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MALNUTRITION TREATMENT AND PREVENTION: A CASE STUDY WITH CAROLINA FOR KIBERA
Jeff Walker2017 MPH-RD Candidate
Advisor: Peggy Bentley
OBJECTIVES
This case study was conducted through a two month internship with Carolina for Kibera (CFK). It was determined that the objectives of the project were:
1. To assess the program’s credibility by asking staff which policies and guidelines staff members followed during treatment.
2. To understand participants’ outcomes by examining quantitative data collected by CFK, interviews with staff, and focus groups with participant families.
3. To explore the programs’ benefits beyond clinical treatment by asking focus group participants and interview staff about household- and community-level changes.
4. To solidify and further the discussion about the future direction of CFK’s nutrition programs by collecting stakeholders ideas in one place.
DATA COLLECTION METHODOLOGY
To understand Lishe Bora’s programs quantitative and qualitative data was analyzed. Data was collected through:
Use of Lishe Bora’s patient records
Household visits
Participant observation
Focus groups with parents of current and past LisheBora participants
Interviews with stakeholders of CFK’s nutrition programs
INTRODUCTION TO KENYA Country of more than 48 million people1
44 different tribal and ethnic groups, most with local languages or dialects1
Major commercial, cultural, and political hub of East Africa
Political environment became favorable in nutrition in 20112
High levels of food insecurity and low to medium severity of stunting/wasting prevalence according to the World Health Organization (WHO)1
Photo Credit: The Commonwealth Secretariat, http://thecommonwealth.org/our-member-countries/kenya
INTRODUCTION TO KIBERA Informal settlement or slum of ~250,000 people3
Three largest tribes or ethnic groups are Luo, Luhya, and Kisii
Made up of thirteen villages located southwest of Nairobi’s Central Business District
46.5% employed in casual labor, with poor investment in transport, electricity, and sewage infrastructure4
Health care access more restricted, but still available through community clinics
Limited income and food costs often restrict diets to basic staples like ugali, sukuma wiki, chapati, beans, mandazi, and black tea
Stunting prevalence of 38-48%, categorized as high or very high severity by WHO5
KIBERA FACING EAST FROM THE RAIL LINE
THIRTEEN VILLAGES OF KIBERA
Photo Credit: Map Kibera Project , http://mapkiberaproject.yolasite.com/resources/villages_names.jpg
CAROLINA FOR KIBERA (CFK)Carolina for Kibera’s mission is “to develop local leaders, catalyze positive change and alleviate poverty in the Kibera slum of Nairobi.”6
Founded in 2001 by Rye Barcott, Tabitha Atieno, and Salim Mohamed
Committed to addressing malnutrition in Kibera
Rooted in participatory development; the community is heavily involved in identifying needs, program planning, and giving feedback
Three departments: Economics and Entrepreneurship, Health, and Social
Health Department operates many programs beyond Lishe Bora
CFK’S PEDIATRIC NUTRITION PROGRAMSClinical Programs
Lishe Bora Mtaani (Better Community Nutrition) is a Severe Acute Malnutrition (SAM) treatment program with early child development (ECD) components for children under five
Outpatient Therapeutic Program (OTP) for children with Moderate Acute Malnutrition (MAM)
Community Outreach Program
Multicomponent providing health ed, resources for healthy behavior, and community mobilization
GUIDELINES FOR LISHE BORA
WHO Guidelines
WHO Child Growth Standards (2006)7
WHO child growth standards and the identification of severe acute malnutrition in infants and children (2009)8
Guideline: Updates on the Management of Acute Malnutrition in Infants (2013)9
Kenyan Guidelines
Integrated Management of Acute Malnutrition (2009)10
Maternal, Infant, and Young Child Feeding Policy (2013)11
THE EVIDENCE-BASE OF LISHE BORA Intersection of nutrition and ECD is an important current topic among child development, education, medicine, public health, and nutrition researchers
Series in the Annals of the New York Academy of Sciences published in 2014 focuses on integrated nutrition and ECD interventions12
Integrated programs targeting undernourished children seemed especially beneficial13
Age range captures 1st and 2nd 1000 day windows14
Center-based programs in Malawi were improved outcomes especially for children who were orphaned, in poverty, or disabled15
QUANTITATIVE RESULTS
328 children enrolled and treated for SAM since opening in May 2013
Villages of Gatwekera, Kianda, and Soweto West have accounted for 86.9% of admissions
Three diagnoses for SAM include:Mid-Upper Arm Circumference (MUAC) of less than 11.5 cm – 68.6% of admissions Weight-for-height z-score of less than -3 – 26.8% Edema – 4.6%
289 children have been discharged, with 91.4% successfully cured
Same criteria were used to admit and discharge a child in 61.4%of cases
DISTRIBUTION OF CASE DURATION
2.18%
9.45%
49.82%
27.64%
4.73% 6.18%
1-5 Weeks
6-10 Weeks
11-15 Weeks
16-20 Weeks
21-25 Weeks
26+ Weeks
QUALITATIVE RESULTS5, 17-28
Benefits to the Child Beyond Anthropometrics
Increased activity levels, socialization, and physical abilities
Benefits to the Family
Nutrition and ECD information and resources provided
Improved financial stability during enrollment
Benefits to the Community
Increased difficulty in identifying children with malnutrition
Strong community partner in supporting and developing capacity
DISCUSSION OF CHALLENGES AND CONCERNS5, 17-28
Internal
Sustainability of the program
Declining enrollment
Lack of data for monitoring and evaluation
Limited communication between Community Health Workers (CHWs) and leaders at the program and department level
External
Household food environment
Lack of quality ECD centers and daycares
Lingering HIV stigma
DISCUSSION OF FUTURE DIRECTION5, 17-28
Collaboration with ECD centers and daycares in Kibera to provide nutrition education and services
CFK-owned and operated ECD center with admission limited to children discharged from malnutrition treatment programs
Promotion of Lishe Bora as a resource in the community and increased nutrition-focused household screening
Improvement of the monitoring and evaluation system to remain accountable to local stakeholders and improve CFK’s ability to prove impact and value in community
QUESTIONS?
REFERENCES1. Kenya National Bureau of Statistics et al. (2014). Kenya Demographic and Health Survey 2014, 14.
2. Scaling Up Nutrition Movement. (2017). Kenya - SUN. Retrieved November 27, 2017, from http://scalingupnutrition.org/sun-countries/kenya/
3. Desgroppes, A., & Taupin, S. (2009). Kibera: The Biggest Slum in Africa? Hal, 1–13. Retrieved from https://halshs.archives-ouvertes.fr/halshs-00751833/file/Amelie_Desgroppes_Sophie_Taupin_-_KIBERA.pdf
4. Kyobutungi, C., Ziraba, A. K., Ezeh, A., & Yé, Y. (n.d.). Population Health Metrics: The burden of disease profile of residents of Nairobi’s slums: Results from a Demographic Surveillance System. https://doi.org/10.1186/1478-7954-6-1
5. Obanyi, H. (2017). Sub-County Nutritionist Transcript. Kibera, Kenya.
6. Carolina for Kibera. (2017). CFK | Talent is universal, opportunity is not. Retrieved November 18, 2017, from http://cfk.unc.edu/
7. WHO Department of Nutrition for Health and Development. (2006). WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. https://doi.org/10.4067/S0370-41062009000400012
8. WHO child growth standards and the identification of severe acute malnutrition in infants and children. (n.d.). Retrieved from http://apps.who.int/iris/bitstream/10665/44129/1/9789241598163_eng.pdf?ua=1
9. World Health Organization. (2013). Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. World Health Organization, 1–123. https://doi.org/10.1007/s13398-014-0173-7.2
10. Kimani, F., & Sharif, O. (2009). National Guideline for Integrated Management of Acute Malnutrition. Clinton Foundation HIV/AIDS Initative, (June), 1–51.
REFERENCES11. Njiru, J., & Matiri, E. (2013). Maternal, Infant and Young child nutrition: National: National Operational Guidelines for health workers, 18–
160. Retrieved from http://pdf.usaid.gov/pdf_docs/PA00JTGD.pdf
12. Chan, M. (2014). Investing in early child development: An imperative for sustainable development. Annals of the New York Academy of Sciences, 1308(1). https://doi.org/10.1111/nyas.12376
13. Grantham-Mcgregor, S. M., Fernald, L. C. H., Kagawa, R. M. C., & Walker, S. (2014). Effects of integrated child development and nutrition interventions on child development and nutritional status. Annals of the New York Academy of Sciences, 1308(1), 11–32. https://doi.org/10.1111/nyas.12284
14. Gertler, P., Heckman, J., Pinto, R., Zanolini, A., Vermeersch, C., Walker, S., … Grantham-Mcgregor, S. (2014). Labor market returns to an early childhood stimulation intervention in Jamaica. Science. Retrieved from http://science.sciencemag.org/content/sci/344/6187/998.full.pdf
15. Black, M. M., & Rao, S. F. (2015). Integrating Nutrition and Child Development Interventions: Scientific Basis, Evidence of Impact, and Implementation Considerations 1–3. https://doi.org/10.3945/an.115.010348.852
16. Munthali, A. C., Mvula, P. M., & Silo, L. (2014). Early childhood development: the role of community based childcare centres in Malawi. SpringerPlus, 3(1), 305. https://doi.org/10.1186/2193-1801-3-305
17. Akoth, V. (2017). Lishe Bora ECD Teacher Transcript 1. Kibera, Kenya.
18. Areso, J. (2017). ECD Center Director Transcript. Kibera, Kenya.
REFERENCES
19. Kaburia, F. (2017). Tabitha Nutritionist Interview Transcript 2. Kibera, Kenya.
20. Lang’at, F. (2017). Tabitha Clinic Manager Transcript.
21. Madahana, M. (2017). Lishe Bora ECD Teacher Transcript 2. Kibera, Kenya.
22. Moturi, J. (2017). Tabitha Nutritionist Interview Transcript 1. Kibera, Kenya.
23. Muasa, M. (2017). CFK Head of Health Department Transcript.
24. Nekesa, J. (2017). Lishe Bora Data Clerk Transcript. Kibera, Kenya.
25. Omala, H. (2017). CFK Executive Director Transcript.
26. Opana, E. (2017). Lishe Bora Nutritionist Transcript. Kibera, Kenya.
27. Parents of Discharged Children 1. (2017).
28. Parents of Discharged Children 2. (2017).