of the project target for ANC2. Addi-

tionally, 2,198 mothers received one postnatalcare visit within 28 days of delivery.

Discussion e MHT pilot was successful in raising aware-ness on and improving the coverage of healthand nutrition services to remote populations inone province of Afghanistan. e main enablersof this success were the integration of healthand nutrition service delivery into a single plat-form; community engagement to identify ac-ceptable locations for service delivery; and goodcoordination with government authorities atprovincial level. Another key factor was thesupport that communities provided to MHTsin the delivery of health-promotion activitiesand accommodation of MHT staff. While effectivein the short term, there are still challenges tomobile service provision in this context, including: • High cost: Bids for BPHS services that include MHT services are rarely accepted by the MoPH due to their high cost. On average, one integrated MHT costs around USD70,000-80,000 per year (there is no clear data on the cost of a fixed health facility against which to compare this). • Limited coverage: e number of target villages exceeds the capacity of existing MHTs. Additionally, challenges such as rugged mountainous terrain, harsh weather conditions during the prolonged winter, insecurity and time taken for teams to move between villages remain barriers to greater coverage. • Limited support to adult groups for communicable and non-communicable diseases: As RNMCH MHTs were delivered, rather than ‘all-age’ teams, the health kit included medicines to treat childhood diseases only (e.g. amoxicillin powder oral suspension, co-trimoxazole tablets and syrup, paraceta- mol, oral rehydration salts, and IFA for pregnant women). Adult communicable and non-communicable diseases were therefore le untreated. • Exit strategy: Communities become reliant on these services, making it difficult to withdraw once funding or programming has finished. To address some of these issues, UNICEF, inconsultation with government and the imple-

menting NGO, agreed to extend the programmeperiod by six months, during which time effortswere made to scale up SAM treatment servicesin health sub-centres (HSCs).8 HSCs are healthfacilities located closer to communities that covera population of about 7,000 people, thus improvingaccess to SAM treatment services in remote vil-lages. Efforts to extend SAM treatment servicesthrough HSCs and phase out existing MHTs areongoing. During the first three months of 2019,with Common Humanitarian Fund (CHF) fund-ing, AADA built the capacity of HSC staff throughformal trainings and provision of anthropometricequipment and other supplies. A total of 11HSCs in the same catchment area as the pilotMHTs were upgraded to provide SAM, MAMand IYCF services. CHF support concluded on30 August 2019 and the programme was at thatpoint handed over to a new BPHS implementer(Sanayee Development Organization) to be con-tinued with government funding. is strategywill allow remote villages to be reached withoutthe high costs associated with MHTs.

Conclusion MHTs have been an important vehicle in theimmediate term to improve coverage of healthand nutrition services in hard-to-reach areas ofAfghanistan. ey have also served to increaseawareness among remote populations of theimportance of health and nutrition services,sensitising them to seek services in future. How-ever, considerable challenges remain in the useof this model, including high costs, impedimentsto physical access to certain pockets of the pop-ulation and supply chain issues. Despite theselimitations, this pilot programme demonstratesthat MHTs can be a useful way of providingcritical services in the immediate term whilethe capacity of the existing system is built up toachieve a more sustainable model of accessiblehealthcare.

For more information please contact AhmadNawid Qarizada at [email protected]

7 A five-in-one vaccination against diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenza B.

8 Vaccinations and deworming of children with clinical signs of gastrointestinal worms are already provided by HSCs as part of the BPHS. Other children also receive deworming on national immunisation days (NIDs).

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MHT vaccinator vaccinating children, Charkhi village,Almar District, Faryab Province, Afghanistan, 2019

Field Article


Editorial teamJeremy Shoham Marie McGrath Chloe AngoodTamsin Walters

Office SupportClara RamsayJudith FitzgeraldMary MurrayPeter Tevret

Contributors for this issue:

Front coverPregnant women eating asupplementary meal at an ICDScentre, West Bengal, 2018; CINI

The Team

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Abdul QadirBaqakhilAhmad NawidQarizadaAlexandraHumphreysAlice BurrellAndi KendleAntenehGebremichaelDobamoBaidar BakhtHabibBakhodir RahimovBayleyegnBimerewBazlul KabirJoarderBijoy SarkerCindy HwangDanka PantchovaDeepak KumarDr Nagma NigarShah

Dugsiye Ahmed

Esther Busquet

Figsum Aregawi

Hala Khudari

Himali de Silva

Iris Bollemeijer

Isabelle Modigell

Mahmoud Bozo

supported by:

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Thanks to all who contributed or helpedsource pictures for this issue.

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Documents

· Field Exchange issue 61, November 2019, Contents 1 Editorial Field Articles 3 Improving minimum dietary diversity for children aged 6-23 months