July 2024 ISSUE 73

Exchanging learning between
colleagues around the world
FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

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Contents
Editorial

3Views
4 Scaling up clean cooking in India:
What this means for nutrition, health,and beyond

7 Appropriate nutrition support forchildren in institution-based care: Is it too
much to ask?

10 Vijana Twaweza Club: Food security via
a refugee-led organisation in Kenya

13 Food systems, climate change, andnutrition: Taking a unified approach

Original Articles
15 Reviewing the FHI 360 mother-tomother support experience in Yemen

18 Kenya: Linking information to action.
Synthesis of coverage assessment
findings

22 Trialling a multi-MUAC tape to screen atrisk infants under six months in East Africa

25 Experiences implementing a rapid© UNICEF Photo/Karel Prinsloo

nutrition determinants assessment
in Nepal

29 Baxnaano: Integrating social
protection, health, and nutrition
in Somalia

Research Snapshots

32 Stunting in the first year of life:
Pathway analysis of a birth cohort

32 Intimate partner violence and childstunting in South Asia

33 Postnatal interventions for infants
under six months: A systematic review

33 Rwanda: Before and after study ofa national supplementary feeding
programme

34 Adolescent pregnancy and childundernutrition: A meta-analysis

34 Bangladesh: Experiences ofadolescent mothers in caring for theirpreterm babies

35 Characteristics of global data onadolescents’ dietary intake

35 Finding the most vulnerable: Ways toidentify malnourished infants

36 Are children with disabilities more likely
to be malnourished?

Villagers work in a vegetablegarden, made possible by theconstruction of a water reservoir
in South Western Madagascar

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FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

36 Children with disabilities lack accessto nutrition, health, and other services

37 Impacts of cash transfers on maternaland child health outcomes in subSaharan Africa

37 Navigating school health programmes
amidst COVID-19: A scoping review

Report Summaries

38 Building synergies between childnutrition and social protection

39 Climate change and health: A draft
resolution

39 Global resilience report
40 Improving maternal nutrition: The
UNICEF acceleration plan

40 Making food systems work forcomplementary feeding

41 Scaling up severe wasting
programming

42 Responding to nutrition in
emergencies within the climate crisis

42 Supporting infants aged under six
months with feeding difficulties anddisabilities

EditorialA

warm welcome to the 73rd issue ofField Exchange. In this issue we are excited to bring you articles on a varietyof themes and contexts.

The topic of food systems has of course
gained traction in recent years and remains ofcritical importance. In a views piece, Richardson
draws attention to the intersection of food systems, climate change, and nutrition. This article builds upon recent learning from a variety of sources, drawing in particular from ENN’s
recent literature review on food systems (ENN,2024). Given each of these topics remain complex, interconnected, and codependent, the author highlights four collective actions we can all
take now to address these pressing issues. By future-proofing solutions, we can address current
challenges while at the same time proactively engaging with future effects, ensuring sustainability in doing so. More systematic and intentional collaboration – between climate andnutrition actors – can boost co-benefits. Fragile and conflict-affected contexts need greaterattention because these populations are mostvulnerable to climate change, food system failures, and undernutrition. Lastly, more stories
of how positive change can happen need to beshared. This last point is true across all sectors,
as we seek solutions to challenges rather thanstraightforward critique.
Providing a great example of this last point inaction, O’Keeffe and Luundo describe a smallscale community farming project to address
food insecurity in Kakuma refugee camp. The
authors take us through the evolution of the Vijana Twaweza Club run by students in the camp,from a small fishpond to an internationally renowned success story. As well as generating income, which is then reinvested into the farm andadditional training activities, the club provides avaluable nutrition source for over 500 families.
This is even more prescient with the recent news
that rations in the camp are to be reduced by
60%, on top of further cuts seen in the previous
year. Beyond this success story itself, the authors
also underscore the value of refugee-led development in the broader humanitarian space.
Turning our attention to India, Fracassi et al
speak to the value of improved, clean cookstoves and how scaling up this technology can
improve nutrition and health in rural areas. The
health and environmental benefits of cleaner
cooking appliances – such as improved indoor
air quality and reduced carbon emissions – havebeen well documented, but this article delves
into the nutrition-specific benefits. Clean cookstoves can directly enhance the nutrient quality of foods and increase overall dietary diversity,
as cooking becomes more efficient and people
are better able to handle a diverse array of foodtypes. These changes can have an impact on nutritional status, but such cookstoves also resultin time saved when both cooking and collecting firewood. In this setting, women reported
saving up to two hours per day on firewood collection and a further 50 minutes on cooking-re-Using a pellet-based improved
cookstove. India

lated time. Such savings can, in turn, lead to further income-generating opportunities and thecombatting of detrimental social norms.
Several articles touch on the theme of linking information to action. To do this, understanding nutritional determinants and causal
pathways remains critical for the design of contextualised and targeted programmes. Existing assessment approaches are useful, and havebeen used successfully, but they may be timeand resource intensive. Blanarova et al describe the pilot of a rapid nutrition determinants
assessment approach in Nepal, undertaken by
the Moderate Wasting Initiative in partnershipwith Action Against Hunger. The approach was
widely accepted and demonstrated value in improving local government understanding of thecausal pathways to undernutrition in three municipalities. Lessons learned from the pilot highlight how, as with the introduction of any new
methodology, robust training of assessment
teams is crucial to ensure quality within a designated timeframe.
In Kenya, Maina et al synthesised data from18 independent coverage assessments to inform the scale-up of services to address wasting
across Kenya’s arid and semi-arid counties. The
pooled analysis highlighted where inter-county collaboration can address specific geographical issues and how poverty alleviation, stronger
community systems, and gender equity are critical to increasing treatment coverage and promoting prevention.
Remaining in East Africa, Brennan et al revisit
the use of mid-upper arm circumference (MUAC)
as a screening tool for at-risk infants aged under six months. This approach was first highlighted by Rana et al in Field Exchange 64. In
this new article, the authors explore operational pilots in Ethiopia, Somalia, Kenya, and South
Sudan where, despite data gaps, the findings
highlight important design improvements tooptimise MUAC tapes for infants and pregnant
and breastfeeding women. These pilots also
highlight key challenges when using these multi-MUAC tapes, which bring their own learning
opportunities.
Also in East Africa, we feature an article
which zooms out from nutrition and speaks
to social protection more broadly. Specifically, Kureishy et al describe the development ofSomalia’s first national social protection programme, Baxnaano. This account provides important lessons learned for the scaling up of
government-led cash transfer programmes andthe introduction of adaptations such as conditionalities, to address the challenges of low uptake of health and nutrition services. A scop-© Ecosense Appliances TeamDear readers,

Editorial

ing review by Ngamasana and Moxie affirms
the use of conditional cash transfers to positively impact maternal and child health outcomesin sub-Saharan Africa, while a report by UNICEF
provides guidance on building synergies between social protection and nutrition.
Several of this issue’s articles focus on the neglected topic of infant and child feeding and disability. An analysis by Rotenberg et al analyses
data from multiple indicator cluster surveys in 30
low-and middle-income countries. They foundthat children aged two to four years with disabilities were significantly more likely to be stunted, wasted, and/or underweight compared tosimilar aged children without disabilities. Exacerbating these inequalities, work by Rice et al
showed that households in Uganda that havechildren with disabilities lack access to essential
nutrition and health services. A views piece by
DeLacey draws our attention more specificallyto institutional-based care, where one-quarterof children are disabled and one-third of themexperience feeding difficulties. While global
policies focus on discouraging institutionalisation, on a more immediate and practical level
positive impacts can be achieved by improving
caregiver training, providing appropriate feeding interventions, and with stronger government engagement. In support of addressing
gaps in this area, ENN has provided an overview of resources and evidence around identifying and supporting infants under six months
with feeding difficulties and disabilities.
We can’t capture every article here, withthis issue featuring a wealth of additional content to explore. This includes an original article by Ibrahim et al on mother-to-mother support groups in Yemen and research summaries
on topics ranging from climate change to theeffectiveness of postnatal interventions to adolescent mother experiences in Bangladesh.
Happy reading!

Anne, Nicki, Phil, and Tom

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3Views
Views© Ecosense Appliances Team

Using a pellet-based improved
cookstove. India

Scaling up
clean cooking
in India:
What thismeans fornutrition,
health, andbeyondPatrizia Fracassi
Senior Nutrition and Food
Systems Officer at Food andAgriculture Organization (FAO)
Tiziana Pirelli
Coordinator of the Global
Bioenergy Partnership (GBEP)
at FAO
Tomoko Kato
Nutrition Officer at FAO

Constance Miller
Deputy Coordinator of GBEP at
FAO

Ketaki Kokil
Director at Ecosense Appliances
Pvt Ltd

Linda Migliorati
Nutrition Mainstream Intern at
FAO

4What we know:

Each day, millions suffer from inhaling hazardous smoke from inefficient,
traditional cook stoves. Clean cooking solutions offer a promising alternative,
emitting fewer pollutants, while being more efficient and environmentally
sustainable.

What this adds:

Conventionally, the discussion around clean cooking has centred on its healthand environmental benefits. This article explores some of the nutritional
benefits of using improved cookstoves (ICS), such as increased dietary
diversity, while highlighting additional challenges and opportunities to scaling
up this practice drawing on a case study from India.

G

lobally, one in three individuals still rely on traditional
cook stoves and/or open fires
for cooking. Indoor air pollution has an impact on multiple health outcomes, including eye irritation, coughing,lung congestion, increased blood pressure, childhood pneumonia, lung cancer,
and cardiovascular diseases (Kumar et al,2023). Formaldehyde release from biomass
combustion increases the risk of low birthweight, even at low levels, while use of kerosene and coal is linked to an increased
risk of neonatal death (Epstein et al, 2013).
Compounding this, the use of solid biomass fuels contributes to greenhouse gas
emissions, deforestation, and habitat destruction (Brooks et al, 2016).
A range of clean cooking solutions, including improved biomass cookstoves, biogas/biodigester systems, ethanol cookstoves, and liquified petroleum gas orelectric stoves, are readily available (IEA,
2023). Technologies like pellet-based improved cookstoves (pellet ICS) offer advantages in areas where access to more
expensive solutions such as liquified petroleum gas and electric systems is unattainable. Pellet ICS are more efficient than traditional cooking methods. They save time interms of cooking and collecting firewood

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex(Jagger et al, 2019) and reduce smoke, butthey also promise wider benefits. Environmental preservation, improved health, andenhanced social well-being – including opportunities for education, employment,
and leisure (Jagger & Das 2018) – are alloutcomes associated with this technology.
Recent studies also indicate potential direct and indirect impacts on nutrition-related outcomes (figure 1). ICS canincrease dietary diversity (Anderman etal, 2015; Jada & Van Den Berg 2022) andthe number of meals eaten per day (Fadly
et al, 2023), and can improve the nutritional quality of food. Karanja and Gasparatos (2019) state that the consistent use ofclean cooking stoves leads to a higher dietary diversity and consumption of nutritionally rich foods, thanks to easier temperature control and the ability to prepare
previously avoided meals that required
time-consuming preparation. Time savedon cooking and collecting firewood canlead to indirect benefits on both nutrition
and well-being as women have more timefor feeding and childcare activities, as wellas income generating or employment opportunities (Jagger et al, 2019; Jagger &Das 2018). Freeing up time also enables
girls to attend school (Karanja & Gaspara-

Viewstos 2019), which in turn can help break the intergenerational cycle of malnutrition (Wodon
et al, 2018).
Evidence also shows the potential for circular economy benefits from pellet ICS. Foodwaste or agricultural residues can be used as biomass feedstock, like in the case of cashew nut
shells, or transformed into pellets and thus contribute to income generating activities and local employment across the clean cooking value
chain (Babu et al, 2022).
Still, there are significant barriers to thesuccessful scaling up of clean cooking technologies. For pellet ICS in particular, these include shortages of pellet production equipment
and spare parts, costs of pellets compared withfree charcoal or wood (Jagger et al, 2019), andcultural factors rooted in traditional cooking
norms (Karanja & Gasparatos 2019). These are
explored in the following case study from India.

Case study: The Clean
Cooking Initiative

The Clean Cooking Initiative is a public–private partnership led by the Ecosense Appliances enterprise in collaboration with various
Indian government ministries. The initiative
has developed pellet ICS for rural communities that predominantly rely on traditional biomass-based cooking methods. The current pilot has reached approximately 500 households
in the Indian states of Maharashtra and Gujarat. Stoves are distributed for free, while households are responsible for purchasing the pellets. To encourage pellet ICS uptake, a networkof village agents has been established. Report-

Figure 1

ed findings in this article are based on regularhousehold-level assessments carried out by thevillage agents at baseline, and then at three- andsix-month intervals thereafter.

Household and individual benefits

The village of Kalsar is one of the pilot areas in
Gujarat, where 200 households have received
pellet ICS. Here, women traditionally travel toa nearby forest to collect firewood with their
young daughters, spending up to four hours oncollection. Each time, women collect up to 30–
40kg of firewood, which they then carry homeon their back and consume within the subsequent 3–4 days. When using pellet ICS, womenreported saving up to two hours each time theycollect firewood, freeing up time for other activities including (importantly) girls’ education.
They also reported saving up to 50 minutes per
day of cooking-related time – including on theignition of stoves, cooking time, and cleaning ofutensils, kitchen walls, and floors (as pellet ICS
do not emit smoke).
At baseline, almost all households in the
project area reported eye irritation and coughing when using traditional cook stoves. Some
women also mentioned suffering headaches.
The portability of pellet ICS also allows movement inside or outside the house depending on
the season, lessening the risk of these symptoms. Cooking outside with more space wasalso mentioned by users as being conducive toengaging the entire family in cooking. Whencooking on traditional cook stoves, in a closed
kitchen, it is often only women who are involvedin the cooking activity. This segregation further
entrenches detrimental social norms.

Community and environmental
benefits

Babul trees grow in marginal lands aroundKalsar village. They absorb ground water, creating water management challenges. The project utilised these Babul trees and agricultural crop residue to create pellets. A village-levelproduction unit was established close to the local market, farms, and the forest to facilitate access. Around 500 kg per day of pellets are produced, creating employment for five people. By
using Babul trees, broader deforestation is also
limited. According to laboratory testing, eachpellet ICS promoted by the Clean Cooking Initiative reduced carbon emission by five tonnes
each year, along with a 60% reduction in firewood usage.

Challenges to uptake: Tradition vs.
innovation

To understand the barriers rooted in traditional cooking norms in the village of Kalsar,
the initiative conducted a behaviour and emotional study. The study conducted door-todoor visits of households relying on firewood
for cooking to gain a better understanding of
cooking practices, family dynamics, and potential financial barriers. The study highlighted the importance of several aspects to consider when promoting pellet ICS. Traditional
cooking was strongly associated with preserving cultural identity and traditional tastes. On
the contrary, switching to clean cooking technologies was associated with modern life andwomen working outside the home, which still
carries negative bias in the community. Particular barriers were encountered from older

Pathways linking improved cookstoves to better nutrition

CLEAN COOKSTOVE IMPACTS

REDUCED INDOOR AIR
POLLUTION
Reduced eye
irritation
Reduced coughing
and lung congestion
Reduced risk of
neonatal death

REDUCED DRUDGERYTIME SAVED FROMCOLLECTING FUEL AND
COOKING

INCREASED DIET
DIVERSITY

INCREASEDNUTRITIONAL FOODQUALITY

Reduced back pain
Increased birthweightBETTERHEALTH

INCREASED DIETADEQUACYBETTER
NUTRITION

REDUCED FIREWOOD
EXPENDITURE

REDUCED
DEFORESTATION

Income generating
activities
Childcare activities(e.g. nutritious meal
preparation forchildren)
Increased school
attendance
Leisure activities

WOMEN
EMPOWERMENTAND ENHANCEDWELLBEINGBETTERENVIRONMENTFIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

5Views“It not being our way of cooking” is a quotethat captures the culture, habits, and values that
oppose the new in favour of traditional practices. “The traditional cooking stove is free of cost”
was another statement that was recorded, which
does not account for the unpaid work that women spend in collecting firework and cooking.
This speaks to a lack of financial independence
for women, who may be hesitant to ask husbands to invest in new cooking appliances forthe house when the traditional method is free.

The campaign for change

To overcome these barriers, the Clean Cooking Initiative undertook a ‘campaign for change’
aimed at promoting the uptake of ICS within the community, emphasising health benefits and smoke and firewood reduction. The
campaign involved various steps, from choosing community champions to undertaking promotional events during weekly markets and/or
through community groups, schools, and individual visits. Some basic principles were applied: a focus on women being the change agent,
including a mix of young girls through to elder
women; community presence of the project
team to promote familiarity and trust; productavailability at a local store for purchase and after-sale services; and sustainable local production of biomass fuel as described above.
During household visits, the project team
noticed that school-going children were interested in understanding the new cooking technology. As a result, they conducted demonstrations of pellet ICS in schools and gave readingmaterial to the children to share with their parents. The project also designed a special pellet
ICS to be used in a school canteen, cooking for
100 children at a time.

Lessons learned

In contexts grappling with the consequences of
traditional cooking methods, the developmentof pellet ICS represents an important innovation. This technology brings various advantages, from saving women's time to reducing harmful emissions and ensuring the safety of homes.

© Ecosense Appliances Team

family members who fear changes in taste andfood not being cooked properly.

Using a pelletbased improved
cookstove. India

However, traditional stoves remain popular,
more often because of societal norms and emotional ties than challenges with affordability.
In this clash between old and new, the initiative has successfully used a behaviour change
campaign to champion the adoption of pellet ICS. This campaign went beyond marketing the product; it discussed social behaviours
and involved a wide range of groups, including
school children, young women and men, married women and their husbands, and older family members. The campaign orchestrated awareness-building sessions at schools, community
gatherings, and women’s homes, creating opportunities for potential users to witness thetransformative impact of the pellet ICS. To increase the nutrition sensitivity of pellet ICS, additional campaigns could integrate healthy recipes when promoting cooking demonstrations.
The pellets, sourced from agricultural waste,
not only contribute to reducing deforestationfrom the collection of firewood but also play arole in improving public health. The ash generated in the cooking can be used as fertiliser. Thisholistic approach forms the foundation of a social enterprise, turning agricultural residue intoa valuable energy source—a true embodimentof the “waste to energy” mantra.
The initiative recognises the disproportionate impact of traditional cooking methods on
women, both in terms of the physical drudgery
involved in firewood collection and the adverse
health effects, as well as the missed opportuni-

ties due to time constraints. This article highlights the imperative need to include womenand the community at large in the design andexecution of solutions for clean cooking energy access. In relation to the nutrition benefits of
the use of clean cooking technologies, the following three research gaps have been identified
when looking ahead. First, finding best practices on how to integrate nutrition into upscaling
approaches. Second, the evaluation of impact
on diet diversity, young child feeding practices, and broader nutrition outcomes. Third, theneed for feasibility studies on using such technologies in institutional settings (e.g. schools).
These gaps are being addressed via a collectionof case studies.
For more information and to submit your bestpractices, visit https://www.fao.org/in-action/
global-bioenergy-partnership/programme-ofwork/working-areas/bioenergy-and-nutrition/en
For more information, please contact Linda
Migliorati at linda.migliorati@fao.org

References
Anderman T, DeFries R, Wood S et al (2015) Biogas cook
stoves for healthy and sustainable diets? A case study
in Southern India. Frontiers in Nutrition, 2Babu S, Singh Rathore S, Singh R et al (2022) Exploring
agricultural waste biomass for energy, food and feed
production and pollution mitigation: A review. Bioresource Technology, 360, 127566
Brooks N, Bhojvaid V, Jeuland M et al (2016) How
much do alternative cookstoves reduce biomass fueluse? Evidence from North India. Resource and Energy
Economics, 43, 153-171
Fadly D, Fontes F & Maertens M (2023) Fuel for food:Access to clean cooking fuel and food security in India.
Food Security, 15, 2, 301-321
IEA (2023) A vision for clean cooking access for all. iea.org
Jada K & Van Den Berg M (2022) Energy efficiency,
women empowerment, and food security: The caseof improved cook-stove in Ethiopia. SSRN Electronic
JournalJagger P & Das I (2018) Implementation and scale-upof a biomass pellet and improved cookstove enterprisein Rwanda. Energy for Sustainable Development: The
Journal of the International Energy Initiative, 46, 32-41

Demonstration of improved
cookstoves. India

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FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex© Ecosense Appliances Team

Jagger P, Das I, Handa S et al (2019) Adoption andimpacts of clean bioenergy cookstoves in Kenya. Renewable and Sustainable Energy Reviews, 102, 285-306
Kumar P, Singh A, Arora T et al (2023) Critical review on
emerging health effects associated with the indoor air
quality and its sustainable management. Science of the
Total Environment, 872, 162163
Wodon Q, Montenegro C, Nguyen H et al (2018) Missed
opportunities: The high cost of not educating girls.
worldbank.org

ViewsAppropriate
nutrition
support forchildren in
institutionbased care:
Is it toomuch toask?
Emily DeLacey
Director of Nutrition and
Health Services at Holt
International
The images shown in this article featurevulnerable children in institution-based care.
Full consent was obtained and care wastaken to feature appropriate imagery which isrelevant and important to this story.

G

lobally, between 3.18 million and 9.42
million children are estimated to beliving in IBC (Desmond et al, 2020).
Prior to their admission into IBC,
many orphaned and vulnerable children may
have faced compounding adversities. Prenatal substance exposure, trauma, neglect, abuse,and conditions such as HIV/AIDS or disabilities are commonly observed, making these children more vulnerable to developing malnutrition (Dozier et al, 2012). Those who are at higher
risk – such as infants and children with disabilities – are overrepresented in IBC. More than one
in three children in IBC are estimated to be aged
under one year and one in four are estimated tohave a disability (DeLacey et al, 2020). However,despite there being a large population of vulnerable children in IBC, this group is still regularly excluded from global nutrition conversations,research, and programming, as well as from routine essential health and nutrition services, surveys, and policy decisions. Much about theirneeds remains unknown.
In 2021, we conducted research to fill theinformation gap on the nutrition-related epidemiology of children living in IBC across six
low- and middle-income countries: Mongolia,
India, Ethiopia, Vietnam, China, and the Philippines (DeLacey et al, 2021). We used healthrecords collected from Holt International’s nutrition screening database between 2013 and2020. Data analysis of baseline nutrition screening from 2,926 children aged 0–18 years old revealed that children living within IBC were ex-

What we know:Children living in institution-based care (IBC) represent a forgotten population for thenutrition sector. This group remains particularly vulnerable to malnutrition, but many
data and service gaps exist, especially for those with disabilities who make up a quarterof children in IBC.

What this adds:

While global efforts focus on policies to discourage institutionalisation, more needs
to be done to realise the rights of children living in IBC to appropriate nutrition andthe engaged quality care needed to support growth and development. Good nutrition,
growth, and development are, in turn, critical to home finding. This article highlights
the positive impacts that can be achieved through caregiver training, appropriate
feeding interventions, comprehensive monitoring and evaluation systems, and coherent
government engagement.

periencing underweight (34.1%), stunting(37.3%), and wasting (12.6%). Overweight/obesity (12%), small head circumference (31%), andanaemia (28.7%) were also present. These levelsof malnutrition were higher than any global or
low- and middle-income country averages.
As mentioned, a quarter of children in IBC
have a disability. Children with disabilities often
experience feeding difficulties, such as choking
and aspiration (inhalation of fluid or food into
the lungs) during mealtimes – which can increase the risk of infections, respiratory complications, morbidity, and mortality. The presenceof a feeding difficulty can also directly lead tomalnutrition. Children might resist eating due
to associated negative experiences or caregivers may provide nutritionally inadequate foods
that they hope are easier for the child to safely
swallow. Compounding this, feeding difficulties
and accompanying malnutrition can both cause
disability and exacerbate existing disabilities. In
another study using the same programme data,
we found that 11.3% of children in IBC had
feeding difficulties. Among children with disabilities, 29.7% had feeding difficulties compared
to 5.9% of children without disabilities. After
adjusting for confounders, we found that children with disabilities had five times greater relative risk of having feeding difficulties than those
without a disability (RR 5.08, 95% CI 2.65–9.7,
p ≤ 0.001) (DeLacey et al, 2022a).
Collectively, these adversities greatly increase
the risk of children not reaching their full potential. As a child spends more time in IBC, there
are increasing consequences for their physical,
cognitive, and interpersonal development.

Institution-based care: Ourcurrent reality

While not an ideal option, many orphaned andvulnerable children live in institutions that arenecessary for their immediate care or protection. Living conditions are often insufficient toaddress the individual needs of children. Thisis especially true for infants and children withdisabilities who rely on caregivers to meet basic
needs and who may be unable to convey theirrequirements. Facilities are frequently limited
in terms of staffing, funding, training, and re-sources. As such, caregivers have many competing priorities for their time, limiting responsive
caregiving.
Children living in IBC have the same rights
as other children in terms of appropriate nutrition, safe and enjoyable mealtimes, and the engaged quality care needed to support growthand development. These lifelong rights havebeen clearly outlined by several UN conventions and resolutions.
To date, global efforts have focused on policies to discourage institutionalisation – throughguidance from the European Union, UNICEF,
the World Health Organization, and others.
There has been little to no focus on addressing
the immediate needs and rights of children in
IBC or actions to improve their current circumstances (Hope and Homes for Children, 2020).
Funding remains insufficient for community initiatives to strengthen families, support caregivers, expand family-based care and respite care(short-term relief for primary caregivers), reunify families, and provide accessible healthand nutrition services. Some governments have
set up IBC reforms within their social welfare
systems and developed family-based care alternatives, such as foster care. But those too remain unacceptably under-resourced, especiallywhen children require highly specialised care or
are malnourished.
Deinstitutionalisation is imperative to improving children’s developmental outcomes.
However, it does not guarantee that all children
experience optimal nutrition and health. Indeed, there is evidence that children and families in the same communities may be worse
off than children living in IBC (Whetten et al,2014). In these cases, IBC may offer more consistent access to nutritious meals and to thetrained caregivers, peer support, and resources to provide impactful education, healthcare,and specialised therapies. The transition awayfrom IBC is therefore nuanced and requires utmost care. Understanding the needs of families
within communities, and learning why abandonment happened, is clearly an important step
toward deinstitutionalisation. Otherwise, theprocess risks being detrimental if children are

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

7Viewssubsequently returned or placed in unsafe environments that are unable to meet their needs(Desmond et al, 2020).
Finally, the opportunity for family placement remains limited, especially when children
are malnourished, sick, or unable to do activities of daily living. Disability-inclusive programming – from organisations such as Holt
International, the Ubuntu-hub, and MAITS– provide training for caregivers that can improve child health and development and provide support to caregivers in communities, IBC,

Figure 1

Quinn, moving with theaid of a walking frame
to support a congenital
disorder in IBC

and foster care. When children are well nourished, it speeds up the process and increases
the chance of placement in family-based care,family reunification, or adoption. This thendecreases the time children spend in care andavoids the time and cost of nutrition treatment
once they are placed with families.
As we work to strengthen families and support deinstitutionalisation efforts, we also needto address the current needs of the large andhighly vulnerable population who remain in IBC.

Addressing child nutrition in
institution-based care

Through its child nutrition programme, Holt
International aims to both address the nutrition needs of children while they are in IBC
and ease subsequent life options outside IBC.
The programme includes comprehensive assessment, training, and monitoring and evaluation, and works in strong partnership withgovernment structures to support both implementation and scaling.

© Holt International

We provide training for caregivers and nutrition and feeding interventions for children
in institutions, foster care, and community programmes in nine countries, over 130 sites. Morethan 15,000 children have participated in the
programme, with more than 7,000 caregivers
trained. We use a training of trainer’s approach to
improve individual- and site-level care practices.
We provide caregivers and site staff with training
on the following topics: providing safe and engaging mealtimes for children of different ages,
feeding and positioning, hygiene and sanitation,
growth monitoring, treating common illnesses,
anaemia screening and treatment, micronutrient deficiencies, and other development topics.
Within this, there is a special focus on the needsof infants and children with disabilities (DeLacey et al, 2022b).

© Holt International

Figure 2 Children being fed at a government-run institution in Vietnam

Quinn is highlighted by the yellow arrow (shown above)

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FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

In addition to robust monitoring and evaluation systems, the programme uses an electronic nutrition screening system that tracks
growth measurements according to World
Health Organization growth charts, incidenceof illness, iron status and supplementation, andfeeding interventions for each child. The system automatically calculates malnutrition risk
and supports caregivers to examine children’s
nutrition and growth over time and instigatechanges to care if, for example, a child’s growth
chart trends flat or downwards.
Analysis of programme data has showed thepositive effects the child nutrition programme
has had on feeding difficulties. Among children with feeding difficulties at baseline, 33.1%
of 163 children with disabilities and 53.8% of
106 children without disabilities no longer had
feeding difficulties after one year of participation in the programme (DeLacey et al, 2022a).
This is likely related to improved caregiver
practices, better positioning, and support fromcaregivers to develop skills like self-feeding.
This analysis helped us to improve programme
implementation by identifying sites with persistent nutrition issues or additional need forsupport. Sharing these findings with global audiences has helped raise awareness about theneeds of children in IBC.

Quinn’s story: Frominstitution-based care to apermanent family

In 2012, Quinn was abandoned as a newborn
at a government-run institution in Vietnam by
her birth family. It is unknown whether she wasborn premature or low birth weight. Quinn has
arthrogryposis multiplex congenita, a condition
present from birth that affects muscle development and often limits mobility and the ability to
self-feed (figure 1).

ViewsFigure 3 developing well,Quinn growing andpost-adoption

propriate training content and support would
allow caregivers to provide responsive caregiving, safe and enjoyable feeding, and support
for children with disabilities. There is increasing evidence that sensory stimulation, including touching or playing with food, plays animportant role in child development and recovery from malnutrition (Kamble et al, 2022).
Exploring the importance of engaging, enjoyable mealtimes is just one example of how appropriate caregiver training can improve nutrition outcomes. Another, more obvious focus
is on malnutrition screening and prevention.
Specifically, ensuring that caregivers are awareof sufficient, age-appropriate dietary intake
and can identify and treat malnutrition early and effectively. This requires high-quality
training and ongoing support.

© Quinn's FamilyInterventions to address malnutrition facedby children in IBC, especially infants and children with disabilities, must be part of the overall care plan and standard practice of every institution. Nutrition and feeding interventions
need to be integrated into an organisation’s
workflow. Institutions can then work to support staff with frequent training, provide environments to enable best practices (e.g. easily accessible handwashing stations), and clear
guidance on expectations.
Her health records indicate that, at 34 monthsof age, she was having difficulties chewing andwas fed infant formula from a bottle or spoonfed rice cereal. Her records also indicate that she
was frequently hospitalised and experienced fevers and nausea/vomiting. She was stunted (according to height-for-age), underweight (according to weight-for-age), and anaemic. She
was identified as malnourished and her caregivers received additional training from the nutrition programme staff on ways to improve herdiet and to help her safely develop her chewing
and feeding skills (figure 2). She was also provided with vitamins and iron supplementation.
In 2017, after four years and nine months ofliving in IBC, Quinn’s nutrition and health status had improved and she had learned to safely feed herself. She became healthy enough to
be adopted by a family. Her adoptive family received extensive training by Holt during the
adoption process on strategies required to meetthe complex needs of a child with a disability, as
well as skills to build trust and a strong relationship with a child who has experienced adversities. With support from her family and occupational and physical therapy, Quinn no longer
has feeding or nutrition issues and is growing
and developing well (figure 3).

Avenues to improve nutrition
support in institution-basedcare

While we work to unite children with families,
children in IBC still need to receive appropriate
care and nutrition. With this in mind, we highlight some strategies that can improve nutrition
support in IBC.
Caregivers need more training. They usually have limited education on caring for children, especially those with disabilities. Ap-

IBC sites should create systems of accountability to ensure consistent and routine assessment of the nutrition and health of individual
children and across a given site. Stronger routine monitoring and evaluation systems would
not only enable governments to have a better
picture of the number and conditions of children in IBC – thus raising visibility – but also
improve the implementation of programmes
supporting children in IBC. Such systems also
help institutions to provide transparent andobjective data, increasing accountability to
governments.
Additionally, governments and organisations need to ensure nutrition and health standards are key aspects of any family-based careprogrammes, such as foster care or kinship care.
Child protection, deinstitutionalisation, andfamily strengthening plans should also include
core components of nutrition, hygiene and sanitation, safe feeding, and support for caregivers.
As children become well nourished and caredfor, family-based care (foster care, kinship care)should be the next stage whenever possible, as apart of permanency planning (family reunification, adoption).
Responsibility for IBC, child nutrition anddevelopment, healthcare services, disability services, foster care, and child protection are often
spread across several government ministries.
Governments will need to develop a clear visionand collaborate across all departments and levels to ensure meaningful actions create environments that best support children’s development.
Increased funding to train caregivers and support family-based care is essential. With funding and resources aligned to policy and global
reforms in child welfare practices, deinstitutionalisation can become actionable and prevent the
detrimental consequences to children’s development seen in IBC.

Conclusion

Although not ideal, millions of children live in
IBC today, and their needs cannot be ignored.
We need to work to ensure all children live in
conditions that will support their full and adequate development. As the global community
works toward strengthening families and deinstitutionalising children, the children currently
in IBC need to be included in the conversation,
especially infants and those with disabilities.
Nutrition status and development are critical elements in finding appropriate homes for thesechildren. We therefore need to improve practices in IBC in the immediate term.
Governments need to better monitor children in IBC in their respective countries, including the large number with disabilities ormalnutrition. This is crucial so that we can better understand and respond to the needs of thisunique population. Evidence-based research offers a strong platform to raise awareness about
this highly vulnerable population and to advocate for their needs and rights to be met. By thesame token, sharing successful case studies andthe learnings from interventions also remain
powerful tools for change.
More can be done to ensure that children reach
their full potential, regardless of where they reside early in their lives.
For more information, please contact Emily
DeLacey at emilyd@holtinternational.org

References
DeLacey E, Tann C, Groce N et al (2020) The nutritional
status of children living within institutionalized care: A
systematic review. PeerJ, 8, e8484
DeLacey E, Hilberg E, Allen E et al (2021) Nutritional statusof children living within institution-based care: A retrospective analysis with funnel plots and control chartsfor programme monitoring. BMJ Open, 11, 12, e050371
DeLacey E, Allen E, Tann C et al (2022a) Feedingpractices of children within institution-based care: A
retrospective analysis of surveillance data. Maternal &Child Nutrition, 18, 3, e13352
DeLacey E, Tann C, Smythe T et al (2022b) Learningfrom the implementation of the child nutrition
program: A mixed methods evaluation of process.
Children, 9, 12
Desmond C, Watt K, Saha A et al (2020) Prevalence andnumber of children living in institutional care: Global,
regional, and country estimates. The Lancet Child &Adolescent Health, 4, 5, 370–377
Dozier M, Zeanah C, Wallin A et al (2012) Institutionalcare for young children: Review of literature and policy
implications. Social Issues and Policy Review, 6, 1, 1–25
Hope and Homes for Children (2020) Beyond institutional care: A roadmap for child protection and caresystem reform for governments in Latin America andthe Caribbean. hopeandhomes.org
Ivey R, Kerac M, Quiring M et al (2021) The nutritional
status of individuals adopted internationally as children: A systematic review. Nutrients, 13, 1, 245
Kamble N, Mathur R, Gavali V et al (2022) Sensory
stimulation and play therapy: Benefits in the treatment
of severe wasting in India? Field Exchange 68. https://www.ennonline.net//fex/68/sensorystimulationandplaytherapycombatseverewastinginindia
Whetten, K, Ostermann, J, Pence, BW et al (2014)
Three-year change in the wellbeing of orphaned andseparated children in institutional and family-basedcare settings in five low-and middle-income countries.
PLOS ONE, 9, 8, e104872.

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

9ViewsVijana Twaweza
Club: Food
security via a
refugee-ledorganisationin KenyaAmisi from Vijana Twaweza
Club holding a catch of fish.
Kenya, 2024

Paul O’Keeffe
Assistant Professor of Global Challenges
at the School of Law and Government,
Dublin City University© VTC

Luundo Wa Luundo
Chairperson at Vijana Twaweza Club,
Kakuma Refugee Camp

What we know:

Food insecurity and population displacement are widespread in the East and Horn ofAfrica and Great Lakes region, and are exacerbated by climate-induced shocks, poverty,
and conflict. Home to huge refugee camps, such as Kakuma and Dadaab in Kenya, theregion currently hosts 20% of the world’s refugee population (Reliefweb, 2022).

What this adds:

The authors present a case study of Vijana Twaweza Club, a refugee-led farming projectthat aims to improve food security for people living in Kakuma refugee camp, albeit
on a small scale. The club has created a successful farm, as well as a training division,
illustrating the potential of refugee-led organisations to find successful communitylevel solutions to improve food security.

Although clearly outlined in Article 25of the 1948 Universal Declaration of
Human Rights, the right to food remains elusive for many. For the 110
million forcibly displaced people globally, thisis particularly true. By 2050, estimates point toan increased global population of 9 billion people, resulting in a 60% increase in food demand(Breene, 2016). With global efforts to feed agrowing population veering off track – notably,
the Sustainable Development Goal of ‘zero hunger by 2030’ – addressing demands for food is
becoming ever more urgent.

“The idea of gaining global
consensus on the need toensure food security looks
unlikely any time soon.”
The international development policy discourse on meeting global challenges, such as

10

food security, is awash with optimistic jargon.
The terms ‘resilience’, ‘participation’, ‘empowerment’, and so on only capture the current situation in vague and simplistic forms (Schnable et al, 2020). These terms often form the
backbone of policies that deflect decisive action and encourage the transfer of responsibility to those living in poverty, all for problems
that are seldom of their own causing. The concept of ‘resilience’ has long enjoyed prominence
in development policy relating to food security programming in developing countries. Whileostensibly implying that the poorest have thepower and capacity to feed themselves, if only
they just showed enough determination to doso, the concept has increasingly been criticisedby social and political analysts (Jaspars, 2020).
The term ignores the reality of unjust power dynamics and resource shortages in food systems
around the world.
Accounting for power dynamics, along withmany other factors that influence access to ad-

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

equate food, the reality of the ‘right to food’ asa universally accessible concept becomes questionable. Like other universally agreed humanrights, this is pertinent when considering those
whose legal status is defined by exclusion of one
or more of these rights, rather than inclusion.
Refugees, being the case in point, live predominantly in conditions that exclude them from exercising the right to food to its fullest.

Focusing on East Africa

After six consecutive years of drought and otherclimate-induced shocks, displacement and foodinsecurity are endemic in the East and Horn ofAfrica and Great Lakes region. This situation isdriven – and further reinforced by – widespreadpoverty, conflict, and violence in a complex andperpetuating cycle. Home to huge refugee camps,
such as Kakuma and Dadaab (both in Kenya),
the region currently hosts 20% of the world’s refugee population (Reliefweb, 2022). In Kakuma
alone, nearly 250,000 people rely on food rations
from the World Food Programme to make ends
meet while they wait out their exile.
With a reduction in resources allocated to
refugee camps the world over, people living incamps like Kakuma are very much at the receiving end of global humanitarian funding
cuts. Although up-to-date figures are hard tocome by, the World Food Programme generally provides monthly rations that equate to 70–
75% of people’s food requirement. However,
the amount of food refugees receive fluctuatesfrequently in the region. In February 2024, rations were reportedly reduced from 80% to 50%
in Kenya’s Dadaab refugee camps (UNHCR,
2023a). In Kakuma, rations were cut by 60% in
May 2024 (USCRI, 2024).

Views“From an academic vantage
point, it is easy to see the failingsin our global humanitarian anddevelopment systems. What isharder is to point out viable
solutions that could prevent
some of the worst outcomesthat these failings accrue.”
In recent years, refugee-led development is
one solution receiving more attention in the international development discourse. Defining
refugee-led organisations as legitimate stakeholders in refugee policy and programming in
2023, the United Nations High Commission for
Refugees (UNHCR) heralded a shift in development thinking (Harley, 2023). Transitioning
from a top-down approach to a more grassroots
view allows refugees to play the primary leadership role in deciding and managing objectives
and activities to meet their own needs.
Considering its relative novelty, refugee-led
development is an under-investigated approach.
Taking a cue from the Localisation agenda promoted over the last decade in the humanitarian sector, the development sector is increasingly
aware of the power asymmetries that characterise top-down global development methods.
With this in mind, refugee-led approaches todevelopment offer another pathway to course
correct. Specifically, advocates of refugee-led
development applaud its proximity to boththe communities it serves and the issues it addresses. They suggest that refugee-led organisations’ understanding of, and connection to, local problems afford them a level of legitimacy
and transparency that other development actors do not have. Ultimately, supporters of refugee-led organisations champion their capacity
to be more effective and achieve more impactful
outcomes than development organisations directed from afar (Sturridge et al, 2023).

Discussion of development is often confined
to abstract academic discourse. One can easily
forget that it is a concept grounded in the real-life experiences of people who are seldom
part of the academic arenas in which it is debated. Discourse surrounding food security isfrequently held at a level that may obscure theindividual experiences of those that it most effects. Cutting through this noise, we offer here
an example of a small but successful refugee-led
farming project aimed at improving food security within Kakuma refugee camp. By sharing
this experience, we hope to bridge the gap between discourse and reality. We highlight theability of refugee-led organisations to find theirown development solutions and the implications of such schemes.

clude sugar, flour, and cooking oil – amounting
to roughly 75% of their food requirements. Various services are provided in the camp, such as
basic healthcare and education, but conditions
are overcrowded.

Case study:
Vijana Twaweza Club

Vijana Twaweza Club

Kakuma refugee camp

Kakuma refugee camp is in northwestern Kenyain the semi-arid Turkana state. Along with theneighbouring Kalobeyei integrated settlement,
Kakuma is home to more than 250,000 refugees
from 24 different ethnic communities (UNHCR, 2023b). The camp has been open since
1992, when the ‘lost boys’ of Sudan (a group ofyoung people fleeing civil war in the country)
were first granted sanctuary there. It is administered by the Kenyan government and UNHCR.
Life in Kakuma’s desert-like conditions is difficult, with temperatures regularly exceeding 35C
degrees. Conditions are those of survival.
While Kenya’s 2021 Refugee Act foresees atime when its refugee camps will be converted
into settlements, the reality is that the country
currently operates an encampment policy. Asylum seekers who enter the county are sent to one
of its huge refugee camps while they await processing of their asylum claim. When they arrivein Kakuma, refugees are allocated some building materials (usually wooden poles and tarpaulin sheeting), a mosquito net, and some space to
set up their own huts. Monthly food rations in-

Beyond rations, Kakuma’s residents rely on
trading and an informal market economy tomeet their food requirements. Despite their efforts, malnutrition is an issue with around 11%of children aged 6–59 months experiencing
wasting and an estimated 60% suffering fromanaemia in 2017 (Njagi, 2022). With the regional drought, pressure on global food production,and now reduced rations, there is a worsening
food crisis in the camp. There are few sustainable solutions on the table.
Vijana Twaweza Club is a community-based organisation in Kakuma refugee camp that sustainably produces food to feed people living in
the camp. Since its formation in 2018, the project has produced over 1,200kg of fish. This has
supplied more than 500 families in Kakuma
with produce, which the club sells at affordable
prices throughout the camp. Vijana Twaweza
Club is composed of 23 young refugees who
represent all the different ethnic and national backgrounds of Kakuma’s diverse population. The club started life as an idea generated
by refugee students who were studying the University of Geneva’s undergraduate ‘One Health,
Basic Medical Training and Introduction to Human Rights’ course being delivered in the camp.
These students wanted to use their knowledge
and skills to find solutions within the camp.
With some seed money donated from friends
overseas, Vijana Twaweza Club was born. It
took its first steps toward becoming a food-producing organisation by digging a small fishpond in the refugee living quarters in the camp.
The pond, which was lined with plastic sheeting bought from the nearby Kakuma town, wasthen filled with water and populated with Tilapia fish captured from a nearby river.

© VTC

Members of Vijana Twaweza Club
harvesting their fish. Kenya, 2024

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

11ViewsAfter a few trials (and errors), the students
began contacting various humanitarian organisations working in Kakuma refugee camp andthe wider international development community to scale up their project. Project members took additional training courses in aquaculture, agriculture, permaculture, and project
management – both in person and through online platforms. After connecting with the Jesuit
Refugee Services in Kakuma, Vijana Twaweza
Club was granted some additional space tobuild more fishponds in 2020. Moreover, theJesuit Refugee Services stood as a referee forthe club’s first successful funding application
to Caritas Italiana Kenya. The funding they received allowed Vijana Twaweza Club to build a
new 20m by 8m fishpond, which was then used
to raise tilapia and catfish.
It was at this time that the project began
to garner international attention. The UKbased Permaculture Magazine awarded Vijana
Twaweza Club the ‘Youth in Permaculture Prize’for 2020. The World Food Programme quickly
followed suit, bestowing the ‘Young East Africa Innovators Award’ in 2021. The prize money garnered from both afforded Vijana Twaweza
Club the opportunity to invest into new tilapia
and catfish stocks. This money also supported
scale-up efforts, which focused on the construction of new fish tanks.
The growth of Vijana Twaweza Club has notbeen without setbacks. The COVID-19 pandemic and its associated lockdown in 2021/22
impacted Kakuma in unique ways, placing agreater onus on refugees to meet their own
needs. With entry and exit to the camp largely closed and little guidance and health management penetrating the camp, Vijana Twaweza
Club mobilised itself as a community-based organisation. Members used their health knowledge to produce short advisory videos onsocial distancing, hygiene, and general healthcare, which were made in English, French, andKiswahili. Videos were shared around the camp
via the free WhatsApp instant messaging app(which has high penetration in Kakuma) to empower fellow refugees. Through their provisionof this social good, Vijana Twaweza Club gained
further prominence in Kakuma as a vehicle forrefugee-led development. Anecdotally, it seems
this also paved the way for further conversations inspiring fellow refugees in Kakuma to begin their own food security journeys. Many individuals approached club members for advice
on how to start their own gardens and farming
projects in the camp.
After realising the food security role thatrefugee-led organisations could play, combinedwith their successful fish farming experiences,
Vijana Twaweza Club began developing a side
project. On land granted by Jesuit Refugee Services, the club set up a small vegetable garden
to grow murere – a local spinach-like crop thatyields highly nutritious greens. The successful
production of murere enabled Vijana Twaweza
Club to quickly scale up the gardening project
to include carrots, onions, spinach, kale, amaranthus, banana, cowpeas, sweet potatoes, tomatoes, and sugar cane. The vegetables are harvested at regular intervals and distributed toclub members or sold in the local market, withprofits being put back into the project.
Using the profits gained from selling vegetables and fish, Vijana Twaweza Club set up other side projects raising rabbits and ducks, as well
as rearing crickets for protein. The crickets anddroppings from the rabbits and ducks are thenused to feed the fish in a cycle that complements
the club’s founding permaculture principles.
With the help of the World Food Programme, construction of five additional 15m
fishponds, made from cement, is underway.
The ponds will be supplied with water that isused in a circular manner to water the crops in
the gardens. In addition, Vijana Twaweza Clubhas recently received funding from Credit Agricole Assurances to initiate a poultry farming
training programme for refugee women in Kakuma. The project, which began in February

2024 (the time of writing), is training 10 refugee women over six months to become independent chicken farmers.

Conclusion

Being a refugee-led organisation driven byyoung people, part of Vijana Twaweza Club’s
ethos is to build the agriculture management
capabilities of its members for the future. Thismeans that all members take part in and learn
from new projects as they progress. This typeof forward-looking capacity development is an
important learning point for other refugee communities who wish to become more self-sufficient in achieving food security. Refugee-led organisations, such as Vijana Twaweza Club, canplay a pivotal role in supporting food security
for future generations. This can be whether refugees stay in camps where resources are limited, are resettled overseas where cutting-edge agriculture management skills are required, or ifthey return home to rebuild their own agriculture systems.
As the world moves toward an uncertain future, with challenges such as population growthand climate change weighing heavily on current food systems, innovation is needed morethan ever. Drought, famine, inequality, and conflict may seem like impossible foes, but projects
such as Vijana Twaweza Club show that young
people can and will find ways to overcome adversity. Even in the most difficult of circumstances, the success of the project represents thehard work of the club’s members. The power ofknowledge to inspire new ways of thinking, doing, and – above all – the possibility of humanity to forge a sustainable future for everyone ison show. Vijana Twaweza Club provides an example to all.
To learn more, please visit the club website athttps://www.vijanatwawezaclub.org/
For more information, please contact PaulO’Keefe at paul.okeeffe@dcu.ie

References
Breene K (2016) Food security and why it matters.
weforum.org
Harley T (2023) Defining refugee-led organisations: An
analysis of UNHCR’s 2023 definition. unsw.edu.au
Jaspars S (2020) Protracted crisis, food security and thefantasy of resilience in Sudan. Security Dialogue, 52, 3
Njagi D (2022) Kenyan refugees use gardening to fightmalnutrition but hunger lingers. devex.com
Reliefweb (2022) East and Horn of Africa, and the Great
Lakes Region Operational Update (April–June 2022)
reliefweb.int
Schnable A, DeMattee A, Sullivan Robinson R et al(2020) International development buzzwords: Understanding their use among donors, NGOs, and academics. The Journal of Development Studies, 57, 3, 1–19
Sturridge C, Girling-Morris F, Spencer A et al (2023)
The failure to fund refugee-led organisations: Why thecurrent system is not working, and the potential forchange. odi.org© VTC

UNHCR (2023a) Kenya December 2023: Operational
update #12. unhcr.org
Preparing fish to betransferred to the market
via a refrigerated tricycle.
Kenya, 2024

12

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

UNHCR (2023b) Kenya: Registered refugees and asylum-seekers as of 31 January 2023. unhcr.org
USCRI (2024) Starvation and suicide: Refugees in Kenya
camps. reliefweb.int

ViewsFood systems,
climate change,
and nutrition:
Taking a unified
approach
Leah Richardson
Senior Technical Associate at
Emergency Nutrition Network(ENN)

Children help planting thecommunity garden of theMunicipality of Guatemala

What we know:

Current food systems are largely failing those who rely upon them and there is a global
imbalance in food availability, food costs, environmental impacts, and – ultimately –food justice. The broader topic of food systems has been gaining greater attention inrecent years, which is important, but framing the learning from this renewed focus into
practical steps remains a challenge.

What this adds:

This article consolidates some of the recent food systems learnings, highlighting criticalinsights and areas of focus that can be taken forwards. Ultimately, nutrition, foodsystems, and climate change are interconnected and efforts to improve any one of these
entities relies upon the others.

T

he intricate relationships between
food systems, climate change, andnutrition have become increasingly
evident. These interconnected challenges present a daunting task but also an unparalleled opportunity for collaborative action.
Despite the challenges, there are still some cards
left to play. Evidence does exist, proven strategies can be put into place, and innovations arebeing ushered in on areas where we currently
fall short. Yet, as ever, although we may havethe cards in our hand, discerning which ones
have value – and how to play them – can be
overwhelming. By drawing from the insightsof recent publications (ENN, 2024; FAO, 2023)
and webinars (ANH Academy, 2024a; UN Nutrition, 2024) we can reorient ourselves among
all the noise. There is a path forward that leverages existing knowledge, fosters partnerships,
and drives impactful change.
This article seeks to inspire collective action
and to highlight practical steps that can be taken immediately to address these critical issues.

Understanding theinterconnections

Food systems significantly influence nutritional outcomes by determining the accessibility
and quality of foods available. Food security andhealthy diets are crucial for maintaining optimal
nutritional status as they ensure consistent accessto sufficient, safe, and nutritious food that meets
dietary needs for an active and healthy life. A lackof food security can lead to malnutrition, while

an unhealthy diet can contribute to nutrient deficiencies and chronic diseases – both of which
impair physical and cognitive development andoverall well-being. The diets of mothers, infants,
and young children are particularly vulnerable todisruptions in food systems. These groups often
have both increased nutrient needs and less agency over what they consume, which is constrainedby gender inequality and sociocultural norms.
Concurrently, food systems contribute substantially to environmental degradation, exacerbating climate change, which in turn heightens
the risk of malnutrition (figure 1). Agricultural activities, including deforestation for crop andlivestock production, contribute to habitat loss
and biodiversity decline. The use of synthetic fertilisers and pesticides leads to soil degradation
and water contamination, further stressing ecosystems. Additionally, the extensive water use required for irrigation depletes freshwater resources, while food transportation and processing add
to the carbon footprint. Livestock farming is particularly impactful, producing large quantities ofmethane, a potent greenhouse gas. Together, theseprocesses release about one-third of the world’s
greenhouse gases and contribute decisively to
global warming, altering weather patterns and intensifying the effects of climate change.
At the same time, climate change negatively
affects food systems by altering rain patterns andthus reducing soil fertility, crop yields, and nutrient composition, leading to a reduction in macro- and micro-nutrients in the global food sup-© UNICEF/UNI551117/Willocq

Views

ply. These changes are compounded by indirect
impacts, such as increased pests, and contributeto increased spoilage and food safety hazards.
Climate change can also disrupt food supply
chains and transportation, increasing food pricevolatility and reducing food accessibility.
It is the poorest people in all societies, andthose living in low- and middle-income countries, who are likely to suffer the most from exposure to climate shocks, to unsustainable foodsystems, and to the livelihood threats posed byill health and poor nutrition (FAO, 2023). And it
is often these populations that are most exposed
to climate shocks and disrupted food systems
who are also most vulnerable to malnutrition.

Four immediate steps forcollective action

In a recent literature review including 135
peer-reviewed articles and reports, ENN examined how the intersections of food systems, climate, and nutrition have evolved (ENN, 2024).
We identified key topics that have emerged orremained neglected since the first UN Food
Systems Summit in 2021. Key emerging topics
include an increasing focus on ‘all forms of malnutrition’ and the growing linkages across urban,
peri-urban, and rural areas. Infants, women,
and children continue to be disproportionately
affected by malnutrition, the negative effects ofclimate change, and weaknesses in current foodsystems. At the same time, there is greater recognition of the co-benefits of more systematic,
multisectoral, and longer-term action that integrates climate and nutrition considerations into
food systems policies and programmes. Two areas were singled out as neglected but of critical importance: i) how sustainable food systems
can be leveraged to prevent malnutrition; andii) establishing sustainable food systems in conflict-affected settings.
My reflection from leading this review is that,while work on generating evidence continues, we
can now boldly move forward as we already haveenough learning that can be immediately used tocollectively gain momentum. Here are four things
we can all start applying in our work today:

Future-proof solutions

Policies and programmes should not only respond to current drivers but also to increasing

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

13ViewsFigure 1

Food systems and the environment for nutrition
Distal Outcomes

Environmental
InputsSoil Quality
Arable Land
Water Quality
Weather Patterns
Seasonality
Temperature
Ocean Acidification

Food System
Food Supply
Agriculture
Livestock
Aquaculture
Processing
PackagingTransportation

Proximal Outcomes

Food
Environment

Consumer
Behavior

Food Availability
Food Quality
Food Safety
Food Affordability

Acquisition
Preparation
Meal Practices
Storage

Food Safety
Exposures
Diet
Food Loss andWaste

Nutrition and Health
Malnutrition
Chronic Disease
Food-Borne Illness
Environment
GHG Emissions
Air Pollution
Depletion of natural Resources
Deforestation
Eutrophication
Rising Temperatures
Rising Sea Levels

Source: Fanzo et al, 2021

challenges such as rapid urbanisation and therising burden of obesity. Long-term planningshould be embedded within current initiatives toensure sustainability. For example, using climate
forecasting to target nutrition interventions to atrisk populations can help address both immediate
and future nutritional needs. Climate scientists
can share relevant climate information, such as
weather forecasts and climate variability projections, with health and nutrition practitioners. By
delivering this information in a simple manner,
the nutritional needs of communities adapting
to a changing climate can be addressed throughbetter targeting and management of climate-impacted infectious diseases that can lead to malnutrition. Health ministries can also use climate
information to improve planning, surveillance,and preparedness to protect nutrition and publichealth by enhancing resources and infrastructure,
helping communities adapt better to both shortterm and long-term climate effects.

Boost climate-nutrition collaboration

There is a clear link between climate policies andnutrition outcomes. Collaborative efforts canhelp develop co-benefits between environmental and nutritional goals. There needs to be increased representation of nutrition priorities andneeds within climate dialogues so that climate
action has a positive impact on the nutritional status of the world’s population. In order forthis to happen, we need to both demand a seatat the table and be welcomed. Similarly, working closely together across food systems, climate,and nutrition will help us ensure that co-benefits between environmental outcomes and diets/
nutrition are not left to chance. There is ever-increasing guidance such as the Centre for Food
Policy’s “45 actions to orient food systems towards environmental sustainability” (Caleffi etal, 2023), which also examines co-benefits withnutrition. We need to invest in systematic andintentional efforts from the outset.

Don’t forget conflict-affected andfragile settings

It is likely that in years to come that there will
be more fragile settings, given the impact of climate change, global economic pressures, andconflicts at scale. Establishing sustainable foodsystems in conflict-affected areas is often overlooked. Yet it is exactly the populations in theseareas who are most in need of sustainable nutrition and food security, economic opportunities, and mitigation of climate impact. A holistic

14

approach that includes the "missing middle" ofthe food system – beyond mere agricultural production – is essential. This means supporting theentire food system, from production through toconsumption, and ensuring knowledge sharing
across programmes to build resilient food systems in these fragile contexts. Often, this may bemost viable through smaller-scale, contextuallybased practices, involving communities themselves (and women in particular) in their design
and implementation. Building an understandingof how humanitarian assistance impacts local
food systems and communities and how it canbe more effective in strengthening these systems
through longer-term funding is also key.

Document and share success stories

Something that came up repeatedly as we did
our literature review is that we need more stories of how positive change has happened. We
need to know more about what the practical doable actions are for increasing integration, navigating trade-offs, and building co-benefits. We
can all do more to ensure a greater representation of low- and middle-income contexts in thelearning shared. Understanding how globally focused theories and practices translate into different contexts will support the establishment of
national priorities and investments. Learning already exists at the country level. It is often only
a matter of capturing it and improving dissemination through, for example, national or regional academic partners and via engagement with
global communities of practice such as the Agriculture, Nutrition and Health Academy. The
Agriculture, Nutrition and Health Academy
comprises of interdisciplinary researchers, practitioners, and policymakers that work on agriculture and food systems for improved nutritionand health, with over 9,000 members in over
145 countries. Peer-to-peer publications, suchas Field Exchange, can also facilitate the sharingof experiential, evidence-based learning, beyond
more formal journal publications.

Leveraging existing tools andpartnerships

To navigate the wealth of existing knowledge,
stakeholders can utilise tools such as the Climate
Nutrition Evidence Data Base (Stronger Foundations for Nutrition, 2024) and the interactive Evidence and Gap Map (ANH Academy 2024b) thatlinks climate change to food systems, nutrition,and health. Joining alliances like the Initiative on
Climate and Nutrition (ATACH 2024) and the

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

Coalition of Action for Healthy Diets from Sustainable Food Systems for all (World Health Organization, 2024) can also provide a platform forshared narratives and coordinated action.

Moving forward together

The need for immediate and collaborative action
is clear. While perfect solutions may not be available, we cannot afford to wait. By leveraging existing knowledge, fostering partnerships, and taking
pragmatic steps, we can address the intertwined
challenges of food systems, climate change, andnutrition. Each sector – climate, nutrition, andfood systems – must recognise their roles as a partof this integrated approach, working together tocreate sustainable and resilient solutions. By doing so, we can ensure that food systems contribute to both environmental sustainability and improved nutrition, paving the way for a healthierand more resilient future for all.
For more information, please contact Leah
Richardson at leah@ennonline.net

References
ANH Academy (2024a) Webinar: Making progress at
the intersections of food systems, nutrition and climatechange. anh-academy.org
ANH Academy (2024b) An evidence and gap map of intersections between climate change and food systems,
nutrition, and health. anh-academy.org
ATACH (2024) Climate action and nutrition working
group. atachcommunity.com
Caleffi S, Hawkes C & Walton S (2023) 45 actions toorient food systems towards environmental sustainability: Co-benefits and trade-offs. London, UK: Centre
for Food Policy.
ENN (2024) Exploring new, evolving and neglected
topics at the intersection of food systems, climatechange and nutrition: A literature review.
https://www.ennonline.net/exploring-new-evolvingand-neglected-topics-food-systems-climate-changeand-nutrition
Fanzo J, Bellows AL, Spiker ML et al (2021) The
importance of food systems and the environment for
nutrition. The American Journal of Clinical Nutrition,
113, 1, 7–16.
FAO (2023) Climate action and nutrition: Pathways to
impact. fao.org
Stronger Foundations for Nutrition (2024) Climate–nutrition evidence map. Stronger-foundations.org
UN Nutrition (2024) Webinars – Peer-to-peer learning
forum on “healthy diets in fragile contexts”. unnnutrition.org
World Health Organization (2024) The coalition ofaction on healthy diets from sustainable food systems
for children and all (HDSFS). who.int

Original Articles
Original Article

Lead mother, explaining to mothers
how to express breastmilk. Yemen

What we know:

Mother-to-mother support groups (MtMSGs) provide a peer support environment
where women come together to discuss infant and young child feeding (IYCF) issues
and share their experiences overcoming problems. These groups can effectively improve
IYCF practices, including in emergency contexts.

What this adds:© Crisis Response FHI 360 Yemen

This FHI 360 experience illustrates the importance of peer support groups, especiallyin crisis contexts, reaffirming their potential to provide benefits in terms of IYCF
practices, mutual support, health and wellbeing, and cost savings from reduced
purchase of commercial milk formula and medication. We identify strategies
to enhance support for lead mothers and to strengthen mothers’ engagement insupport groups, for additional benefits.

Reviewing
the FHI 360
motherto-mothersupportexperiencein YemenA

fter 10 devastating years of war, withthousands of civilian casualties andover four million internally displaced people, violence and insecurity remain endemic in Yemen. A profound economic crisis threatens the government's ability
to sustain vital public services. Multiple domestic and external shocks are exacerbating the situation, including extreme weather events, thefinancial repercussions of the COVID-19 pandemic, and the wars in Ukraine and Gaza. A recent Humanitarian Needs Overview from the
UN Office for the Coordination of Humanitarian Affairs (OCHA, 2024) reported that 7.7 million people require nutrition services: 2.7 million women and 5 million children.
According to data from the Nutrition cluster,
8/21 Yemeni governorates have wasting rates thatexceed the 15% WHO emergency threshold: Al
Hudaydah, Lahj, Taiz, Hajjah, Abyan, Mahawit, Sa’ada, and Dhamar (IPC, 2023). These gover-Figure 1

norates include 76 districts, accounting for 36%
of the national wasting caseload. In the districts
served by FHI 360 (figure 1), the level of nutrition severity is 5 (the highest), with a wasting rateof 28.9% in Hudaydah (Hays) and Taiz (Dhubab,
Mawza and AlMokha (Al Makha)). Poor IYCF
practices are a key factor contributing to the highwasting rates in the country.

The intervention

MtMSGs are among the strategies implemented
by FHI 360 to support communities to redress
the dire situation. These groups complement andlink with community health volunteers’ (CHVs)
work. FHI 360 has implemented the MtMSG approach in five locations since 2023: Al Ghaded,
Al Kadaha, Al Roa’a, Al Gharaffi, and Al Shatheliah. FHI 360 adopted the guidance and recommendations from the Yemen Ministry of Public
Health and Population, while also drawing fromthe organisation’s experience in similar contexts
such as north-east Nigeria and Ethiopia.

FHI 360’s areas of intervention

Mohannad Ibrahim
Community Health Officer, WAMERO, SUIHAY,
FHI 360
Lina Muhammad Al-Khatri
Community Health Officer, WAMERO, SUIHAY,
FHI 360
Hazem Samra
Health and Nutrition Coordinator, WAMERO,SUIHAY, FHI 360
Mohammed Helmi
Meal Manager, WAMERO, SUIHAY, FHI 360
Kelly Thayer
Deputy Crisis Response Coordinator, WAMERO,SUIHAY, FHI 360
Alessandro Iellamo
Senior Emergency Nutrition Adviser at FHI
360
Sarah Brittingham
Technical Advisor, Research Utilization at FHI
360
Gina Etheredge
Senior Technical Advisor, Strategic
Information at FHI 360
MtMSGs are active in the Al Makha and Dhubab districts

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15

Figure 2 Visual counselling card examples

Original Article
Evidence suggests that MtMSGs canbe effective in emergency contexts. In
the Dadaab Refugee camp (Kenya), there
were 713 MtMSGs across three different
camps, with 581 facilitators being trained
over one year. Despite an increasing programme size due to refugee influxes, IYCF
behaviours continually improved (World
Alliance on Breastfeeding Action, 2024).

ic. She facilitates the group to share theirknowledge and engage in discussion.
The lead mother then suggests what they“would” do to help others practice what isrecommended or “what they will do to try
to practice it themselves.” Members thenreview and agree on recommendations toaction themselves and promote to theircommunities.

What are mother-to-mothersupport groups?

Members commit to attend the sessions
and participate by sharing experiences orideas, trying out (and hopefully sustaining)recommended practices, and supporting
the learning of other mothers living in theirarea. Members also refer mothers who mayneed additional support. A member will be
asked to share their experiences of helping
other mothers during the group sharing
activity. Lead mothers also visit members’
homes to discuss how the support to other
women is going.

There are important considerations when
deciding to establish MtMSGs. In Yemen, FHI 360 looks for the following conditions: some stability in the context of
operations (e.g. no major security threats
in terms of fighting or social unrest),
that people are likely to continue residing in the area for some time (at least six
months), and that there is a sense of community. If the population is mobile and/or
living in an unstable context, other strategies such as home visits and community
discussions by community health and nutrition volunteers may be more effective.
To target the window of opportunityof the first 1,000 days of life, the recommended members of MtMSGs are pregnant women and mothers (primary caregivers) of children aged 0–2 years. In
Yemen, where men must be informed andapprove when women leave the house, it
is very important for a mother to have theagreement of her family to join a MtMSG.
As this is a new activity for FHI 360 andthe community, it is important that thelead mothers and group members ensurethat their husbands agree to and support
their participation.
Lead mothers are selected from among
the MtMSG members based on various criteria, including community knowledge,
successful IYCF practice, communication
skills, and time to dedicate to the initiative.
They generally host group meetings in theirhomes. They are provided with two training
days in IYCF facilitation and communication, as well as basic information, education,and communication materials to support
group discussions and exchanges. The leadmothers also link with the health facility andthe CHVs, sharing their group's updates, issues, and challenges.
FHI 360 MtMSGs are set up so thatgroup members do not need to walk morethan 30 minutes to attend. Each MtMSG has
between eight and 15 members. MtMSGs
must be supervised and supported bytrained CHVs and the health and nutrition
staff of the nearest health facility.

MtMSG activities

The lead mother follows the proposed programme of thematic sessions on maternal,
infant, and young child feeding, preparing
each session in advance.
At the start of each session, the leadmother presents a visual counselling card
(Figure 2) that describes the session's top-

16

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Assessing success

After more than one year of implementation and anecdotal success, FHI 360
conducted a rapid assessment of the experience to learn from and inform thesubsequent phases of the work. This assessment collected qualitative information on how IYCF practices among participants in the MtMSGs have changed
after 16 months. The primary assessment outcomes were self-reported changes in knowledge about IYCF, self-reportedchanges in IYCF practices, and preferred
topics discussed during support groups.
Other benefits of participation in MtMSGs
were assessed, as well as challenges or negative aspects, the level of engagement withother community members, and recommendations to improve the groups.
The study was conducted on the west
coast in south Yemen, where FHI 360 is
implementing an emergency response
project. Five areas in Taiz were selectedbased on FHI 360’s extended presence inthe area and the associated trust that has
been built with communities. The assessment was conducted in December 2023
using focus group discussions (FGDs)
and in-depth interviews to elicit the experiences of mothers and lead mothersin MtMSGs. Fifteen FGDs were conducted, with a total of 79 participants. Each
FGD took between 60 and 90 minutes
and included two note takers. Thirteen
in-depth interviews were conducted withlead mothers, representing half of all leadmothers in the assessment area. Each interview took up to 60 minutes, with either the interviewer or a notetaker taking notes. Purposive sampling was used
to identify and select the participants for
the FGDs and the interviews.

Study limitations

A compressed timeline limited the assessment team’s ability to pre-test the interview and FGD guides and limited the time
for in-depth data analysis. Mothers did
not feel comfortable with audio recording,Original Article
so the assessment data consisted of notes takenby the team. These notes highlighted key themes
and quotes from participants. In the results below, when frequencies are reported, these refer to the number of FGDs in which a particular theme emerged. While images would havebeen helpful, many participants did not want tobe photographed (a traditional value on the west
coast of Yemen).

Results

FGDs with participant mothers

Most women attended between 40 and 50
MtMSG sessions and noted that the location was easy to access, comfortable, and safe.
Participants in all FGDs emphasised optimal breastfeeding and complementary feeding when asked what they had learned. The
importance of exclusive breastfeeding in thefirst six months emerged as a critical learning across all FGDs (n=15). In addition, participants mentioned breastfeeding attachment (n=4), breastfeeding positioning (n=8),
and hygiene, including personal and child hygiene (n=12). When asked about the benefits of these practices to the child and mother, they noted that their children are healthierand experienced a reduced incidence of disease, especially diarrhoea. Mothers credited the knowledge gained for their children’s
improved nutrition/freedom from malnutrition, body growth, weight gain, development,
and sleep, as well as comfort and confidence
for mother and child (n=12). Mothers sharedadditional benefits, such as a reduction in thecost of purchasing both commercial infant
formula and medications/medical care. Mothers in all FGDs associated increased immunity
and improved health with changes they madedue to their participation in MtMSGs.

“It affected my comfort because
my child’s comfort is my comfort.”– FGD participant

When mothers were asked what they perceived to be the most significant change that resulted from their participation in MtMSGs, thekey themes highlighted in the FGDs were improved breastfeeding (n=13) and complementary feeding (n=5), alongside cost savings (n=4)
and improved family and home situations (n=3).
Mutual support emerged as an important element of MtMSGs. Mothers valued the exchangeof opinions and experiences with each other and,
subsequently, their families and communities.
Women from all but one FGD had invited neighbours or other women to join their MtMSG. The
FGD facilitators asked participants about opportunities for MtMSGs to provide additional support and possible MtMSG adaptations. Mothers in more than half of the FGDs identified theprovision of incentives and assistance, citing hygiene kits, nutritional support, and cash support
as options that support groups are well placed toprovide. Suggested adaptations ranged from varying the topics of the sessions and changing theleaflets and posters to providing snacks/meals,
mats, and more materials for sessions. Participants noted that more groups could be created
to benefit more women, children, and families.

“Breastfeeding has been achallenge because… mothers
believed that breastfeedingalone was insufficient to satisfy
the child's hunger and thatusing formula feeding andintroducing solid foods would
contribute to faster growth.
There was a misconception thatbreastfed children might be more
susceptible to illnesses due totheir slender and weak bodies.”– Lead mother, TaizInterviews with lead mothers

Reflecting on sessions they facilitated, leadmothers found the sessions that addressedbreastfeeding, complementary feeding, and personal hygiene to be most impactful (in line withparticipant views). In terms of the successes ofthe MtMSGs, all lead mothers noted that, by
successfully conveying information to members,
they saw mothers make more positive choices.
These included avoiding complementary feeding
until the seventh month and prioritising vaccination (after initially fearing them). Anecdotally, lead mothers also reported seeing an overall
reduction in disease and malnutrition among
members’ children.
Nine out of thirteen (69%) lead mothers
shared that the most challenging part of theirrole was managing misconceptions related tobreastfeeding and complementary feeding, as
these made it difficult for mothers to accept the
information being given. Other reported challenges included difficulty motivating members and the need to adapt information to suitmembers’ education/literacy levels. In addition, mothers had concerns about their own nutrition. Some mothers were unable to consume
regular meals and they feared that this would affect their breastfeeding. Other challenges citedby lead mothers focused on logistical challenges(n=6) such as the distance between homes, lackof transportation, challenging roads, high winds,and presence of dogs.
Lead mothers mentioned educating (n=12)
and building relationships with/respecting
mothers and the community (n=3) as theirfavourite part of being a leader. When asked
how one might improve upon MtMSGs, leadmothers suggested additional training forleaders (n=3) to be able to discuss new topics
and providing cash incentives (n=5) for participating mothers.

“MtMSGs are a vehicle forbehavioural change, valuing eachmember's experiences, views, andopinions. It provides a learning
opportunity, receiving support,
and supporting others without
being judged or shamed.”– Lead mother

Recommendations for support
group implementation

The findings of the qualitative assessment provide several recommendations on ways tostrengthen MtMSGs that could lead to greater effects. The provision of joint session review meetings for lead mothers would support
them to understand and agree on strategies
that work to make MtMSG sessions more engaging. These session review meetings would
also give the lead mothers a chance to shareexperiences with each other. Communicationmaterials need to be adapted for specific contexts to address local misconceptions and myths.
The possibility of supporting MtMSG memberswith basic in-kind materials (e.g. hygiene kits
or cooking utensils,) or linking members withother local programmes for additional support(e.g. food security and livelihoods programmes),needs to be explored. Practical solutions to address issues of distance and transportation need
to be identified (e.g. rotating venues to vary transit time among different group members and reducing session frequency from twice to once perweek). Motivation and engagement can be improved by providing recognition to MtMSG
members and the lead mothers for what they
do, through certificates or a simple ceremony,or more simply through refreshments provided
during the sessions.
The recommendations and suggestions fromlead mothers and members are very valuable.
Mothers feel they are not just part of the initiative but leading it. All the recommendations
are practical and feasible in the medium to longterm, but FHI 360 will need to network and linkwith other partners and programmes to respondsuccessfully to each of them.

Conclusion

Despite some challenges in methodology within this setting, this qualitative assessment has
shown the value of MtMSGs in this context in regard to improving the understanding of optimal
IYCF and mutual support generated between
mothers. Notably, the evaluation has identified
key areas that can be enhanced to support thelead mothers and strengthen mothers’ engagement for future benefits. Following this, FHI 360
will continue supporting the MtMSGs and expanding the interventions in other villages. At
the same time, thanks to the initial encouraging
feedback and experiences, FHI 360 will also start
supporting father-to-father support groups inrecognition of men's critical role in Yemen in the
improvement and care of the health and wellbeing of their families.
For more information, please contact
Alessandro Iellamo at
AIellamo@fhi360.org

References
IPC (2023) Yemen: Acute malnutrition situation October
2022 – May 2023 and projected June – September
2023 (partial analysis). ipcinfo.org
OCHA (2024) Yemen humanitarian needs overview
2024 (January 2024). reliefweb.int
World Alliance on Breastfeeding Action (2024) Mother-to-mother support groups in the Dabaab refugee
camps. waba.org

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

17

Kenya: Linking
informationto action.
Synthesisof coverageassessment
findings
Lucy Maina Gathigi
Nutrition Specialist, Information
System, Monitoring & Evaluation,
Nutrition Section, UNICEF Kenya
Country OfficeCharles Mumbi
Nutrition Support Officer, Data
and Monitoring at the Nutrition
Section, UNICEF Kenya Country
OfficeLucy Kinyua
Monitoring & Evaluation Manager
at the Division of Nutrition andWellbeing, Ministry of Health,Kenya
Ellyn Yakowenko
Project Director, Scaling
Nutrition at International Rescue
Committee (IRC)
Everlyne Adhiambo
Nutrition Policy and Research
Uptake Advisor at IRC

Shadrack Oiye
Public Health Nutrition Specialistat the Intergovernmental
Authority on Development(IGAD)
This integrated management of acutemalnutrition (IMAM) coverage assessments
synthesis was funded by United States Agency forInternational Development (USAID). The authors
recognise the leadership of the Government of
Kenya in this work. Special thanks to Veronica
Kirogo, Head of Nutrition at the Ministry of Health,and Dr Ismael Teta, Chief of Nutrition at UNICEF
Kenya, for their leadership and guidance. Technicalinputs from members of the Nutrition Information
working group (NITWG) led by Lucy Kinyua
and Samuel Murage, as well as the Emergency
Nutrition Advisory Committee (ENAC) led by Grace
Gichohi, are appreciated. We acknowledge inputs
from the UNICEF Kenya Country Office team,including Francis Wambua (Emergency Nutrition
Specialist) and Victoria Mwenda (former Nutrition
Sector Coordinator), and UNICEF nutrition fieldteams led by Francis Kidake and Tom Amolo.
Special thanks to Edwine Ochieng from theInternational Centre of Policy and Research
Solutions (ICPRS) for his inputs.
The analysis, interpretation, and conclusionreflected in this article are those of the authors.
They do not necessarily represent the views of
USAID, UNICEF, IGAD, ICPRS, or IRC.

18

Original Article

Screening for acutemalnutrition in a Kenya© Kelsey Jones, Kenya, 2013

Original Article

What we know:

Since August 2010, Kenya has adopted IMAM programming as part of routine healthservices. Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) surveys
are conducted regularly to provide localised, contextual information on IMAM
services.

What this adds:

The need to systematically combine SQUEAC survey results to generate allinclusive recommendations for improving IMAM coverage across the Arid andSemi-Arid Land counties (ASALs) was recognised. This article explores thesynthesis of findings from 18 independent surveys. Most IMAM programmes
in ASALs have attained coverage above 50% targets, but there is room for
improvement. Key barriers and facilitators are explored and recommendations toimprove policy, programmes, and coordination are provided.

I

n Kenya, around 5% of children aged under five years are wasted and about 18%
stunted (KNBS, 2022). However, the national prevalence of wasting obscuresimportant sub-national patterns – particularly in the ASALs where wasting is generally more prevalent than the national average(Figure 1). The scale-up of IMAM servic-

Figure 1

es in the ASALs is a key component of Kenya’s country roadmap toward achieving andsustaining the Global Action Plan targets on
wasting. IMAM is implemented by the Ministry of Health in collaboration with UNICEF,
the World Food Programme, and implementing partners as part of the emergency nutrition response in the ASALs.

Wasting prevalence in different Kenyan counties

Classification of Wasting(WHO 2017)
Very low <2.5%
Low 2.5 - <5%Medium 5 - <10%High 10 <15%
Very high =>15%

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

AREA
COUNTRYWASTING
Arid
WAJIR
22.8%
Arid
TURKANA
22.6%
Arid
MARSABIT
20.4%
Arid
MANDERA
17.3%
Arid
SAMBURU
15.4%
Arid
GARISSA
15.3%
Arid
BARINGO
13.6%
Arid
TANARIVER
11.3%
Semi-arid WEST POKOT
11.0%
Semi-arid KAJIADO
7.6%
Arid
ISIOLO
7.2%
Semi-arid KILIFI
7.2%
Semi-arid KWALE
6.2%
Semi-arid MERU
6.0%
Semi-arid EMBU
5.3%
Semi-arid KITUI
4.9%
KENYA
4.9%
Semi-arid TAITATAVETA
4.1%
Semi-arid MAKUENI
4.0%
Semi-arid LAMU
3.5%
Semi-arid MACHAKOS
3.5%
Semi-arid THARAKA
3.1%
Semi-arid NYERI
2.7%
Semi-arid LAIKIPIA
2.6%
Semi-arid NAROK
2.1%
Wasting prevalence data source: KDHS 2022

Original Article
Figure 2

The Kenya Nutrition Information Technical
Working Group (NITWG) recognised the need tosystematically review localised data, from SQUEAC surveys, to generate all-inclusive recommendations to address key challenges to IMAM coverage across the ASALs. This single, high-levelcomprehensive outlook could then be used for advocacy, planning, and resource mobilisation, informing the scale-up of IMAM in the ASALs.

Key steps used to conduct SQUEAC surveys in Kenya

STAGE 1
Quantitative: Analysisof routine programme data
Quantitative: contextual data
analysis(Identification ofBarriers/Boosters to
Access services)

Methods

STAGE 2+

Small Area
Survey +Small Studies+

STAGE 3
Wide-Area
Survey=Understandingof barriers/boosters
to coverage+coverage estimation (%)+
Recommendations
and Action Plan

Conducting independent SQUEAC
surveys

A total of 18 coverage assessments were conducted between May and July 2023 across 10
ASALs: Turkana, Marsabit, Samburu, West
Pokot, Baringo, Isiolo, Tana River, Mandera,
Garissa, and Wajir. These assessed Outpatient
Therapeutic Programmes (OTPs) and Supplementary Feeding Programmes (SFPs) according to the key steps summarised in Figure 2.
In Turkana and Marsabit, six and four separate

surveys were conducted at the sub-county level, respectively. This was due to the geographicalexpansiveness of these counties.

Synthesis of SQUEAC surveys

We conducted a ‘quasi’ meta-analysis that collated the results of the 18 SQUEAC surveys.
First, the single coverage estimates for either

Figure 3 Analysis framework for SQUEAC survey synthesis
Conducting 18 SQUEAC
surveys in 10 counties

Level 2b: Futhercategorisation
under each generalcategory.
• Futher granular
categorisation
was done to groupalmost similarbarriers/boosters
into sub-category
themes.
• For Example,
under thegeneral categoryof community
level issues, subcategory themes
for barriers were
stigmatisation;
RUTF/RUSF
perceived as food;negative culturalbeliefs; poverty
and food security;
nomadic lifestyleand insecurity.

Level 1: From each survey
report, the barriers/boosters
were drawn and collated ina spreadsheet, where eachsurvey area was allocated aworksheet (tab)Level 2a: Reviewing ofbarriers/boosters andcategorisation them into
general groups.
• These general categories
included: Communitylevel issues, geographicalfactors, maternal/caregiver
determinants and healthsystem issues• All possible categories
included and each category
given a worksheet• Each barrier/booster was
moved manually to therespective category andcoded by country or subcounty (survey area)

Level 3:
Identification ofcommon barriers
and boosters (subcategory themes)• To determine
whether a barrieror booster wascommon, it was
hypothetically
set that it musthave been
identified bynine or moresurvey areas(counties or
sub-counties).

Collection of
information fromthe key informants

Themecategorisationand drawing ofrecommendations
Triangulation,
amalgamation ofarising issues
National outlookof barriers
to coverage,
facilitatorsand common
lessons; andrecommendations

coverage estimates for outpatient and supplementary
Figure 4 Single
feeding programmes compared to observed wasting prevalence

a,b

72.2%
68.7%

80%
70%

Percentage

60%
50%

38.4%

36.6%

40%
30%
20%
10%

OTP

SFP

Wasting

WEST POKOT

WAJIR

TURKANA LOIMA

TURKANA CENTRALTURKANA WEST

TURKANA SOUTH

TURKANA NORTH

TURKANA EAST

TANA RIVERSAMBURUMARSABIT SAKUMARSABIT NORTH HORRMARSABIT MOYALEMARSABIT LAISAMISMANDERAISIOLOGARISSABARINGO

0%

Minimum Sphere Coverage Standing

Wasting prevalence was taken from recent Standardised Monitoring and Assessment of Relief and Transitions (SMART) surveys (July 2022
or January 2023).
b
In Turkana and Marsabit counties, sub-counties were assessed separately due to the expansiveness of these areas. Highest and lowest
coverages are labelled.
aprogramme (OTP or SFP) were compiled forcomparison. From each survey area, coveragebarriers and facilitators were collated into an
Excel worksheet. Each survey area was allocated a separate worksheet. This was the ‘level one’analysis of OTP/SFP barriers/facilitators.
In ‘level two’, barriers and facilitators were reviewed and categorised into four general groups:
community-level issues, geographical factors,
caregiver determinants, and health system issues. The barriers and facilitators that were similar in each of the general groups were further organised into more granular sub-category themes.
Sub-categories were then coded in a drop-downmenu for ease in enumerating which survey areas
reported which barriers and/or facilitators. This
allowed us to determine the number of survey areas that reported each sub-category. Our threshold for determining whether a barrier or facilitator (sub-category) was common was that it musthave been reported by nine (50%) or more survey
areas (counties or sub-counties).
Key informant interviews were also conducted to draw on a broader perspective andto complement county-specific issues. Purposively selected national-level interviewees included: the Ministry of Health National Manager for Emergency Nutrition (n=1), the Ministryof Health Monitoring and Evaluation Manager (1), national staff of implementing partners
supporting IMAM (4), the UNICEF Monitoring & Evaluation Specialist (1), the Nutrition
Sector Coordinator (1), the UNICEF Emergency Nutrition Specialist (1), nutrition supply chain officers (2), national-level World
Food Programme staff (1), the UNICEF Data
and Monitoring Nutrition Support Officer (1),and UNICEF Nutrition Specialists at zonal level (2). Guide questions for the key informant interviews were drafted and distributed appropriately across these key informants. This gatheredadditional information about IMAM coveragethat may not have been addressed through the
SQUEAC survey methodology alone.
The information collected from key informants was categorised into common themes.
These were then triangulated with the synthesised barriers and facilitators to inform the national outlook of issues affecting IMAM programming in Kenya’s ASAL areas (Figure 3).

Results

Programme coverage

There were seven OTP and five SFP survey areasthat reported single coverage estimates of less than
the 50% minimum standard for rural areas (Figure 4) (Sphere, 2018). When SFP and OTP cov-

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

19Original Article
erage and wasting data were merged, and regression analysis performed, a positive relationshipwas observed – coverage increased in line with increasing wasting rates. Almost two in every threesurvey areas (64%) with high wasting rates (over15%) had higher coverage rates (greater than 50%)for both OTP and SFP. From the synthesis, we noted that areas with higher wasting prevalence also
had many nutrition partners supporting IMAM
programming, thus explaining the higher cov-

Table 1erage estimates. However, this did not come intoplay for areas with high levels of insecurity (suchas Samburu and Laisamis).

Common barriers to coverage andtreatment

In both OTPs and SFPs, 94% of survey areas reported the sharing of ready-to-use therapeutic
food (RUTF) or ready-to-use supplementary
food (RUSF) – or exchanging them for moneyor food – as a major barrier (Table 1). Similarfindings were reported by key informants, who
noted nutrition commodity sharing was commonplace. Some caregivers who consumed alcohol would also exchange RUTF for money or
alcohol. Maternal workload was also highlighted as a key barrier, as well as poor active casefinding and referral. Long distances to health facilities and migration (due to drought or floods)
were also important barriers to access.

Barriers and facilitators to outpatient and supplementary feeding programme coveragea
Supplementary Feeding Programme

Outpatient Therapeutic Feeding Programme
Surveyareas%

Commonly reported barriers

RUTF sharing or exchange for money or food

17

94%

Poor active case findings and referral system

15

83%

Commonly reported barriers

Surveyareas%

RUSF sharing or exchange for money or food

17

94%

Challenges with HCWs

16

89%

83%

Long distance from health facility

16

89%

Challenges with CHVs

15

Maternal workload

14

78%

Maternal workload

15

83%

Long distance from health facility

13

72%

Poor active case finding and referral

15

83%

Poor knowledge on causes and treatment ofsevere wasting

12

67%

Migration due to drought and floods

15

83%

Negative cultural beliefs, practices, and myths

12

67%

Migration due to drought and floods

12

67%

Challenges with the CHVs
RUSF and other commodity stockouts

14
14

78%
78%

Poverty and food insecurity

11

61%

Stigmatisation of households with moderatechild wasting

13

72%

Stigmatisation of households with severe childwasting

1056%

Poor documentation/records

950%

Poverty and food insecurity
Maternal knowledge and perceptions

12
12

67%
67%

Nomadic lifestyle and insecurity

8

44%

11

61%

Poor health seeking behaviours

8

44%

Poor knowledge on causes and treatment ofmoderate wasting
Negative cultural beliefs, practices, and myths

10

56%

10

56%

Alcoholism
Challenges with HCWs

8
8

44%
44%

Poor health seeking behaviours
Nomadic lifestyle and insecurity

950%

RUTF and other commodity stockouts

844%

Poor or impassable roads

950%

RUTF is perceived as food

7

39%

RUSF perceived as food

8

44%

7

39%

Limited defaulter tracing and follow-up

739%

Limited defaulter tracing and follow-up

Maternal knowledge and perceptions

6

33%

Poor documentation/records

7

39%

Surveyareas%

Alcoholism

633%

Health facility amenities

6

33%

Awareness on causes and treatment of severe
wasting
Health Care Worker capacity to implement IMAM

18

100%

Commonly reported facilitators

Survey
areas

%

18

100%

100%

17

94%

Positive health seeking behaviours

16

89%

Awareness of and limited stigma regarding
moderate wasting
Active case finding and referrals

18

RUTF and other supplies available (no stockouts)

18

100%

Community Health Volunteer capacity to
implement IMAM

16

89%

HCW capacity to implement IMAM

17

94%

16

89%

Active case finding

14

78%

Support supervision and programme review

14

78%

Collaboration between HCWs, CHVs,
communities, and leaders
Active outreach services and mass screening

16

89%

Family led MUAC and self-referral

13

72%

CHV capacity to implement IMAM

15

83%

Active outreach services

13

72%

Family led MUAC and self-referral

15

83%

Positive health seeking behaviours

13

72%

RUSF supplies available (no stockouts)

13

72%

Stakeholder support and coordination

12

67%
61%
61%

Commonly reported facilitators

Stakeholder support and coordination

12

67%

Collaboration between HCWs and CHVs

10

56%

OTP services available at health facilities

950%

Availability of screening, referral and reporting
tools

9

50%

Defaulter tracing mechanisms
Support supervision and programme review

11
11Active community and leader’s involvement

8

44%

SFP services available (at various service points)

10

56%

Defaulter tracing mechanisms

8

44%

Availability of equipment

7

39%

Recognition of role of CHVs

6

33%

Proximity to health facilities

6

33%

Only commonly reported barriers / facilitators have been shown here (i.e. those reported in six or more survey areas)
RUTF/RUSF = Ready-to-use therapeutic/supplementary food; CHV = Community Health Volunteer; HCW = Health Care Worker;
MUAC = Mid-upper arm circumferencea20

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

Original Article
Kenya’s community health strategy waslaunched in 2006 to improve community accessto healthcare. Since then, most counties haveadopted it – including all the survey areas featured in this article. However, continued challenges were observed in regard to the community health strategy. In some areas, there were nocommunity health volunteers (CHVs). Where
they existed, numbers were often not adequate
to support in active case finding, defaulter tracing, and referral. Some CHVs had capacity gaps,
as was reported by a partner staff key informant.

“Knowledge of IMAM by CHVs
has enhanced screening and active
case finding in the community.
However, a good number of CHVs
have not been trained on IMAM
due to limited resources.”– Key informant, nutrition partner

Demotivation, due to a lack of or a delayed
stipend, was commonly reported for CHVs
across the survey areas. We also observed thata barrier may have a geographical aspect due
to geopolitical and sociocultural similarities.
An example is maternal alcoholism, which wasreported in Turkana Central, Turkana South,
Turkana West, Samburu, West Pokot, Baringo,
Laisamis, and North Horr. These areas bordereach other, and this finding calls for inter-county collaboration in addressing the challenge.

Common facilitators of coverage

Most health systems facilitators were common
across the survey areas for both OTPs and
SFPs. These included HCWs and CHVs’ availability and their capacity to provide IMAM
services, active case finding, active outreaches, and mass screening exercises. Also important were no stock-out of nutrition commodities, provision of supportive supervision andprogramme reviews. All the surveyed areas indicated awareness of the causes and treatment
of severe and moderate wasting as a key community-level facilitator.
Common maternal/caregiver facilitators
identified were positive health seeking behaviour, training caregivers to identify early signsof malnutrition in their children using MUAC(“Family-led MUAC”) and self-referral. Only
Turkana North reported availability of active
mother support groups as a facilitator.

What next?

The synthesis of findings from the independent surveys, together with the consolidationof insights from key informants, highlightactions to be considered to scale up IMAM
across Kenya’s ASALs.

Policy and strategy considerations

Developing and implementing a national strategy for peace, security, development, and humanitarian operations, as well as tackling poverty and infrastructural challenges, all remain
important. Poverty and childhood malnutrition
are interlinked – and they are mediated by inadequate diets, lower education, poorer living
standards, and limited access to healthcare fa-

cilities and appropriate water, sanitation, andhygiene. This clearly articulates the need forpolicies and guidelines that prioritise overall
poverty and malnutrition reduction.

grammes as a facilitator. National and county
governments, and partners, must scale up social
safety net and poverty alleviation programmesthat integrate nutrition.

Kenya has chosen the primary healthcare
system to deliver universal health coverage.
A ‘community health strategy’ has been given prominence in all the survey areas. However, challenges to full strategy implementation
still exist, as only two counties are reported to
be giving CHVs a monthly stipend. There is aneed for county governments to collaborate
with partners to develop and implement community health acts. These acts will provide a legal basis for counties to allocate funds for renumeration and provide adequate supervision of
CHVs. This will result in CHVs who are better motivated, better equipped, and who areaccountable when providing health services atcommunity level.

The adequacy and availability of nutrition
supplies was a key facilitator leading to the success of the IMAM programme. Although the
supply chain is government led, procurement isheavily supported by donors. Advocacy efforts
should continue at both the national and county
levels for resource allocation to cover nutrition
supplies and for ring-fencing finances to protect
any allocated funding for this task.

Programmatic issues

Across 18 independent SQUEAC surveys, witha few exceptions (Turkana East, Turkana Loima, and Wajir), the OTP was found to performbetter in both coverage and outcome indicators
than the SFP. This is despite both programmes
being implemented jointly in all the survey areas. This calls for further analysis to understandthe associations and unique factors that could
be causing this difference.
Maternal workload was highlighted as a key
caregiver barrier. Programming should be designed to encompass male involvement in childcare activities and not purely focus on mothers and children. Counties and partners could
also support establishing peer-to-peer support
groups for fathers at community level, whichhave been proven to positively influence childfeeding practices (Bogale et al, 2022; Atuman
et al, 2023). Fathers can be involved in financial and resource support, as well as social andphysical support, such as shared responsibility
for the nutritional wellbeing and health of thechild. A study in Ethiopia found that, for children aged 6–23 months, dietary diversity in thehousehold increased by 13.7% when fathers
were involved in infant and young child feeding(Gebremedhin et al, 2017).
Community engagement, sensitisation, andmobilisation clearly remain as barriers to increasing coverage for both OTPs and SFPs. Addressing these issues will be central to achieving greater
coverage in IMAM programmes. As well as developing guidelines and strategy documents, it is critical for counties and partners to allocate resources
for improved community engagement.
The sharing and commodification of RUTF/
RUSF was a major barrier. This directly affects
programme outcomes, increasing both lengthof stay and non-response in a programme. Ultimately, children who remain wasted remain atheightened risk of mortality and morbidity associated with malnutrition. Such practices also
increase the cost of programmes. To curb this, itis critical to link households with malnourishedchildren who have exited as ‘cured’ from IMAM
programmes to social safety net schemes. However, in this analysis, only two survey zones reported the availability of social safety net pro-

Coordination actions

Several coordination mechanisms for nutrition
exist in the country at national level, providing
opportunities for collaboration and to strengthen partnerships between the Ministry of Healthand nutrition stakeholders. These include the
Nutrition Technical Forum, ENAC, and NITWG. Counties could establish such coordination structures for inter-county information
sharing and collaboration, seeking to addresscommon barriers and documenting best working practices.

Conclusion

This systematic synthesis of findings from 18
SQUEAC surveys highlighted that most IMAM
programmes in ASALs have attained OTP and
SFP single coverage above 50% but there isroom for improvement and a need to sustain thegains already made. OTP was noted to performbetter compared to SFP.
The identified common barriers and facilitators, and additional key observations, provide relevant information for policy, advocacy,
and programmatic efforts to scale up the management of wasting across the ASALs. Moreover,the synthesis diagnoses the need for inter-county collaboration in tackling specific barriers, given their geographical spread. Ultimately, systems
need to be strengthened to prevent children frombecoming wasted in the first place. Poverty alleviation, stronger community systems, and gender equity (all advocated for above) will not only
reduce barriers to increasing treatment coverage
but also promote prevention.
For more information, please contact Lucy
Maina at lmaina@unicef.org

References
Atuman S, Langat O, Iellamo A et al (2023) Father-to-father support groups in northern Nigeria: An emergency response initiative. Field Exchange 70. https://www.
ennonline.net/fex/70/father-to-father-support-groupsin-northern-nigeria
Bogale S, Cherie N & Bogale E (2022) Fathers’ involvement in child feeding and its associated factors among
fathers having children aged 6 to 24 months in Antsokia Gemza Woreda, Ethiopia: Cross-sectional study.
PLoS One, 17, 11, e0276565
Gebremedhin S, Baye K, Bekele T et al (2017) Predictorsof dietary diversity in children ages 6 to 23 months ina largely food-insecure area of South Wollo, Ethiopia.
Nutrition, 33, 163–8
KNBS (2023) Kenya demographic and health survey
2022 – Key indicators report. dhsprogram.com
Sphere (2018) Humanitarian charter and minimum
standards in humanitarian response.
spherestandards.org

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

21© GOAL

Original Article
What we know:

There is building evidence that mid-upper-arm circumference (MUAC) is areliable tool and a good predictor of mortality in infants aged under six months(Hoehn et al, 2021). However, practitioners have faced challenges in accessing
and producing tapes for research and programming.

What this adds:
Training mothers on theuse of the multi-MUAC
tape. Ethiopia, 2023

Trialling a
multi-MUAC
tape to screen
at-risk infants
under sixmonths inEast Africa
Eilise Brennan
Nutrition Technical Officer at GOAL Global
Amir Samnani
Nutritionist at Emergency Nutrition Network (ENN)
Hatty Barthorp
Nutrition Advisor at GOAL Global
Alice Burrell
Senior Humanitarian Nutrition Advisor (MAMI) at
Save the Children
Fabrizio Loddo
Senior Humanitarian Nutrition Advisor at Save theChildrenAngelina Nasira Boi
Former MAMI Coordinator at MOMENTUM Integrated
Health Resilience (MIHR), IMA World Health South
Sudan, an affiliate of Corus International South Sudan
Marlene Traore-Hebie
Senior Technical Advisor for Nutrition at MIHR, Corus
International, USA
Nicky Dent
MAMI Global Network Coordinator at ENN
Marie McGrath
Technical Director at ENN
We would like to express our deepest gratitude to thecountry offices and the dedicated health workers at
the MAMI sites for providing exceptional care to at-risk
mother–infant pairs, and the unwavering commitmentof the mothers that made this multi-MUAC pilot
possible. We would like to acknowledge the ministriesof health in South Sudan, Ethiopia, Kenya, and Somalia,
as well as MIHR MAMI International Consultant Hedwig
Deconinck. We also extend our sincere thanks to ECHO,
the Bill & Melinda Gates Foundation, the Department
of Foreign Affairs Ireland, BHA, USAID, and Latter Day
Saints Charities, who supported this research.

22

Operational pilots by GOAL, Save the Children, and MIHR of a prototype
multi-MUAC tape found that healthcare workers (HWs) and caregivers in
Somalia, Kenya, and South Sudan could effectively and feasibly use it to screen
infants under six months of age. Recommendations for design improvements
and contextual influences have informed an updated World Health Organization(WHO) and UNICEF MUAC tape for women and infants (aged six weeks to six
months), which is now available from UNICEF regional and country offices.

The ‘management of small and nutritionally at-risk infants undersix months and their mothers’
approach (MAMI) refers to thecontinuity of respectful quality care for atrisk mother–infant pairs across systems ofhealth and nutrition. ‘At-risk’ or vulnerable
pairs include infants and mothers who may
be identified in many ways. They include
infants born too early (preterm) or too
small (low birth weight), infants who arewasted, underweight, or growing poorly,
and mothers with nutrition, mental/physical health, and social problems (McGrathet al, 2024).
Since 2019, MUAC has been used ininfants aged under six months in a limited number of settings, building valuable evidence of its application in this age
group. These efforts have contributed to a
recommendation on the use of MUAC to
identify infants at risk of poor growth anddevelopment (MUAC <110mm, infants
aged six weeks to six months) in the 2023
guideline on the prevention and management of wasting and nutritional oedema(WHO, 2023).
In 2022, a working group was convened by the MAMI Global Network to address challenges in accessing or producing
a quality MUAC tape for use with infants.
This was a time-sensitive challenge given
imminent opportunities to include MUAC
for infants aged under six months in research, and the potential for a WHO recommendation to emerge. While a MUAC
template for infants aged under six months
was available (Rana et al, 2021a), in-country replication was proving difficult to thenecessary specifications.

Figure 1

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The working group oversaw the designof a pilot ‘multi-MUAC’ tape, produced forresearch purposes by UNICEF in collaboration with WHO. The aim was to produce apractical, high-specification MUAC tape thatwas designed to assess infants aged under six
months, while also incorporating mother’s
assessment alongside. The tape also included
children aged 6–59 months to avoid the needfor multiple different MUAC tapes.
The multi-MUAC tape was piloted bythree agencies (GOAL, Save the Children,
and MIHR) to test its feasibility and effectiveness for screening infants aged under six
months by HWs and caregivers. This article shares the collated findings of this collective effort.

Methods

Design and production

The multi-MUAC tape design (figure 1)
was developed by the working group using the GOAL template as a strong starting
point. One side measures infants and children (mm, colour-coded), while the othermeasures women (mm only). At the timeof development there were no guidelines
for the use of MUAC in infants. To identify
infants at heightened risk of malnutrition
requiring referral for further assessment
and support, we used <110mm (infants
aged 0–6 weeks) and <115mm (aged sevenweeks and above). Infants above these cutoffs and <125 mm were still considered to
be at risk of deteriorating nutritional status
and referred to community HWs for additional counselling and support. The material thickness of the multi-MUAC tape
was adjusted to address problems with the
UNICEF MUAC tape for children aged

‘Multi-MUAC’ tape designOriginal Article
6–59 months (Rana et al, 2021b). The tape design was managed by UNICEF Supplies Division and a limited number were rapidly produced for research purposes only.

Figure 2

Number of participants trained at each study site

Operational pilots

GOAL developed a study protocol that informed the basis for the operational pilots,
adapted to each country’s context and capacity.
In Ethiopia, GOAL tested the tape with HWs
and caregivers in three study sites (figure 2).
Save the Children tested the tape with HWs,
caregivers, and community nutrition volunteers (CNVs) – community members who receive brief training on health and nutrition – intwo study sites in Kenya and three in Somalia. In South Sudan, MIHR tested the tape with
HWs in three study sites. Training on the useof the multi-MUAC tape varied by setting but
in general was cascaded from nutrition supervisors (or equivalent) to the different HW cadres and caregivers.

Data collection

Figure 3 Calculating the sensitivity and specificity of measurements

Data was collected over various time periods
between December 2022 and July 2023. While
all infants included in the pilots were aged under six months, the exact age of the infant at thetime of assessment was not recorded. Information on measurement accuracy, which side of
the tape was preferred, and any challenges intape usage were collected from study participants. Information on preferred side of the tape
was not collected in South Sudan, but recommendations for future development of the tapewere gathered.
In Ethiopia, Kenya, and Somalia, HWs
measured five infants each. In South Sudan, 10
infants were measured by each HW. Across thestudy sites, verification measurements were taken by the Nutrition Supervisor (or equivalent)on the same infants. In Kenya and Somalia,
CNVs measured five infants each, with verification measurements taken by HWs on the same
infants. Caregivers measured their own infant’s
MUAC using the colour classification only,
which was compared to measurements taken by
HWs (Ethiopia) or CNVs (Somalia, Kenya).

MUAC measurement trainer
MUAC <125 mm
MUAC >=125 mm

Findings

Accuracy of MUAC measurements

Apart from in Kenya, over 70% of HWs and
CNVs were able to correctly measure the infant’s
numeric MUAC value to within 1mm, compared
to measurements taken by trainers on the same
infant (table 1). There was high specificity of numeric MUAC measurements by HWs and CNVs
across all countries. Apart from CNVs in Kenya, there was high sensitivity of numeric MUAC
measurements by HWs and CNVs.

True positive (TP)

False positive (FP)

False negative (FN)

True negative (TN)Sensitivity = TP/TP+FN Specificity = TN/TN+FP

Table 1aMulti-MUAC measurement accuracy (>=125mm) by participant
Measurements within +/1mm of the referencea

Sensitivity of numeric
measurements

Specificity of numeric
measurements

HWs

CNVs

HWs

CNVs

HWs

CNVs

Ethiopia

119 (79%)

-

97%

-

99%

-

Kenya

79 (43%)105 (29%)

99%

65%

84%

89%

Somalia

142 (95%)

79 (81%)

97%

94%

97%

96%

South Sudan

106 (71%)

-

96%

-

95%

-

Reference = Measurement taken by a trainer on the same infant Healthcare workers (HWs); Community nutrition volunteers (CNVs)

Table 2

Risk classification (by colour) accuracy arranged by participant

Colour classifications thatmatched the referencea

Data analysis

To assess performance, absolute numeric MUAC
measurements and risk classifications by colour
were compared (HWs vs nutrition supervisors,
CNVs vs HWs, and caregivers vs HWs/CNVs).
For numeric MUAC measurements, a standardof error of +/- 1mm was applied across study
sites. We also calculated the sensitivity and specificity of numeric MUAC measurements and risk
classifications by colour using a MUAC cut-off of
125 mm (Figure 3).

MUAC <125 mm
MUAC >=125 mm

MUAC
measurement trainee

Specificity of colour
classifications

HWs

CNVs

Caregivers HWs

CNVs Caregivers HWs

CVNs Caregivers

Ethiopia

123 (82%)-

135 (90%)

83%

-

87.5%

99.5%

-

99%

Kenya

163 (89%)

269 (75%)288 (93%)

98%

67%

97%

85%

85%

98%

Somalia

147 (99%)

90 (93%)151 (93%)

99%

95%

89%

97%

93%

98%

-

-

95%

-

-

93%

-

-

South Sudan 133 (87%)
aSensitivity of colour
classifications

Reference = Measurement taken by a trainer on the same infant Healthcare workers (HWs); Community nutrition volunteers (CNVs)

A higher percentage of HWs and CNVs
were able to correctly identify infants' risk classification using colour coding compared to numeric MUAC measurements. Similarly, a highpercentage of caregivers were able to correctly
identify the risk classification by colour (table2). Across all countries, there was high sensitivity and specificity of risk classifications by colourfor HWs, CNVs, and caregivers.

Challenges using the multi-MUAC
tape

HWs reported some challenges in reading thetape (table 3) due to the small font size of meas-

urements, the window of the tape being too
narrow (making the measurements difficult
to read), and the infants wriggling during assessment. CNVs in Kenya reported challenges in reading and interpreting the tapes due tolow literacy rates, coupled with small text size.
Training also greatly varied between study sites.
Response rates were low for questions on challenges (4–16%), so these results should be interpreted carefully.
The South Sudan MAMI team identified design problems with the women’s tape side that
confused interpretation: specifically, the place-

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

23Original Article
Table 3

Reported challenges in multi-MUAC tape usage
Reported challenges
physically using the tapeReported challenges reading
the tape numerically

Reported challenges
interpreting results

HWs

CNVs

HWs

CNVs

HWs

CNVs

Ethiopia0-

10 (33%)

-

0

-

Kenya

6 (15%)

5 (6%)

3 (8%)

12 (15%)2 (5%)

9 (11%)

Somalia000

1 (5%)

00South Sudan0-

3 (20%)-

2 (13%)-

Healthcare workers (HWs); Community nutrition volunteers (CNVs)

ment of the breastfeeding mother image alongside the 235 mm measurement point implied tosome that this was the cut-off to apply to breastfeeding mothers (rather than 230mm). Whilemeasurements were recorded in millimetres
they were presented on the tape in centimetres,
which also caused confusion. The length of thetape was reported as too long and inconvenientwhen measuring very young infants.
When asked which side of the tape they preferred, 79% of HWs and 59% of CNVs who responded found the coloured side of the tape(the child side) easier to use. However, the response rate was also low for this question (26%HWs, 31% CNVs).
In Somalia and the Garissa region in Kenya, data on the challenges in using the tapes in
infants were reported per group of caregivers(not individuals). Caregivers reported difficulties in using the tape in Wajir (Kenya) (32% ofcaregivers), Garissa (Kenya) (13% of groups),
and Ethiopia (19% of caregivers). Caregivers reported challenges in reading / interpreting theresults in Wajir (21% / 37% of caregivers), Garissa (20% / 13% of groups), and Somalia (6% /3% of groups), respectively. A range of challenges in physically using the tape were reported bycaregivers, such as in estimating the midpointof the infant’s arm, measuring small infants due
to crying and wriggling, and confusion on how
to lace the tape correctly through the windows.

Suggestions to improve the MUAC
tape

The respondents highlighted several designchanges that could improve the multi-MUAC
tape. These included increasing the font sizeof measurements, colour coding both sides,
and reducing the number of windows throughwhich the tape is laced. The MUAC design teamrecognise that three windows through whichto lace the tape is greater than many tradition-

Figure 4

al MUAC tapes, but this was done to reduce thelateral movement of the tape and reduce measurement inaccuracies more common with a single window design. Respondents also suggested
using millimetres on the tape (to improve accuracy and precision), reducing tape length, andimproving tape durability (in reference to thecolouring fading quickly). One team suggested
moving the pregnant and breastfeeding women images to the head of the tape to avoid confusion. To improve legibility, including colour
coding only in the middle of the tape was alsosuggested.
Respondents were eager to ensure that cutoffs are adjusted to align with specific contexts
and national protocols (e.g. cut-offs for women should align with admission criteria for supplementary food programmes where operational). Using ‘0–6 weeks’ and ‘seven weeks andabove’ as classification descriptors was noted asinconsistent with both the MAMI Care Pathway (which uses ‘infants under six weeks’ and‘infants six weeks to six months’) and the latest
WHO recommendation (‘six weeks and above’).

Discussion and conclusions

As the studies were opportunistically implemented by different agencies at different operational settings, implementation varied between
study sites. Qualitative data and discussions
with the implementing teams indicated considerable variation in training and delivery modality. There was also considerable variability in the quality of data collection, with a large
amount of missing data for qualitative findings
from Somalia and Kenya. Results should therefore be interpreted carefully.
Our findings indicate that the majority of
HWs, CNVs, and caregivers could feasibly andeffectively use the multi-MUAC tape to screen
infants aged under six months, to varying degrees. Caregivers found the tape most challeng-

Mother/infant MUAC tapes available from UNICEF

Version 1 (23cm cut-off):

Version 2 (21cm cut-off):

ing to use and interpret, followed by CNVs, andthen HWs. Several factors affected the usability of the piloted tape: some of these were specific to the tape design, and some not. Our experience emphasises that while the tool itself may be
simple, contextualised training and support will
be important for practice.
The multi-MUAC tape was developed as afirst-step test prototype, anticipating it would
likely need amending and adaptation to contexts. Our findings have been shared and they
informed a subsequent version that has been
co-developed and produced by UNICEF and
WHO under the Wasting and Nutritional Oedema (Acute Malnutrition) Technical Advisory
Group (Infants Sub-Working Group) (WHO,2024). This version only includes infant MUAC
cut-offs for those aged six weeks and over, forconsistency with the 2023 recommendation(WHO, 2023). There are two versions with
21cm or 23cm cut-offs for pregnant women/mothers (figure 4).
For more information, please contact Eilise
Brennan at ebrennan@goal.ie
To order mother/infant MUAC tapes, pleasecontact UNICEF regional and country offices for supplies, guidance and to provide user
feedback.

References
Angood C, McGrath M, Mehta S et al (2015) Research priorities to improve the management of
acute malnutrition in infants aged less than six
months (MAMI). PLOS Medicine, 12, 4, e1001812
Hoehn C, Lelijveld N, Mwangome M (2021) Anthropometric criteria for identifying infants under 6 months of age at risk of morbidity andmortality: A systematic review. Clinical Medicine
Insights: Pediatrics, 15
MAMI Global Network, ENN, LSHTM (2021)
MAMI Care Pathway Package, Version 3.
www.ennonline.net/mamicarepathway
McGrath M, Wrottesley S, Brennan E (2024) Invisible pursuit: Global policy guidance on careof vulnerable infants under 6 months and theirmothers: A scoping review.
https://www.ennonline.net/global-policy-guidance-on-care-of-vulnerable-infants-under-sixmonths-and-their-mothers
Rana R, Barthorp H, Murphy M (2021a) Implementing the family-MUAC approach for infants
under 6 months in the context of COVID-19 inEthiopia. Field Exchange 64.
https://www.ennonline.net/fex/64/ethiopiagoalcovidadaptations
Rana R, Barthorp H, McGrath M et al (2021b)
Mid-upper arm circumference tapes and measurement discrepancies: Time to standardize
product specifications and reporting. Global
Health, Science and Practice, 9, 4,1011–1014
WHO (2023) WHO guideline on the prevention
and management of wasting and nutritional oedema (acute malnutrition) in infants andchildren under 5 years: Web annex A: Guideline
questions and outcomes. iris.who.int
WHO (2024) UNICEF/WHO technical advisory group on wasting and nutritional oedema(acute malnutrition) – members and secretariat. who.int

24

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Original Article
What we know:

A focus group discussion withmothers of children aged underfive years in Badimalika. Nepal

An understanding of nutritional determinants and causal pathways is
critical for designing contextualised and targeted programmes that address
undernutrition in all its forms. Current assessment approaches are useful but
may be time and resource intensive.

What this adds:

As part of its broader work to support innovative solutions to respond to moderate
wasting in children under five, the MWI, in partnership with Action Against
Hunger, piloted a rapid nutrition determinants assessment (NDA) approach in
Nepal. This article describes the development of this qualitative approach andchallenges, opportunities, and lessons learned through the experience.

© ACF

BackgroundExperiences
implementing
a rapidnutrition
determinants
assessment
in NepalManu Adhikari
Senior Programme Officer at MWI,
Action Against Hunger Nepal
Lenka Blanarova
Senior Nutrition Assessment
Coordinator at Action Against
HungerAndi Kendle
GNC Operations Team Coordinator– Programmes at Action Against
Hunger Canada
Erin McCloskey-Rebelo
Independent Consultant andModerate Wasting Initiative (MWI)
LeadMartha Nakakande
Global Nutrition Cluster (GNC)
Community Management of
Acute Malnutrition Advisor at
International Medical Corps, MWI

Most NDAs, also called nutrition causal
analysis assessments (NCAs), seek to understand the multi-sectoral nature of nutrition determinants within a given area,
to inform contextualised programmatic
responses. In recent years, the Link NCA
method – spearheaded by Action Against
Hunger – has been a popular method forassessing nutrition determinants througha participative, mixed-method approach.
A key strength of Link NCA has been its
ability to not only show relationships between various factors but also to describe
how determinants are related to each other and the relative importance of each to
the risk of developing undernutrition. Although fruitful, this approach has provento be time and resource intensive, reducing its accessibility, especially in emergency and/or underfunded contexts.
The Nutrition Determinants Working
Group (NDWG), a sub-working group of
the GNC’s Nutrition Information Systems
Global Thematic Working Group (GNC,2024), discussed the need to develop a simple and affordable toolkit to help identify –and explain the relationship between – context-specific determinants, while promoting
community engagement. The ultimate goal
would be to encourage a more efficient andeffective use of nutrition determinants databy programme implementers. This article describes the experiences of the GNC’s
MWI, in partnership with the NDWG and
Action Against Hunger, with funding from
Irish Aid, in developing and testing a rapid
qualitative NDA in Nepal.
The MWI aims to contribute to addressing the challenges that nutrition
stakeholders have in developing, accessing, and utilising feasible, effective, andinnovative solutions to respond to moderate wasting in children under five years
old at scale. It seeks to support the development of programmatic solutions through arange of contextualised options, including
the current standard of traditional nutritional supplementation with the provisionof specialised nutritious foods. The MWI
aims to use the outputs of the Nepal experience to feed into a larger pilot that supports countries to diversify and better con-textualise approaches for the managementof moderate wasting.

Rapid NDA

The Rapid NDA methodology was developed by Action Against Hunger and further contextualised in situ by the Action
Against Hunger Nepal and MWI teams.
The methodology aimed to fill specific information gaps, be quick to implement, be
accomplished by a small team, and include
a community validation exercise. Considering these specific needs, a qualitative approach was considered most appropriate.
The specific objectives of the assessment were to identify key determinants ofundernutrition among the study population and to understand how determinantsof wasting interact with each other, so as
to determine which causal pathways arelikely to explain most cases of wasting. The
MWI in Nepal was specifically interested
in moderate wasting. However, as communities could not differentiate causes ofwasting and stunting, or the associated severity, the respondents were not asked tolimit their responses to moderate wasting. Therefore, general undernutrition wasconsidered in this setting.

Sampling and data collection

Three pilot locations were selected in collaboration with Nepal’s Nutrition Technical Committee and the Integrated Management of Acute Malnutrition Working
Group. Locations were selected to represent the three different geographical areas of Nepal – the mountains, the hills, andthe ‘terai’ (lowlands) – to compare nutritional determinants in these areas. This
would provide a contextualised analysis
for the design of locally resourced solutions to improve the relevance and efficiency of moderate wasting programmingin these locations.
The assessment was designed to bequick and easy to implement. Therefore,
the number of community consultations
was reduced from that required by a Link
NCA (table 1) while trying to maintain thescope of thematic areas covered for it to remain relevant for the multi-sectoral analysis of nutrition determinants. The Action

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25Original Article
Table 1

Table 2

Rapid NDA and Link NCA comparison table
Rapid NDA

Link NCA

Methodology

Qualitative

Qualitative and quantitative, including areview of secondary data sources

Timeframe (datacollection andanalysis)

One or two weeks

20+ weeks

Objective

Studies the relationships between
determinants for undernutrition

Studies potential differences in causal
mechanisms of undernutrition and anaemia

Day 3

Data validation

Community validation of data, with a focus
on community priorities

Triangulation of data between several
qualitative and quantitative sources,
including community validation

Day 4

Implementationarea

Sub-district (municipality) level (samples
one locality)

District level (samples four localities)

Community
consultations

10–11 key informant interviews

Nine focus group
discussions

54 key informant interviews

Team

Can be implemented by programme/local
Can be implemented by local teams withteams with training and specialised support training and specialised support

Implementationreach

One country and three finalised studies

29 countries and 52 finalised studies

Proof of concept

Promising but needs to be tested in more
contexts and in contrast to other methods

Demonstrated reliability

In each location, the research team conducted 10 or 11 semi-structured interviews and nine
focus group discussions. Focus group discussions
were with community leaders, traditional healers,
health staff, representatives of local organisations,and the carers of children aged under five years.

Assessment tools

Initial community meetings
2x key informant interviews

48 focus group
discussions

Figure 1

Data collection and validation
Day 1
Day 2

Against Hunger research team was comprisedof one supervisor and two research assistants.
The team was further supported by a community mobiliser, with technical support provided
by the MWI/Action Against Hunger team bothin country and remotely. The team spent a maximum of six days in each location, which included three and a half days for data collection,
one day for data synthesis and analysis, and one
day for community validation (table 2). Government stakeholders were involved in the assessment preparation and as respondents during data collection.

Data collection andvalidation days permunicipality

Interview guides covering the main determinant categories of undernutrition were developed for the semi-structured interviews and focus group discussions. These categories were:
health and nutrition, mental health and carepractices, food security and livelihoods, WASH,
and gender. The interview guides were organised by sector but included questions for eachdeterminant within that sector. Therefore, theteam had the flexibility to ask questions according to feedback from the community. A varietyof visual aids were used with the objective of assisting respondents to consider various determinants of undernutrition in the study area and tocategorise them in terms of importance. Seasonal and historical calendars were used to identify temporal variations in determinants and theireffect on child outcomes (figure 1).

3x focus group discussions
3x key informant interviews
3x focus group discussions
3x key informant interviews
3x focus group discussions
3x key informant interviews

Day 5

Data synthesis and analysis

Day 6Community validation

The community validation exercise remains
a critical part of the data collection process andis intended to provide an additional level ofsense-checking of the information emerging.
For this process, active participants from the focus group discussions and key informant interviews are asked to come together and prioritise
major and important determinants first throughchoosing individually (three stones for major
and one stone for important) and then throughgroup consensus. The outcome is intended toelucidate a more in-depth understanding of thecommunity’s experience of the determinants
and the various pathways.

Data analysis

Qualitative data was recorded manually in a
notebook and reproduced electronically at theend of each data collection period in a sampled
location, usually at the end of each day. The
data was compiled in an Excel spreadsheet organised according to the five determinant categories to allow for an efficient analysis. Synthesis sheets (figure 2) allowed all determinants tobe tracked to see the frequency with which they
were raised throughout the sessions. All views
were analysed using qualitative content analysis
methods, whereby raw data was condensed into
categories or themes and coded based on valid
inference and interpretation.

An example of a seasonal calendar from Badimalika municipality, Nepal
Badimalika Municipality, Martadi, Bajura, Sudur Pashchim Province, Nepal

MONTH (Nepali)

Poush/
Magh
Jan

Magh/
FalgunFeb

Falgun/ChiatraMar

SEASONAL CALENDAR
Chiatra/ Baishak/ Jestha/
Baishak Jestha
Asar
Apr
May
June

Asar/
Shrawan/ Bhadra/
Shrawan Bhadra
Aswin
July
Aug
Sept

Aswin/
KartikOctMonth (English)
WeatherDry Season
Rainy Season
Low High temp
HealthFever
flu
Diarrhea
Acute respiratory infections (ARI)
Malnutrition
Access to HF (geographicalbarriers, e.g. flooding)Access to HF (financial barriers,
e.g. lack of resources)
Access to HF (temporal barriers,
e.g. high workload)
Access to HF (socio-cultural
Prohibited to go to temple, and stay in animal shelter at the time of postpartum and mensturation timebarriers, e.g. celebrations)

26

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Kartik/Mangsir
Nov

Mangsir/Poush
Dec

seasonalOriginal Article
Figure 2 Example of analysis framework
FGD1
FGD2
FGD3
FGD 4
FGD 5
FDG 6
FGD 7
FGD 8
FGD9
(Mothers) (Fathers) (Mothers) (Mothers) (Mothers) (Fathers) (Mothers) (Mothers) (Fathers)

Determinant

Total

A

Limited access to health services

B

Limited utilisation of health services

0C

Low birth spacing/ early, repetitive or unwanted
pregnancies

D

Low birth weightE

Low nutritional status of womenF

Caregiver well-being

0G

Non-optimal breastfeeding practices0H

Non-optimal complementary feeding practices0I

Low quality of interactions between a child anda caregiver

0

0

a

a

2
0

J

Low access to quality dietK

Low access to income sourcesL

Low access to markets

a

1

a
a
a

a
a

2

a
a

a

a

Inadequate accessibility, availability and, qualityof water at household level

O

Poor sanitation practices

P

Poor personal hygiene practices

Q

Poor food and environmental hygiene practices

R

Heavy workload of womenS

Low female autonomy/ decision-making

T

Low social support for women62a

M Low coping capacities
N

a

1
0

a
a

For each location, the teams developed pathways based on how the community explained
their experiences of the key nutrition determinants. These pathways were then confirmed withthe community during the validation process.

General findings

The findings produced from the Rapid NDA include a weighted matrix of nutrition determinants and a series of pathways describing how
the community experiences those determinants
through to illness and/or wasting. The assessment produced municipality-specific determinants and pathways. However, the scope of this

a

a
a

a

a
a
a
a

article does not cover these details. Instead, it
presents generalised findings to provide an example of the type of information produced.
Women’s workload and quality of diet wereconsistently ranked among the priority determinants of undernutrition in all three municipalities. Across the five determinant categories,
the communities perceived gender to have thestrongest influence on undernutrition, followed
by food security/livelihoods, and WASH. Healthand nutrition came next, followed by mental
health and care practices. The dominance of gender across the three municipalities is an interest-

1

a
a

2
3
3

a
a

4
1

ing finding and shows its critical importance tothe community and their perceptions of how it
influences child nutrition outcomes. Unfortunately, gender issues such as female time poverty are often complex cultural issues with limited
programming designed to address them.
The importance of the determinants to undernutrition are weighted twice: once throughthe focus group discussions and key informant
interviews, and then again through the community validation. This two-stage process is important for providing a full picture of how the determinants are related to each other and to child

Figure 3 Summary of nutrition determinants and their ranking for Rolpa district
Category of determinant Determinant

No. of times Ranking
mentioned in from FGS
FGD and Klls and Klls

Community
Validation
ranking

Food security & livelihoods

Low access to income sources

13

1

6

GenderHeavy workload of women

12

2

3

Food security & livelihoods

Low access to markets

5

3

2

Gender

Low female autonomy/decision-making

5

3

8

Health and nutrition

Low nutritional status of women

4

4

10

Food security & livelihoods

Low access to quality diet

4

4

1

Water, sanitation & hygiene

Inadequate accessibility, availability and quality of water at household level

4

4

5

Health and nutrition

Limited utilisation of health services

2

5

9

Health and nutrition

Low birth spacing/early, repetitive or unwanted pregnancies

2

5

13

Health and nutrition

Low birth weight

14

2

5

Mental health & care practices Caregiver well-being

2

5

11

Mental health & care practices Non-optimal complementary

2

5

15

Water, sanitation & hygiene

Poor personal hygiene

2

5

12

Water, sanitation & hygiene

Poor food and environmental hygiene

2

5

4

Health and nutrition

Limited access to health services

1

6

7

Mental health & care practices Non-optimal breastfeeding practices

1

6

0

Mental health & care practices Low quality of interactions between a child and a caregiver

1

6

0

Food security & livelihoods

Low coping/resilience capacities

0

0

0

Water, sanitation & hygiene

Poor sanitation practices

0

0

0

GenderLow social support for women

0

0

0

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27Original Article
nutrition outcomes. Figure 3 shows an example
findings framework from Sunil Smriti Rural
Municipality, Rolpa district. Here, while focus
group discussions and key informant interview
respondents rated low access to quality diet within the fourth level of importance for undernutrition, the community validation process rated
it as top priority. Even when sufficient income
is available for food purchases, nutritious foods
are not always available in the local market and/or not prioritised for purchase. This clarifies theimportance of this determinant when seeking toaddress the local wasting burden.

Challenges, opportunities,
and learnings

Logistical and linguistic challenges

The standard challenges with implementing anassessment in a country like Nepal applied, particularly with respect to the geographical terrain
and difficulties in accessing certain areas. In addition, Nepal’s linguistic diversity meant thatcomposition of data collection teams needed tobe carefully planned to ensure adequate knowledge of the local language within the team, as
well as an appropriate gender balance.

Unfamiliarity with identifying
causal pathways

The data collection teams were familiar with theconceptual framework for nutrition (UNICEF,
2021) but unaccustomed to identifying causal pathways, meaning this step took a significant amount of support. During training, datacollectors and supervisors need enough time tounderstand the basic theory behind causal pathways. Support, supervision, and monitoringshould be planned until teams are well versed inthis aspect of the assessment.

Skills for qualitative data collection
and analysis

The analysis of qualitative data requires setting
aside assumptions and biases regarding behav-

iours, practices, and motivations; this proved
challenging for some team members. Timeneeds to be invested in equipping teams with theskills required for the impartial collection andanalysis of data, and it should not be assumed
that those with previous data collection experience necessarily have these skills. A strong andexperienced supervisory structure is required tocontrol for bias and to promote deeper probing
and triangulation of potentially important causal factors that might be missed by less experienced technicians.

Practical training sessions andpre-testing

Time constraints meant that there were nopractical sessions or pre-testing during training. This led to some misunderstandings on
how to conduct the community feedback andvalidation sessions in the first location. Therefore, this exercise was done differently in eachlocation until the methodology was mastered.
Sufficient practical sessions are standard goodpractice and should not be compromised in any
training schedule.

Balancing time, capacity, and quality

In theory, a key strength of this type of assessment
is the shorter implementation time frame, andthat it can be accomplished by regular programme
teams. However, the assessment demands were
strenuous for such a small team implementing
an unfamiliar methodology in the required timeframe. They worked long hours to find and organise the participants, conduct the data collection,and carry out data entry and analysis. The small
team felt significant pressure to move quickly and,in some cases, did not take enough time to probe
further on some issues that could have deepened
the analysis. Once a team is familiar with themethodology it is unlikely that the time pressures
will be so great. However, extending the assessment by a few more days would limit staff burnout and ensure enough time for the proper probing required in qualitative research.

Visual aid flashcard for maternal
mental health. Nepal

Depth of information required

Historical and seasonal calendars were developed to record significant religious, socio-cultural, climatic, and economic events and otherphenomena over the past 10–15 years. However, these tools were not used adequately at theanalysis stage, largely due to the time investment required to develop pathway maps withteams unfamiliar with the concept. It remains
to be determined if these tools deepen the general understanding of the context in the specific area, or if the other data collection is sufficient for analysis.

Conclusion

The value of the assessment approach is evident. Overall, both the implementers and the
local authorities have found the information
generated by the Rapid NDA to be relevant anduseful and intend to use the results for a determinants-centred programme design process.
From the causal pathways developed, the municipal governments involved in Nepal statedhaving a clearer appreciation of the multisectoral facets to undernutrition.
The NDA tools package itself was found tobe simple, affordable, and efficient, and ensured
a community engagement process for validation of the results. This study indicates that Rapid NDA is a potential approach to qualitatively
study determinants of undernutrition when resources are limited. As with the introduction of
any new methodology, a balance between timeframe, capacity, and quality is needed. Althoughdeveloped within the context of supporting determinants-based programming for moderate wasting, the methodology itself and findings generated have a much broader relevanceto all forms of undernutrition. This Rapid NDA
methodology may be particularly useful in ongoing programme locations to fully understandthe evolving needs and priorities of communities and ensure interventions are designed accordingly. Since completion of the MWI’s support for the initial pilot, the team at Action
Against Hunger Nepal is continuing to expand
to new areas so that they may better understandtheir context and programme effectively.

Next steps

The piloting process for Rapid NDA has helped
to: refine the assessment preparation; determine
an ideal team size and assessment timeframe;contextualise the tools; define the analysis procedures; strengthen the local team’s experienceof this type of qualitative assessment; and, ofcourse, generate usable information on nutrition determinants to support programme planning purposes. The MWI and Action Against
Hunger intend to share the tools and methodology widely once a second phase of implementation of the assessment approach concludes.
For more information, please contact
Erin McCloskey-Rebelo at
moderatewasting@actionagainsthunger.ca© ACF

References

28

Using flashcards to visually represent nutrition pathways
during the community validation process. Each stringreflects how a determinant is linked. Nepal

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

GNC (2024) Thematic areas – Nutrition information
systems. nutritioncluster.net
UNICEF (2021) Conceptual framework on maternal andchild nutrition. unicef.org

© MoLSA/2024

Original Article

Baxnaano:
Integratingsocialprotection,
health, andnutrition in
Somalia
Sumra Kureishy
Senior Nutritionist providing pro-bonoservices for Baxnaano, Ministry of Laborand Social Affairs (MoLSA), Somalia
Fardosa Ahmed Abdullahi
Programme Manager of Baxnaano,
MoLSA
Ali Qureshi
Senior International Development
Professional leading the social protection
and jobs agenda in Somalia for aninternational financial institution
Yussuf Hassan
Isaak Director General of MoLSA

P

rotracted conflict and cycles ofdroughts and floods have afflicted Somalia for over 30 years (Ullán de la
Rosa & Arrey, 2021). This has triggered a humanitarian crisis and has led to widespread poverty and food insecurity (Pape &Karamba, 2019). Nearly 70% of Somalia’s population lives in poverty, with 4.3 million people in need of urgent humanitarian assistancein 2023 (IPC, 2023). An estimated 1.5 million
children under five years of age are facing wasting, with 331,000 experiencing severe wasting. The combined impact of conflict, natural
disasters, and limited availability of basic services is eroding household resilience to future
shocks, reducing the chances of future generations breaking free from this cycle of poverty
and vulnerability.
To alleviate poverty, push economic revival, and engender societal transformation,in 2019 the federal government collaborated
with the World Bank, UN, and other development partners to launch its first national social
protection platform – Baxnaano (which translates to “uplifting”).

Baxnaano: The national social
protection platform

Baxnaano, which is housed at the Ministry ofLabor and Social Affairs (MoLSA), has ena-

Baxnaano beneficiary motherswith her child. Somalia

What we know:

Recurrent and protracted crises have affected Somalia for over 30 years and resulted inwidespread poverty and food insecurity. Social protection programmes can reduce poverty
and vulnerability to shocks and stresses. Integrating health and nutrition conditionalities isknown to generate positive impacts on uptake of services and nutrition-related outcomes.

What this adds:

This article describes the development of Somalia’s first national social protection
platform, and discusses the challenges, lessons learned, and subsequent adaptations. To
address the challenge of low uptake of services in particular, a pilot health and nutrition
conditional cash transfer is to be provided in areas of well-supported integrated healthand nutrition programmes.

bled the federal government to provide safety net support to the country’s poorest people
and respond to the impact of climate-related
shocks. It operates with the full engagementof Federal Member States (FMS) authorities,
in collaboration with humanitarian and development partners involved in social protection across the country. The national platform
continues to evolve with the vision of empowering the poor and vulnerable beyond simple
cash assistance. Baxnaano provides support
through two current programmes (Regularand Shock Response) and will launch a third
programme (Economic Inclusion) in November 2024. Baxnaano will also pilot an additional health and nutrition conditional cashtransfer from July/August 2024.
The Baxnaano Regular Programme is along-term, unconditional cash transfer programme. It aims to address chronic poverty
and food insecurity, build resilience, and enhance the human capital of recipient households. As part of the programme, beneficiaries are provided with information on available
health and nutrition services and encouraged
to seek care as needed. The programme routinely covers 200,000 poor and vulnerable
households with pregnant and breastfeeding
women and/or children under five years in 25
districts across all FMS and Somaliland. A total of USD 20 per month is provided to eachbeneficiary household over a period of three
years. After the standard three years, beneficiary households must undergo recertification
regarding eligibility for continued support.
The Baxnaano Shock Response Programme
is a short-term, unconditional emergency cashtransfer programme that aims to smooth foodconsumption and protect human life. The programme also aims to protect the physical assetsof poor and vulnerable households in the aftermath of shocks, thus enabling recovery. The
programme covers 668,000 households affected by shocks (338,000 drought-affected households, 260,000 locust-affected households, and70,000 flood-affected households). A total of
USD 60 per month is provided to shock-affected households for a period of six months.
The Baxnaano Economic Inclusion Programme will aim to enhance the economic inclusion of poor and vulnerable youth (including women) in urban and rural areas. Under
this programme, the government will launcha pilot to test labour market interventions for
1,000 youth and women by November 2024.
The interventions will focus on improving employability and supporting job creation by providing life skills training, technical skills training with a formal training provider or a mastercraftsman, business development services, labour intermediation, stipends, and grants.

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29Original Article
MoLSA engaged the World Food Programme in 2019 to support the field implementation of the Regular and Shock Response
programmes. As government social protection systems are becoming available, implementation arrangements are transitioning
from UN assisted to direct government implementation modalities. The health and nutrition cash transfer pilot will be entirely government implemented in the Banadir region,
which includes the capital city, Mogadishu.

Baxnaano: Challenges faced

A key challenge experienced during the design phase of Baxnaano was a lack of an existing government-led structure to bring together humanitarian partners involved in cash
assistance programmes. For example, many
partners maintain their own separate lists ofbeneficiaries, raising concerns surrounding
effectiveness, duplication, and targeting. To
this end, MoLSA is building capacity to consolidate social protection programmes by encouraging the use of Baxnaano’s new targeting and delivery systems including the Unified
Social Registry (USR) and the government’s
payment mechanism. The use of common systems will greatly improve coordination, transparency, and efficiency, while allowing different agencies the flexibility to respond tovarying priorities.

Baxnaano beneficiary motherwith her child, Somalia

30© MoLSA/2024

Another challenge faced during implementation was the nascent government capacity and weak systems present in the country (particularly those still under Al-Shabaab
control). Low uptake of available services andan extremely limited supply of nutrition andhealth services is an additional hurdle. Additionally, limited quality education, water, sanitation, and hygiene services, as well as limited
employment and skill development opportunities, persist. To overcome these challenges within the social protection sector, MoLSA
leveraged the UN to support an initial launchof life-saving social protection interventions,while simultaneously building key national social protection systems. This has led toa gradual transition to government imple-

mentation and the introduction of more complex social protection interventions, including
conditional cash transfers and economic inclusion. To address the limited availability of basic
services, the government is leveraging support
provided by international development partners to implement health programmes throughthe UN and civil society.
In Somalia, where protracted conflict, recurrent shocks, and the provision of cash transfers for an extended duration are common,
concerns regarding dependency and reduced
labour market participation often emerge. Inline with evidence (Bastagli et al 2016), for
Baxnaano these concerns are avoided throughsmall, frequent, and reliable unconditional
cash transfers provided over a longer time horizon, combined with conditional cash transfer top-ups for vulnerable households. Thesetransfers are provided through digital payments to beneficiaries’ mobile wallets to ensure transparency and reliability.
Limited data availability remains a persistent challenge for Baxnaano and other social
protection programmes that target the poor. To
address the data gap, MoLSA has developed keysocial protection information systems – suchas the USR and the Management Information
System. The USR collects socioeconomic data toenable dynamic data sharing among potential
stakeholders and objective data-driven targeting of pro-poor programmes. Looking ahead,
the government plans to launch a National Socio-Economic Survey to collect USR data fromall accessible households in Somalia by November 2024. All 1.88 million accessible households
in Somalia (excluding Somaliland) are expected
to be covered in the survey.

Baxnaano: Lessons learned

In Somalia, the importance of leveraging UN
capacities and local non-governmental organisations to implement social protection interventions, under government leadership, wasimportant. This is true of all fragile, conflict-affected, or violence-affected contexts. As these
programmes are launched with support fromdevelopment partners, it is also critical to concurrently build government systems and capacities to ensure sustainability. A transition fromUN to government implementation is possible once key policy principles – such as ‘do noharm’, data protection and privacy, and inclusive systems – are adhered to. Despite this, itremains important to focus on the end goal ofeventually transferring ownership to the government, ensuring that short-term interventions do not become a protracted situation.
Another lesson is the importance of startingwith simple interventions and gradually moving towards more complex and diversified social protection programmes in fragile contexts.
In the case of Baxnaano, a roadmap was used
to develop a government-led social protection
programme. The unconditional cash transfer
was initially launched, followed by shock response emergency cash transfers, now leading to more complex interventions such as thehealth and nutrition conditional cash transfer
described below.

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

The Baxnaano Health andNutrition Co-responsibility
Cash Transfer

The first 1,000 days in a child’s life are criticalfor growth and development (Likhar & Patil
2022). A child’s ability to develop, grow, learn,
and thrive are significantly impacted by the extent to which mother and child are appropriately fed and cared for throughout this period. Thiswindow of opportunity is affected by the pregnant mother’s health, diet, and stress levels. After birth, the child’s environment, health, diet,and care practices are key factors. To improvematernal and child health and nutrition outcomes, Baxnaano plans to implement a Healthand Nutrition Co-Responsibility Cash Transfer(H&N CCT) targeted to the poorest 20% households in selected areas of Banadir.
Low uptake and utilisation of nutrition andhealth services is an issue experienced across Somalia, including under Baxnaano’s regular programme. The regular programme prioritises targeting of poor households with pregnant
women and mothers of children aged 0–5 years.
Although beneficiaries are encouraged to visit
health facilities and access health and nutrition
services, programme monitoring data revealed
few beneficiaries have actually done so. The
H&N CCT seeks to overcome this challenge andencourage uptake of nutrition and health services by introducing co-responsibilities (conditions)
before beneficiaries are eligible to receive cashtransfers. To address supply-side challenges andcreate demand, the new H&N CCT will leverage
existing health programmes financed by international development partners, such as Damal
Caafimaad (World Bank supported) and Better
Lives (UK aid supported). These programmes
are improving access to health facilities, capacity of health staff, and availability of high-impact
services – such as antenatal care, postnatal care,facility births, immunisation, supplementation,and treatment for acute respiratory and gastrointestinal infections.
The H&N CCT – Wasiila Caafimaad, in Somali – will target 16,000 pregnant and breastfeeding mothers, and children aged under two
years in District Daynile of the Banadir region.
Beneficiaries will be the poorest 20% of households from District Daynile. Eligible women will be enrolled and participate in the programme during pregnancy, up to the point theirchild reaches two years of age. Health and nutrition interventions will include antenatal andpostnatal care, maternal and child immunisations, health and nutrition awareness sessions,micronutrient supplementation, growth monitoring, and wasting treatment, where appropriate. All interventions will be carried out at Baxnaano facilitation centres, established in healthfacilities. These health facilities are supported
by existing health and nutrition programmes.
Figure 1 outlines the process flow and interventions for the H&N CCT.
A total of USD 30 will be provided to these
women upon attending a health awareness session on a quarterly basis. The health awarenesssession acts as a key behaviour change communication instrument, encouraging beneficiaries

Original Article
Figure 1

Original Article

Process flow for Baxnaano's H&N CCT
Baxnaano's facilitation centre(located within an existing health facility)

Baxnaano's mobilisation
firm

MOBILISATION(Beneficiary directed for processing)

Verification counter

BENEFICIARY ELIGIBILITY VERIFICATION(Beneficiary verified from USR PMT list)– poverty targeting

Enrollment counter

ENROLLMENT IN H&N CCT

Service delivery counter

AWARENESS SESSION(Beneficiary must attend session on aquarterly basis for compliance)((

Not eligible
Eligiblehousehold))

PREGNANCY & CHILD VERIFICATION(Pregnancy & child's age verified by health staff)– categorical targeting()(

Eligible PLWs & child<2 years

Not eligible)

ANTENATAL &/OR POSTNATAL CARE
(PLWs will be encouraged to seek care during quarterly visits)
IMMUNISATION(PLWs & child < 2 years will be encouraged to complete
immunisation during quarterly visits)

Awareness session will include
information on• Maternal nutrition• Breastfeeding• Infant & young child feedingpractices• Supplementation• Hygiene & sanitation practices• Immunisation

GROWTH MONITORING(Caregiver of child < 2 years will be encouraged to have thechild's growth monitored during quarterly visits)
WASTING TREATMENT(If child < 2 years is MAM/SAM, caregiver will be encouraged
to seek treatment as per national IMAM protocols)
MICRONUTRIENT SUPPLEMENTATION(PLWs & child < 2 years will be encouraged to collectrelevant supplements during quarterly visits)

Compliance counter

COMPLIANCE MONITORING(Beneficiary must attend session on aquarterly basis to obtain CCT)MoLSA and the Ministry of Health are responsible for the coordination and implementation of the pilot. Continuous support and collaboration will be provided by the respective FMS
and district health authorities, UN agencies, andother international development partners.
The key outcome expected from the H&N
CCT is an increased uptake of an essential package of health and nutrition services. The increased uptake may result in reduced risk oflow birthweight, improved vaccination rates,
reduced risk of anaemia and micronutrient deficiencies among pregnant and breastfeeding
mothers and children, and reduced risk of maternal and child morbidities. Pilot outcomes
will be assessed through an impact evaluation,
consisting of a baseline and an endline survey.
Data from the Baxnaano Management Information System, government and third-party spot
checks, and process evaluations (questionnaires,
focus group discussions, and key informant interviews) carried out by a third-party monitoring firm will be used to monitor the H&N CCT.
Programmatic data on the H&N CCT will beavailable starting in November 2024.

Awareness session NOT completed
Awareness session completed))

CASH TRANSFER sent to beneficiaries'
mobilePayment counterto use available services. The payment is bothan incentive for mothers to adhere to the programme and a vehicle for improving nutrition
security – as mothers can utilise these funds topurchase food and other items. The payment isdesigned as a top-up to any other support being
received by targeted households, including fromsocial protection or humanitarian programmes.

((

END OF PROCESSWorld Bank will continue to invest in develop“Focused on the transition
ing human capital through social protection intoward a longer-term
terventions and systems that redistribute indevelopment agenda, whichcome to the poor, reduce poverty, build humanbuilds the government’s capacity capital, and improve labour market outcomes.
to implement its own social
The H&N CCT builds on lessons learned, inprotection programmes. This is creasing the nutrition sensitivity of the existing
programme. If the pilot is successful, the govkey to ensuring sustainability,
ernment plans to expand the H&N CCT to all
inclusivity, efficiency, anddistricts where supply-side interventions are betransparency. Our new H&N
ing made available through Damal Caafimaad.
MoLSA is therefore:
CCT initiative is the first of
its kind and will support the
For more information, please contact Fardosa
government’s vision to build the Ahmed Abdullahi at fardosa@molsa.gov.sohuman capital of our citizens
and bring sustainable economic References
Bastagli F, Hagen-Zanker J, Harman L et al (2016) Cashgrowth in Somalia.”
transfers: What does the evidence say? A rigorous– Key informant, nutrition partner

Conclusion

Baxnaano has been able to reach 200,000 of thepoorest and most vulnerable households, with
100% being female beneficiaries since its inception in 2019. Approximately US$ 500 million
has been dispersed to beneficiaries across thecountry. Most recent estimates from the regular programme indicate that the cash transfers
are being primarily used for purchasing food(99%), purchasing clothing and other household items (52%), accessing healthcare (49%),
repaying debts (44%), and paying educational fees (38%). Moving forward, MoLSA and thereview of programme impact and of the role ofdesign and implementation features. 10.13140/
RG.2.2.29336.39687

IPC (2023) Somalia: IPC Acute Food Insecurity and
Acute Malnutrition Analysis (August–December 2023).
reliefweb.int
Likhar A & Patil M (2022) Importance of maternal nutrition in the first 1,000 days of life and its effects on childdevelopment: A narrative review. Cureus, 14, 10, E30083
Pape J & Karamba W (2019) Somali Poverty and Vulnerability Assessment: Findings from Wave 2 of the Somali
High Frequency Survey (English). worldbank.org
Ullán de la Rosa F & Arrey S (2021) Understanding Somalia’s multidimensional protracted war: An updated
structural-processual analysis. Small Wars & Insurgencies, 32, 7, 1056–1091

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

31Research Snapshots
Stunting in the first year of life:

Pathway analysis of a birth cohortThis is a summary of the following paper: Mwangome M, Ngari M, Brals D et al (2024)
Stunting in the first year of life: Pathway analysis of a birth cohort. PLOS Global Public Health,4, 2, e0002908. https://doi.org/10.1371/journal.pgph.0002908

M

Community-based health worker in
Burkina Faso conducts education
session with mother-to-be© UNICEF/UNI528404/Cisse

alnutrition among infants aged under six months has often been overlooked, leading to gaps in our understanding of the causes of early
infancy stunting. The World Health Organization(WHO) 2013 conceptual framework for childhood stunting divides contributing factors into
three main domains: context (community andsocietal factors), causes (household and family,
feeding, and infection-related factors), and short-and long-term consequences of stunted growth(health, developmental, and economic outcomes). The framework itself does not elucidate
potential pathways and relationships between factors that contribute to stunting, limiting application to prioritising and designing interventions.
This study was set up to examine pathways
including parental and household characteristics, birth size and gestation, and illness in infancy with stunting at birth and months three, six,and 12 using an a priori hypothesised framework.
It was a secondary analysis of a birth cohort of
1,017 infants recruited from four health facilities
in Burkina Faso and followed up for one year.
Among the 1,017 infants included in the
study, after excluding perinatal deaths, 522 (51%)
were male. The median gestational age was 38.9
weeks (interquartile range: 38.2 to 40.2). Forty-eight (4.7%) infants were born prematurely,
and 189 (19%) had low birth weight. Of the 48
infants born prematurely, 34 (71%) also had low
birth weight. A total of 454 infants were born ina health facility (45%), while 399 (39%) and 164(16%) were born at home with and without acommunity-based assistant present, respectively.
The prevalence of being stunted at birth andat months three, six, and 12 was 7.4%, 23%,
20%, and 18% respectively. The fractions ofIntimate partner violence and childstunting in South Asia
This is a summary of the following paper: Lakhdir MP, Ambreen S, Sameen S et al (2024)
Association between maternal experiences of intimate partner violence and child stunting: A
secondary analysis of the Demographic Health Surveys of four South Asian countries. BMJ Open,14, 1, e071882. https://doi.org/10.1136/bmjopen-2023-071882

Women experiencing intimate
partner violence (IPV) may face
adverse health outcomes and behaviours during pregnancy, leading to unfavourable pregnancy outcomes. Physical abuse during pregnancy can directly result ininjuries, impacting pregnancy outcomes, including miscarriages and maternal and foetal mortality. Women subject to IPV are more likely tomiss prenatal check-ups, potentially resulting inadverse pregnancy outcomes such as low birthweight and preterm births. Maternal IPV is also
linked to poor nutrition and inadequate weightgain during pregnancy, as well as increased
stress and depression. These can indirectly affect maternal and neonatal outcomes such as
foetal death, preterm birth, low birthweight, andsmall for gestational age infants. In turn, these32

outcomes may significantly impact a child’s early growth and physical development, potentiallyleading to wasting and stunting.
Researchers aimed to determine whether
there was an association between maternal exposure to IPV – i.e. sexual violence, physical violence, or both – and child stunting, measured
based on the height-for-age z-score of children
aged 6–59 months. The authors used data fromthe seventh round of the demographic and healthsurveys in four South Asian countries (Pakistan,
Nepal, India, and the Maldives). A Cox proportional regression method conducted separately oneach country's data was used to estimate the association between maternal IPV and child stunting.
The prevalence of women who were ever exposed to IPV (since age 15) ranged from 10%

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

month 12 stunting attributable to being stunted at birth, month three, and month six were11% (95% CI 5.0–16%), 32% (95% CI 22–41%),
and 40% (95% CI 31–49%) respectively. Modelling showed male sex and maternal characteristics had direct effects on stunting at birth andthree months, but not subsequently. Prematurebirth, twin birth, and being stunted at a previous
time point were directly associated with stunting
at months three, six, and 12. Both maternal andpaternal characteristics were directly associatedwith preterm birth. Non-exclusive breastfeeding
had a borderline positive direct effect on stunting at month six but not at month 12.
The study's limitations lie in its reliance onan older dataset from an untreated birth cohort,which makes replication challenging. Changes
in healthcare services since 2004 may have influenced associations. Estimating gestational age
using less accurate methods and the lack of variables such as maternal mental health status areamong the limitations. Future studies, throughtreated cohorts, should encompass all factors
in the WHO framework for childhood stunting
and additional items identified here for a comprehensive pathway view.
Through this review, the authors uncover complex connections among child, maternal, paternal, and household characteristics. To
improve birth size, it is crucial to focus on improving women's nutritional status before conception and during the first trimester of pregnancy, improving socioeconomic conditions,and promoting exclusive breastfeeding. By
analysing pathways, we can better understandthe shared and distinct links between wasting,stunting, and underweight, fostering collaboration across communities of practice to develop
more unified strategies.

(Maldives) to 31% (India). The burden of childstunting was the lowest in the Maldives (14%),
followed by Nepal (33%), and then highest in
both India and Pakistan (around 36%).
Although crude data showed a higher prevalence of child stunting in women who experienced
IPV across all four countries, only India and Nepal demonstrated a significant association after
adjusting for maternal age, education, number ofchildren, household wealth ranking, and place ofresidence. In India, children whose mothers were
exposed to IPV showed a 7% increase in the prevalence of moderate and severe child stunting (OR1.07, 95% CI 1.01-1.14). In Nepal, severe stunting was strongly associated with the prevalence ofphysical IPV (OR 1.66, 95% CI 1.01-2.87). There
were no other statistically significant associations that showed a higher prevalence of stunting
among ever-abused women.
The study findings suggest that maternal exposure to IPV could be associated with childstunting. However, further research investigating the relationship between IPV and child outcomes, and using improved and advanced statistical analyses, is required. Further research may
provide substantial evidence to enhance publicawareness and potentially reduce the burden ofchild stunting in South Asian countries.

Research Snapshots

Postnatal interventions for infants undersix months: A systematic review
This is a summary of the following paper: Rana R, Sirwani B, Mohandas S et al (2024)
Effectiveness of postnatal maternal or caregiver interventions on outcomes among infants
under six months with growth faltering: A systematic review. Nutrients, 16, 6, 837.
https://doi.org/10.3390/nu16060837

E

arly life growth faltering (also referred to as failure to thrive) andmalnutrition are major global publichealth problems. Infants aged undersix months with growth faltering are a particularly vulnerable group. These first six monthsof life are a period of rapid maturation anddevelopment with unique dietary needs. The
mother or carer thus plays a critical role in fulfilling the child’s nutritional requirements.
To inform the updated World Health Organization (WHO) guidelines on the prevention and management of growth faltering
among infants under six months, this review examined the effectiveness of postnatal
maternal or caregiver interventions on seven domains. Anthropometric recovery, childdevelopment, anthropometric outcomes,mortality, readmission, relapse, and non-response among infants aged under six months
were all considered.

A total of 13 studies with preterm and/or low
birth weight infants contributed to the final synthesis, which assessed the effects of breastfeedingcounselling or education (n = 8), maternal nutrition supplementation (n = 2), mental health (n =1), relaxation therapy (n = 1), and cash transfer(n = 1) interventions. Overall, the evidence fromthese studies had serious indirectness and a highrisk of bias.
The evidence was limited in scope and primarily ranged from 'low' to 'very low' certainty. Breastfeeding counselling or education compared to standard care might increase infant
weight at one month, weight at two months, andlength at one month, but with very uncertain
evidence (very low quality). Maternal nutrition
supplementation, in comparison to standard
care, may not result in increased infant weightat 36 weeks postmenstrual age and may not reduce infant mortality by 36 weeks postmenstrual age (low quality).

Moreover, interventions for maternal mental health compared to standard care might notincrease infant weight, length, and head circumference at two months, with the evidence ranging from low to very low quality. The effects ofrelaxation therapy versus standard care on infant
weight, length, and head circumference at threemonths are highly uncertain (very low quality). Lastly, the evidence regarding cash transfers compared to standard care on child development scores at three months, changes in weightand head circumference z-score from birth to
three months post-discharge, and readmission
by three months remains highly uncertain, withvery low-quality evidence.
Based on review findings, strong new WHO
recommendations for maternal interventions for
infants under six months with growth faltering
will be challenging to make because these needa more secure underpinning evidence base. The
WHO guidelines of 2013 and 2023 both recommend providing counselling and support, including mental health support, to mothers or caregivers of infants with severe malnutrition, both for
inpatient and outpatient care. Given that the 2023
guidelines are still based on ‘low’ to ‘very low’
quality evidence, with little change since 2013,
the authors urged the need for well-designed,
well-targeted future trials assessing postnatal maternal or caregiver interventions on infants aged
under six months with growth faltering, statingthat this is more urgent than ever.

Rwanda: Before and after study of a national

Community health workers use a measuring mat tohelp identify stunting in Western Province, Rwanda

supplementary feeding programmeThis is a summary of the following paper: Hebert K, Nsengiyumva E, Kayitesi C et al (2024)
Before and after study of a national complementary and supplementary feeding programmein Rwanda, 2017–2021. Maternal and Child Nutrition. https://doi.org/10.1111/mcn.13648

To address the high burden of malnutrition among children from the most vulnerable households, and in addition to other ongoing nutrition-related interventions, thegovernment initiated a national food supplementation programme. This study assessed the effectiveness of locally produced
nutrient-dense fortified blended foods (FBF),
which were provided to children aged 6–23
months and pregnant and lactating women
living in vulnerable households in Rwanda,
on stunting prevalence among children. Thisinitiative was a unique example of the successful nationwide distribution of fully subsidised
FBF products for poor households.
Survey data collected in 2017, 2018, and 2021
included anthropometric and biochemical data,demographic and socioeconomic status, food security, and feeding practices – including the provision of FBF. Primary statistical analysis compared the nutritional status of children before
and after FBF introduction. There was a reduction in stunting from 47% (2017–2018) to 35%(2021), equivalent to a 42% reduction in theodds of being stunted (p<0.001). At baseline, ahigh proportion of children were anaemic andiron deficient, and there was a significant reduction in the odds of these at endline.
The remarkable reduction in stunting overa five-year period can be attributed to several
factors. Notably, the study highlights the use ofa targeted approach to reach the most vulnerable children and a high rate of daily and weekly consumption of the FBF during the last three
years of the evaluation (2018– 2021). General
improvements over time to sociodemographic and household markers, as well as substantial efforts by the government to improve live-© WFP/John Paul Sesonga

A

ccording to the National Institute of
Statistics of Rwanda and the Ministry of Health, 33% of all Rwandanchildren aged under five years arestunted. Stunting prevalence rises from 23% inchildren aged under six months to 39% at 18–
23 months of age, showing a marked increaseduring the window of time when complementary foods are typically introduced. Many
households struggle to access energy- and nutrient-dense complementary foods and only
22% of children aged 6–23 months are fed inaccordance with all recommended infant andyoung child feeding practices.

lihoods, health, and wellbeing over the same
period, were also important.
One of the study’s limitations was the absenceof a control group for comparing the intervention effects, as it was deemed unethical to withhold FBF from households. Further, the study
was only conducted in the lowest tier of Rwanda’s social support scheme households, limiting
the generalisability of the results to only households with similar characteristics.

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

33Adolescent pregnancy and childundernutrition: A meta-analysis
This is a summary of the following paper: Welch C, Wong C,
Lelijveld N et al (2023) Adolescent pregnancy is associated with childundernutrition: Systematic review and meta-analysis. Maternal &Child Nutrition, 20, 1, e13569. https://doi.org/10.1111/mcn.13569

A

dolescent pregnancy is linked to foetal growth issues, raising concerns
about childhood wasting and underweight. However, little is known
about how young maternal age influences childhood anthropometry after the neonatal stage.
This review and meta-analysis explored the association between adolescent pregnancy and childwasting and underweight, delving into possible
social and biological factors.
Peer-reviewed literature from 1990 onwards
were systematically reviewed for studies reporting wasting and/or underweight in children
aged under five years born to adolescent mothers(aged 10–19, or ≤24 where relevant) in low- andmiddle-income countries. Of a total of 92 studies identified, 57 were included for meta-analysis,
while all underwent qualitative synthesis. Flexibility in inclusion criteria was extended to include
infants aged under one month and mothers aged
20–24 years, subject to meeting all other eligibility
criteria. This was due to their being limited studies focusing solely on infants aged one month andmothers under 20 years.
Results from the meta‐analysis showed thatchildren born to adolescent mothers (≤24 years)

compared with adult mothers were associatedwith 1.12 times greater odds of moderate underweight (p = 0.04) and 1.21 times greater odds ofsevere underweight (p < 0.01) in children aged
1–59 months. Pooled analysis for child wasting, presented as odds ratios, showed no statistically significant association between adolescentpregnancy (≤24 years) and moderate wasting(OR 1.05, p=0.17) or severe wasting (OR 1.16,
p=0.59) in children aged 1–59 months compared to adult pregnancy.
While the pooled OR indicated associations
between the subgroup of adolescents aged 10–
19 years versus adult pregnancy and moderateand severe wasting, findings were not significant(moderate wasting, OR p = 0.08; severe wasting,OR 1.15; p = 0.83).
In Asia, adolescent pregnancy (≤24 years)
was found to be associated with a 16% higher
likelihood of moderate underweight (p = 0.02)
and a 9% higher likelihood of moderate wasting(p = 0.04) in children aged 1–59 months compared to pregnancies among adults. Additionally, for severely underweight children in Asia,
there was a 23% higher likelihood for those bornto adolescent mothers (p = 0.03). However, noBangladesh: Experiences of adolescentmothers in caring for their preterm babies
This is a summary of the following paper: Shumona S, Ahmad E, Shema M et al (2024)
Perception and experiences of adolescent mothers and communities in caring for their preterm
babies: Findings from an in-depth study in rural Bangladesh. BMJ Pregnancy and Childbirth,
24, 1, 145. https://doi.org/10.1186/s12884-024-06345-x

B

older mothers who had experienced preterm
birth in the same timeframe were included tocompare perceptions and experiences. Secondary participants included the immediate family
members of preterm infants, community members, and healthcare providers.

To address this gap, a qualitative study was
conducted in rural villages of central Bangladesh
to understand both mother and community perspectives on preterm birth and preterm care. The
study focused primarily on adolescent mothers
aged 15-19 years who had delivered preterm babies within the previous six months. Additionally, adolescent mothers of full-term babies andFindings revealed diverse perceptions of theideal gestation period – described in months,
rather than weeks. Most participants reliedheavily on dates provided during hospital visits to estimate their due dates, underscoring thecritical role of antenatal care. Although participants’ understanding of causes of preterm birth
was generally limited, “poor nutritional status of
the mother or inadequate eating” was one of themost mentioned causes for premature birth. All
participants described preterm infants as “undernourished”, “small”, and/or “weak”, with “lowweight” and having a “frail appearance” or “longand thin hands and legs” also a focus. Despite
both adolescent and adult mothers mentioning
the need for the provision of extra care to pre-angladesh has one of the highest incidences of preterm births globally. The
country also has a high prevalence ofearly marriage and adolescent pregnancy. According to the Bangladesh Demographic and Health Survey (2017-2018), 71% of
women aged 20-49 years were married by the ageof 18. The survey also highlights that 28% of adolescent girls aged 15-19 years have begun childbearing. However, despite high rates of adolescent pregnancy and preterm birth, there is a lackof documentation regarding adolescent mothers’
experiences and the interventions needed to assist them in preterm infant care.

34

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

A midwife provides health care toan adolescent girl at Dhamainagar
community clinic in Bangladesh© UNICEF / Suman Paul Himu

Research Snapshots

effect of adolescent pregnancy on severe wasting was found. In sub-Saharan Africa, adolescent pregnancy showed no effects on moderate
underweight or moderate to severe wasting. No
data was presented on severely underweight.
The study’s strengths were a systematic approach, broad geographical coverage, and thelarge number of papers included in the review.
That said, using numerous cross-sectional studies and open-source datasets does introduce limitations. Efforts were made to validate and remove duplicates, but some datasets may havebeen overrepresented in the meta-analysis – impacting reliability. Certain countries like Bangladesh and India were overrepresented, influencing stronger associations in Asia.
This review shows that being born to an adolescent mother, compared to an adult, increases
the risk of child underweight and, in Asia specifically, moderate wasting. Reviewed evidence suggests that maternal nutritional status may play anintermediary role. This underscores the importance of interventions to delay adolescent pregnancy and improve adolescent nutritional status,
aiming to mitigate childhood undernutrition andbreak the intergenerational cycle of malnutrition.
term babies, adolescent mothers faced challenges pointing to what this care entailed. Adolescentmothers were found to have low decision-making abilities and often consulted family members, depending on female family members for
caregiving and emotional support.
Traditional practices persisted, including
bathing children after birth and non-exclusive
breastfeeding by giving honey and warm water.
Participants in the study widely shared the view
that, for undernourished and weak preterm babies to grow, they must be fed well. For severely preterm babies unable to breastfeed, milk was
expressed and the baby then fed with a spoon.
None of the participants demonstrated awareness of the significance of regular weight monitoring for infants.
Various factors – including local knowledge, socio-cultural practices, and health system limitations – shaped the understanding ofand care practices for preterm infants among
both adolescent and adult mothers. Improving birth outcomes requires increased awareness among adolescents, women, and families
regarding preterm birth, alongside improvements in the quality of preterm birth services
offered at healthcare facilities.

The Field Exchange editorial team would
also like to highlight the importance ofstrengthening interventions to delay
early marriage as a root cause.

Research Snapshots

Characteristics of global data onadolescents’ dietary intake
This is a summary of the following paper: Demmler K, Beal T, Ghadirian M et al (2024)
Characteristics of global data on adolescent's dietary intake: A systematic scoping review.
Current Developments in Nutrition, 8, 1, 102054. https://doi.org/10.1016/j.cdnut.2023.102054

D

espite data on adolescents’ dietaryintake being essential to improve
nutrition status, the availability ofhigh-quality disaggregated data remains limited and with large global differences. These knowledge gaps hinder the assessmentof adolescent diets and the development of evidence-based interventions to improve adolescent health and that of future generations.
A systematic scoping review was conducted
to investigate the availability, characteristics, andgaps in global adolescent dietary data. This included peer-reviewed and grey literature articles (from2010 onwards) on the dietary intake of male andfemale adolescents aged 10–24 years. Studies fromall countries and languages were included, incorporating any information related to types of foodconsumed, diet composition, dietary diversity, or

meal patterns. Studies with insufficient methodological information, sample sizes less than 25,
school-based data sets containing less than six
schools, and studies that focused on pregnant or
unhealthy study populations were excluded. Data,
including year(s) of data collection, age, gender,
sample size, dietary assessment methods, numberof food items/groups, study design, location, andrepresentativeness, were extracted. Of the 722 articles that were included, 677 (94%) were peer reviewed, representing 1,223 data sets, and 45 (6%)
were grey literature, representing 98 data sets. Halfof all data sets were from high-income countries.
Most of the data was collected in cross-sectional
surveys and over half of the data sets (57%) werefrom national representative surveys.
The literature search revealed that there wasno dietary data for adolescents in over one-third

Finding the most vulnerable: How to

identify malnourished infantsThis is a summary of the following paper: Mahmud I, Guesdon B, Kerac M et al (2024) Mortality
risk in infants receiving therapeutic care for malnutrition: A secondary analysis. Maternal &Child Nutrition, e13635. https://pubmed.ncbi.nlm.nih.gov/38433606/

T

his secondary analysis investigated inpatient therapeutic care data for 3,692 infants (aged under six months) across 34
field sites, between 2002 and 2008, from12 countries: Afghanistan, Burundi, the Democratic Republic of Congo, Ethiopia, Kenya, Liberia, Myanmar, Niger, Somalia, Sudan, Tajikistan,and Uganda. Admittance criteria was comprisedof 1) infant too weak to suckle effectively, 2) notgaining weight at home, 3) weight-for-lengthz-score <-3, and/or 4) presence of bilateral pitting
oedema. Multiple variables were collected at admission and discharge, with death at discharge being the outcome of interest in this analysis. Logistic regression was used to examine the associationof various anthropometric deficits and mortality.
In this admitted population, 95.8% were underweight, 82.8% wasted, and 77.8% stunted(figure 1). When applying the Composite Index of Anthropometric Failure (CIAF) – which
combines underweight, wasted, and stunted intoa single indicator of anthropometric deficits –96.8% of children fell under this classification.
Infants with multiple anthropometric deficits
were often more severely wasted, stunted, andunderweight than those with a single anthropometric deficit. This underscores the urgent needfor targeted interventions to address the specificneeds of these vulnerable infants.

compared to anthropometrically normal infants. Severely underweight infants had over triple the odds of mortality (OR 3.3, 95% CI 0.813.6, p=0.09), although this was not a significant
finding due to the broad confidence interval observed. Notably, weight had fewer missing values
and flagged data, making this assessment morepractical. Sex differences were observed, whereboys had greater odds of inpatient mortality
than girls (OR 1.40, 95% CI 1.02-1.92, p=0.03).
In this analysis, the only infants to die were thosewith multiple anthropometric deficits, although
their odds of mortality were not significant due
to the broad confidence intervals observed.
The study excluded participants with missing data and/or outlier data based on predetermined guidelines, which may increase our confidence in the statistical analysis, but may also
introduce selection bias into the sample. As thisFigure 1of countries globally. Most of these countries
were in Sub-Saharan Africa. Furthermore, 14%of all countries (n=22) – primarily in Sub-Saharan Africa, and Europe and Central Asia –lacked nationally representative dietary data.
The review identified a limited amount of detailed dietary information. In many countries,
data on adolescent diets was available for fewer than seven food items/groups, which did notallow for quantification of intake. In the absenceof a validated dietary diversity score for adolescents, assumptions were based on the Minimum Dietary Diversity score for children aged
6–23 months. Despite the existence of the validated Minimum Dietary Diversity for Women(ages 15–49 years, assessing 10 food groups), a
seven-food group count was chosen as a threshold. This was assumed to provide a meaningfulcharacterisation of adolescent dietary intake. A
significant limitation of this review was that only
peer-reviewed journals from one database (PubMed) were included.
The study highlights the critical significance ofaddressing adolescent nutrition, emphasising thepressing need for enhanced, accessible, and comprehensive data on adolescents' dietary intake tosupport effective nutritional interventions.

study took place across multiple sites, variation
in measurements taken by different staff may
have introduced measurement bias. However,
the inclusion of multiple sites increases both thesample size and the generalisability of the findings. Seasonality may also affect our interpretation, as measurements were taken at different
time points in different locations. This analysis
lacked data on participants' co-morbidities, congenital anomalies, prenatal and birth history, orbreastfeeding practices. These factors could potentially influence the observed associations between anthropometric deficits and mortality.
These results are not generalisable beyond thisinpatient setting – which is a subgroup of alreadymalnourished children – so the findings should
be interpreted with caution. This analysis does reinforce existing knowledge that there are sex differences in malnutrition-related mortality andthat children with concurrent forms of malnutrition face the greatest mortality risk. Using morecomprehensive indicators, such as CIAF, offers amore holistic understanding of undernutrition
and risk of infant mortality. Yet, more research isneeded to determine the added benefit of CIAF
whilst balancing its additional burden/complexity for programme staff. Wasting and underweightappear to correlate more strongly with mortality
compared to stunting in this setting.

Prevalence and overlap of different anthropometric deficits andmortality

A total of 141 infants died during inpatienttherapeutic care, of which 116 were severely wasted and 138 were severely underweight.
Severely wasted infants had double the odds
of mortality (OR 2.1, 95% CI 1.2-2.7, p=0.009)
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35Research Snapshots

Are children with disabilities more
likely to be malnourished?
This is a summary of the following paper: Rotenberg S, Chen S, Hunt X et al (2023) Are children
with disabilities more likely to be malnourished than children without disabilities? Evidence
from Multiple Indicator Cluster Surveys in 30 countries. BMJ Nutrition, Prevention & Health,e000779. https://www.medrxiv.org/content/10.1101/2023.09.25.23296066v1

C

hallenges in accessing adequate nutrition hinder children’s development andcompromise their wellbeing. Despite evidence suggesting that children with disabilities are at a greater risk of malnutrition, nutrition programme exclusion, and mortality fromsevere wasting – compared to children without
disabilities – there is limited evidence on the nutritional outcomes of children with disabilities inlarge-scale global health surveys.
Factors that lead to increased risk of malnutrition in disabled children include feeding difficulties, inadequate energy intake, and a higher occurrence of common childhood illnesses (such as acuterespiratory infection, fever, and diarrhoeal disease).
These are worsened when coupled with inequities
in maternal education, poverty, parental employment status, and inadequate water, sanitation, andhygiene and ICT access. Without sufficient focus
on disability, it will be impossible to achieve theSustainable Development Goal to ‘end all forms ofchild malnutrition’ or meet global child mortality reduction targets.
This study analysed data collected between
2017 and 2021 during the implementation of
the sixth round of the UNICEF-supported
Multiple Indicator Cluster Survey from 30 lowand middle-income countries. Estimations
were completed, providing adjusted prevalence
ratios for stunting, wasting, and underweight.
The study compared children aged two to four
years with and without disabilities by country
and sex. To ensure comparative analysis, thesurvey questions were standardised across thedifferent countries included in the study.
Of the 229,621 children included in the
study, 15,071 (6.6%) had disabilities. After adjustment, the overall findings indicated thatchildren with disabilities were at a greater riskof being stunted (RR 1.16, 95% CI 1.11-1.20)
than children without disabilities. The same

Children with disabilities lack access tonutrition, health, and other services
This is a summary of the following paper: Rice I, Opondo C, Nyesigomwe L et al (2024)
Children with disabilities lack access to nutrition, health and WASH services: A secondary
data analysis. Maternal & Child Nutrition, e13642. https://doi.org/10.1111/mcn.13642

P

oor diets, inadequate access to nutritionand health services (NaHS), and poor water, sanitation, and hygiene (WASH) all
increase the risk of malnutrition and infection, especially for individuals with disabilities.
The authors explored access to NaHS, household
WASH, and dietary adequacy among householdswith and without children with disabilities, in
Uganda. The study used cross-sectional secondary data from a survey conducted in 2021 and followed the PECO framework (STROBE, 2024) reporting guidelines. Adjusted logistic regression
was used to explore associations between disabilities, access to NaHS, WASH, and dietary adequacy.

Households with children with disabilities
experienced a higher prevalence of illnesses, including diarrhoea and skin infections.

© WFP/Giulio d'Adamo

Poor water, sanitation, and hygiene (WASH)
increase the risk of malnutrition and infection

36

Of the 6,924 households included in the final
analysis, half of households with children withdisabilities reported not having access to all theservices they needed. Deworming and vaccination were reported as both the most importantand most difficult-to-access services. After adjusting for confounders, households with children
with disabilities reported 30% reduced access toservices on average, when compared to households without disabilities present (OR = 0.70; 95%
CI 0.55–0.89, p = 0.003). Interestingly, improved
WASH adequacy was strongly associated with improved access to services, including for households with children with disabilities.

The proportion of malnourished children(mid-upper arm circumference <12.5cm) was
higher among households with children withdisabilities than households without (6.3% vs.
2.4%, p < 0.001). Only 61% of children aged over
two years with disabilities reportedly ate threemeals a day – and just 14% had an adequate diet.
The study found that households with children have insufficient access to essential NaHS,
especially those households with children withdisabilities. There are concerning gaps in access

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was true of wasting (RR 1.28, 95% CI 1.181.39) and underweight (RR 1.33, 95% CI 1.171.51), where significant differences were also
observed. In sex-disaggregated analyses, bothboys and girls with disabilities were significantly more likely to be malnourished thanboys and girls without disabilities. This study
affirms existing evidence that shows a higher
prevalence of malnutrition in young children
with disabilities compared with those without.
The study highlights several programmaticand policy implications. Recommendations include the development of tailored and financed
programmes within the primary healthcare system that target children with disabilities, as well as
using proactive referral mechanisms for those atrisk of malnutrition. Also, the training of healthcare workers and establishing of parental support
programmes aimed at addressing stigma, cultural
attitudes, and barriers were highlighted.
In summary, children with disabilities face
notably higher risks of various forms of malnutrition (wasting, stunting, underweight). Thisemphasises the urgency of enhancing disability inclusion within nutrition programmes. To
effectively address the nutritional needs of thisgroup, a two-way approach strategy is essential – integrating children with disabilities into
regular nutrition initiatives while also providing targeted programmes to address their specific requirements.

“This suggests that about a thirdof children do not have access toan adequate quantity of food,
while nearly three quarters do
not have access to an adequately
diverse diet, with implications
for undernutrition, particularly
micronutrient deficiencies.”
to NaHS services in Uganda and households ofchildren with disabilities reported worse access,particularly for those with low WASH adequacy.
Surveys were conducted by professional surveyors, reducing the risk of information bias, andthe sample size was large with limited missing data.
However, the cross-sectional secondary data usedin the study is inherently limited and the sample ofthree districts may not be representative of Uganda as a whole. It was also not possible to adjust forindividual confounders or analyse alongside otherinformation as the data was collected at household(and not individual) level.
Nevertheless, the findings clearly indicatethat few children are receiving an adequately
diverse diet, putting them at risk of malnutrition, including micronutrient deficiencies. Gapsin these essential services exacerbate inequalities and have implications for the nutrition andhealth outcomes of children, families, and communities. To better address the need for accessto essential NaHS for families in Uganda, it remains vital that these services are inclusive, accessible, and comprehensive.

References
STROBE (2024) What is STROBE? strobe-statement.org

© WFP/Georgina Goodwin

Research Snapshots
Impacts of cash transfers on maternal andchild health outcomes in sub-Saharan Africa
This is a summary of the following paper: Ngamasana E & Moxie J (2024) Cash transfer,maternal and child health outcomes: A scoping review in sub-Saharan Africa. Global Health
Action, 17, 1, 2309726. https://doi.org/10.1080/16549716.2024.2309726

C

ash transfer programmes are poverty alleviation interventions that policymakers and funders can draw onto improve maternal and child healthoutcomes in low- and middle-income countries.
There is, however, a lack of evidence on the effectiveness of such programmes to positively
impact these outcomes. Most evaluations tend
to focus on the utilisation of healthcare services
and other social determinants of health. Specific health outcomes related to mortality, individuals’ capacity to function, or the subjective senseof well-being are often overlooked. In a time ofcompeting priorities, the allocation of scarce resources needs to rely on a strong evidence base.
The authors therefore conducted a review of evidence in sub-Saharan African countries, where
there are substantial operational differences withother regions (e.g. Latin America).
Authors synthesised current empirical evidence by searching PubMed Central and Google
Scholar and supplemented this database searchwith a backward citation search for studies con-ducted in sub-Saharan Africa for the period
2000–2021. They identified 21 peer-reviewed articles that reported on studies conducted in six
sub-Saharan African countries – Malawi, Kenya, South Africa, Nigeria, Tanzania, and Zambia.
Among the 21 articles included, only one reported on mortality. In this study from Nigeria,
the provision of cash transfers was associatedwith substantial increases in child survival thatwas driven by a large decrease in foetal deaths(a 29% absolute decrease in the treatment groupcompared to the control). Potential causal mechanisms included conditionalities attached to the
cash payment, whereby pregnant women had toattend at least three antenatal care visits, a healthfacility delivery, and one postnatal visit.
Thirteen articles reported on health outcomes related to individual capacities to function – episodes of illness, assessment of depressive symptoms, and incidence of HIV andherpes virus. Participants who received conditional cash transfers reported reduced likeli-

Navigating school health programmes
amidst COVID-19: A scoping review
This is a summary of the following paper: Carducci B, Dominguez G, Kidd E et al (2024) Pivoting
school health and nutrition programmes during COVID-19 in low- and middle-income countries:
A scoping review. Journal of Global Health, 14. https://doi.org/10.7189%2Fjogh.14.05006

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utrition profoundly influences thedevelopment of children and adolescents aged 5–19 years. Recognising its significance, the International Commission on Financing Global Education
Opportunity prioritised health and nutrition interventions for improved learning outcomes.
This scoping review addresses the gap in the literature concerning school health and nutrition
programme adaptations during the COVID-19
pandemic, aiming to synthesise evidence on
strategies, impacts, and challenges. The goal was
to guide stakeholders on immediate and longterm responses to mitigate adverse effects onchildren and adolescents in low- and middle-income countries due to reduced access to essential school-based resources. The review searched
literature from January 2020 to June 2023, focusing on primary and secondary studies conducted in low- and middle-income countries involving children and adolescents aged 5–19 years.
This review encompasses 23 studies, eachpresenting different adaptation strategies andprogramme emphases. These include access toschool meals (n=8), health services such as immunisations, eye health, and water, sanitation,and hygiene activities (n=4), physical activity
curriculum and exercise training (n=3), mental
health counselling and curriculum (n=3), andmulti-component approaches (n=5). Importantly, there was a notable absence of quantitative
data on modified programme coverage, utilisation, and related impacts on children and adolescents' health and nutrition.
Findings revealed that multi-component
programmes in various countries adopted diverse strategies in response to the COVID-19
pandemic. Some continued in-school nutrition
programmes with adjustments for physical distancing, while others shifted entirely to virtual
platforms or distributed services outside schools.
School feeding programmes faced suspension
challenges, prompting alternative approaches
like distributing meals and food kits to students'
homes or providing financial compensation. Inschool health services were mostly halted, leaving students vulnerable to infectious diseases.
Physical activity programmes shifted to virtu-

hood of illness episodes in the past 30 days andreduced likelihood of difficulties in performing
normal activities due to illness. Lack of conditional cash transfers was associated with higher
school dropouts, which in turn were associatedwith a higher risk of HIV and herpes. Unconditional cash transfers were associated with a lower likelihood of reporting depressive symptoms.
Three studies reported outcome measures related to participants’ well-being. Unconditional
cash transfer programmes were found to be associated with improved quality of life and studies reported positive effects on a few subjective
outcomes such as self-reported overall satisfaction with life.
Protective health promoting behaviours werereported in four of the articles. Three studies reported a positive effect of conditional cash transfer programmes on the incidence of HIV andother sexually transmitted infections throughbehavioural mechanisms. One study reported anincreased likelihood of receiving the tetanus toxoid vaccine during the perinatal period.
The main limitation of this review was thelimited number of studies reporting on someof the outcomes of interest. However, the quality of evidence was high as most studies wererandomised controlled trials. Overall, the review suggests that conditional cash transfer programmes are effective in improving child survival and functional health status and in promoting
healthy behaviours, whereas unconditional cashtransfers are more effective for impacting measures of well-being.

al formats, showing promise in reducing anxiety and improving physical fitness. Mental healthprogrammes adapted to virtual counselling, facing challenges in maintaining student engagement and support.
This review underscores the scarcity of evidence concerning school health and nutrition
programming during the pandemic. It stresses the necessity of monitoring such programmes
regularly, both in ordinary times and during crises, to gauge the effectiveness of adapted initiatives and inform evidence-based policymaking.
While adhering to World Health Organization
global standards and indicators is essential at national and school levels, future research should
prioritise establishing a comprehensive monitoring and evaluation framework for schools, utilising existing data sources to track key health andnutrition indicators for children and adolescents.
Following this review, the authors concluded
that if we are to learn one thing from the COVID-19 pandemic and its impact on the health andwell-being of children and adolescents, it is that:“The continued provision of
educational, health, andnutrition services should be ofparamount concern forstakeholders and policymakers
across all sectors and levels ofgovernment.”

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37

Report Summaries
Building synergies between child nutritionand social protection
This is a summary of the following paper: UNICEF (2023) Building synergies between child nutritionand social protection to address malnutrition and poverty. UNICEF Programme Guidance.
https://www.unicef.org/reports/building-synergies-between-child-nutrition-andsocial-protection-address-malnutritionM

alnutrition in early childhood isboth a cause and a manifestationof poverty, and poverty is both acause and a consequence of malnutrition. Child malnutrition and poverty are
therefore inextricably linked and should betackled together, especially in contexts facing
recurrent and multiple shocks. In many countries, interventions do not currently address theunderlying drivers of child poverty and malnutrition, including the financial barriers.
There is evidence that social protection canboth address child poverty and improve children’s diets by removing economic barriers
to nutritious foods, increasing access to nutrition services, and preventing negative coping behaviours. Well-designed cash transfers
can improve child growth, reduce wasting andstunting, and improve birthweight. The impact on child nutrition is enhanced when cashtransfers are combined with evidence-based
nutrition interventions, to improve access tosafe and nutritious foods, positive nutritionand care practices, and essential child services. There is also evidence that school meals,
which are another form of social protection,
can improve nutrition outcomes for schoolage children and adolescents.

tion and social protection are context specific,
this guidance proposes a set of principles and a
programme framework organised around fiveentry points and 10 priority actions (figure 1).
These actions are not listed sequentially or inorder of priority; rather, their relevance and use
should be determined by the context and existing opportunities.
This guidance focuses primarily on social transfers, as this is the most common entry point for synergies between child nutrition and social protection. However, synergies
within other parts of the social protection system are also explored. These include social insurance (including health insurance), labour
market policies (including family-friendly
policies), and the social welfare services workforce. Social transfers (cash, food, food vouchers, and other in-kind transfers) may be led
and resourced by governments, partners, orboth. They may exist at different levels of maturity, coverage, and scale. Humanitarian cashtransfers may be delivered through national
systems or – where systems are unavailable,

Cash transfers combined with one or more
complementary interventions are referred to as‘cash plus’ programmes, which are often used
as an entry point for delivering child nutritionand social protection programmes in synergy.
This guidance builds on the concept of ‘cashplus’ and goes further to describe how synergies can be built between systems for sustainedchanges and impact at scale, including in thefour systems of health, food, water and sanitation, and education.
The guidance includes examples and additional considerations that are outlined for humanitarian and fragile contexts, where government systems may be weak, overwhelmed, or
disrupted. The document focuses strongly oncase studies and provides references and tools
alongside each action, which ensures practicality and ease of use/adaptation.

to strengthen synergies between child nutrition and social
Figure 1 Actions
protection© UNICEF/UN0791790/Mojtba Moawia Mahmoud

UNICEF’s global nutrition and social protection technical teams designed this programming guidance to assist practitioners to support governments in intentionally developing
synergies between child nutrition and social
protection within their policies, systems, andprogrammes. Although actions and approaches to building synergies between child nutri-38

ineffective, or disrupted – directly by humanitarian actors.

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Report Summaries

Climate change and health:Global resilience
reportThis is a summary of the following paper: World Health Organization (2024)
Climate change and health – Draft resolution proposed by Barbados, Brazil, Ecuador, Fiji, Georgia, Kenya, Moldova, Monaco, Netherlands (kingdom of the),Panama, Peru, Philippines, Slovenia, United Arab Emirates and the United Kingdom of Great Britain and Northern Ireland.
https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF7-en.pdf

This is a summary of the following
paper: UNICEF, World Food
Programme, Standing Together
for Nutrition et al (2024) Global
resilience report: Safeguarding thenutrition of vulnerable children,
women, families and communities
in the context of polycrisis.
https://micronutrientforum.org/wp-content/
uploads/2024/05/Global-resilience-report-FINAL.pdf

A draft resolution

In May 2024, the 77th World
Health Assembly passed a Resolution on Climate Change and
Health, emphasising the serious
impact of climate change on global
health and calling for urgent, integrated action to address the profound impacts of climate change on health andnutrition. Climate change is identified
as a significant threat to public health,affecting well-being through extreme
weather events, changing ecosystems,
and driving up diseases.
The resolution highlights that extreme weather and climate change
threaten food security, leading to malnutrition in all its forms. It recognises this is a complex issue that requires
integrated approaches to address. It
acknowledges that climate change
exacerbates health inequalities, disproportionately affecting vulnerable populations, particularly women and girls. It
stresses the need for a comprehensive
approach to tackle these health challenges and address the root causes ofclimate-sensitive health issues.
The resolution calls for coordinated action to build sustainable and climate-resilient health systems. This
includes integrating climate considerations into health policies and fostering collaboration across various sectors
to address the interlinkages between theenvironment, the economy, health, nutrition, and sustainable development. It
advocates for a "health-in-all-policies"
approach, ensuring that climate adaptation and mitigation strategies include© WHO / Pierre Albouy

Closing Plenary meeting of the 77th
World Health Assembly in Geneva

health and nutrition considerations. It
also emphasises the need for international cooperation, financial support,
and the sharing of knowledge and technologies to build climate-resilient healthsystems. The value of initiatives such as
the COP27 Initiative on Climate Action
and Nutrition in helping drive a global
shift on climate and health action is acknowledged. By adopting these measures, the resolution aims to enhance
the ability of health systems to respondto the nutritional and health challenges
posed by climate change.
For more information on the 77th
World Health Assembly, please visit
https://www.who.int/news-room/events/
detail/2024/05/27/default-calendar/
climate-health-events-at-wha77

A note from the Field
Exchange editors

The importance of a WHO resolution
lies in its ability to set global healthpriorities and mobilise international action. Resolutions by WHO canguide national policies, direct funding, and stimulate research and innovation. By formalising commitments
to address climate change and health,
WHO resolutions can drive countries
to integrate these issues into their
public health strategies, ensuring acoordinated and effective response.
This global alignment can help secure
the necessary resources and political
will to implement changes that protect and improve health in the context
of climate change.

R

ecently, the world has experienced a devastating
combination of factors – a ‘polycrisis’ – that is deepening food and nutrition insecurity. The knock-on
effects of the COVID-19 pandemic, climatic andeconomic crises, and new and protracted conflicts are all contributing. However, despite challenges, many governments
have demonstrated notable capacity to safeguard their mostvulnerable populations. These case studies provide lessons forgovernment policymakers and funders to prepare for ongoingand future crises.
The number of acutely malnourished (wasted) children,and the number of people who are moderately or severely foodinsecure, has risen sharply and still remains above pre-pandemic levels. Wasting among children, adolescent girls, andwomen increased by 20–25% between 2020 and 2022 in the
countries most affected by the global food and nutrition crisis.
Women were disproportionately affected, as the food insecurity gender gap increased by 2.5 times. An estimated 47 million
additional women and girls fell into poverty.
Beyond the direct health and economic impacts on individuals and families, these crises disrupt the already fragile
systems – food, health, education, water and sanitation, andsocial protection – that support access to nutritious foods, essential nutrition services, and positive feeding and care practices for children and women.
However, policy lessons can be learned from the positive
impacts that were observed when some governments purposively invested in strengthening systems that support nutrition. Adopting flexible delivery platforms for essential nutrition services, prioritising support for the most vulnerable, andadapting and scaling social protection programmes are examples of this. Governments also strengthened communities’ capacity, engagement, and empowerment, recognising them as
the ‘first responders’ in a crisis and as essential contributors tosafeguarding nutrition. The use of innovative digital technologies and strong coordination platforms also enabled systems
to better adapt in the face of crisis. The detailed findings fromthis report are beyond the scope of this summary. However,based on lessons learned, the report does offer several policy
and programme actions to strengthen the nutrition resilienceof systems, before, during, and after a crisis:First, put in place policies and programmes that enable
all systems to be adaptive, absorptive, and transformative inthe face of future shocks and crises. Second, increase the resilience capacity of key systems to maximise the preventionof malnutrition in countries most vulnerable to polycrisis.
Third, strengthen the predictability and flexibility of funding
to enable the building of stronger and more resilient systems.
Fourth, strengthen the capacity, engagement, and empowerment of communities as participants and contributors to thenutrition resilience of systems. Fifth, strengthen data collection and build robust information systems to better target vulnerable households.

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Report Summaries

Improving maternal nutrition:

The UNICEF acceleration planThis is a summary of the following paper: UNICEF (2024)
Improving maternal nutrition: An acceleration plan to prevent
malnutrition and anaemia during pregnancy (2024–2025).
https://www.unicef.org/media/153581/file/Maternal%20
nutrition%20acceleration%20plan.pdf

Appropriate nutrition is fundamental
to the health and well-being of women and girls. Well-nourished women
have better health and safer pregnancies. They also positively influence the survival,
growth, and development of their children, influencing nutrition and health status throughout
life and into the next generation.

“The evidence is clear: insufficientnutrient intake before and during
pregnancy and while breastfeeding
has debilitating and even deadly
consequences for children.”
Recently, progress has been made to advancethe rights of adolescent girls and women. However, many still struggle to access the nutritious diets, essential nutrition services, and positive nutrition and care practices needed to live full andhealthy lives. There has been almost no change
to the high rates of underweight and anaemia inadolescent girls and women for the past two
decades. In the countries most affected by the
global food and nutrition crisis, acute malnutrition in mothers has risen by 25% since 2020.
To see improvements in the nutritional statusof pregnant adolescent girls and women, nutrition policies and programmes must confront
the inequalities that create, reinforce, and perpetuate the immediate nutritional problems.
UNICEF and partners have launched a
US$320 million acceleration plan to improvematernal nutrition. This aims to prevent anaemia and malnutrition in pregnant women overthe next two years (2024–2025), across 16 priority countries: Afghanistan, Bangladesh, Venezuela, Burkina Faso, Ethiopia, Madagascar,
Mongolia, Myanmar, Nepal, Nigeria, Pakistan,
the Philippines, Rwanda, Somalia, Sri Lanka,
and Tanzania.
If fully funded, the plan will reach a total of
16 million pregnant women with a package offive essential nutrition services: nutrition infor-

Making food systems work forcomplementary feeding
This is a summary of the following paper: Micronutrient Forum (2024)
Making food systems work for complementary feeding in low- andmiddle-income countries. https://micronutrientforum.org/wpcontent/uploads/2024/02/Making-food-systems-work-forcomplementary-feeding-in-LMICs-Meeting-report_FINAL.pdf

While breastfeeding provides a critical foundation, it alone cannot
meet the high nutrient needs ofchildren aged beyond six months.
Nearly half of all children globally are not fed
enough of the right complementary foods at theright time. Limited national supply, high levels offood loss and waste, high prices relative to household incomes, low appeal, and safety concerns areleaving nutritious, complementary foods for children aged 6–23 months unavailable, inaccessible,
unaffordable, and unappealing. These barriers not
only jeopardise children’s immediate health but
can also have a profound impact on long-term
health and well-being.
In response to this issue, the Micronutrient
Forum convened an expert meeting in December 2023 to discuss the question: “how can we
make food systems work for complementary
feeding?” The experts made recommendations
in four core areas that currently limit the availability, affordability, accessibility, and appeal ofsafe and nutritious complementary foods: 1)
knowledge and evidence gaps; 2) limited lo-

40

cal capability and capacity; 3) implementation
barriers due to business constraints and supply
chain inefficiencies; and 4) an unfavourable enabling environment. These recommendations
serve as a roadmap for action to transform foodsystems and ensure access to nutritious complementary foods for young children.
The recommendations cover a wide range of
topics, including reducing food loss and waste,using native, underutilised, and biofortified
crops, and adopting complementary food composition standards. Adopting a “research and development as a service” model was also highlighted
to support small- and medium-sized enterprises.
This model, typically offered by suppliers, aims tolessen research and development expenses and facilitate market entry by providing technical assistance and capacity strengthening. Developing an
investment pipeline for these enterprises to produce safe, high-quality complementary foods, isalso necessary. To realise this vision, a systems approach must be taken by governments, food producers, suppliers, businesses, researchers, investors, and technical agencies.

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

mation, education, and counselling; healthy weightgain monitoring; multiple micronutrient supplementation; deworming prophylaxis and malaria control (according to context); and nutritional screening and referral for supplementation withbalanced energy-protein if needed. The essential
package of services will largely be delivered via antenatal care, with strong links to community systems. The five essential nutrition services includedin the acceleration plan are not new, but they have
not yet been implemented as a high-quality package
and successfully taken to scale.
UNICEF and partners aim to support the implementation of the essential package of services by:strengthening advocacy and policies; improving thedelivery of maternal health and nutrition services;increasing the capacity of service providers; increasing the supplies of essential commodities; and harnessing data and generating evidence and learningin both development settings (implementation research) and humanitarian settings (emergency preparedness and response).
Through this acceleration plan, UNICEF aims
to harness the current momentum and commit toworking closely with national governments and partners in scaling up the package of services across these16 priority countries. These efforts will amplify women’s rights and voices at the country and community
levels through the delivery of proven services, while
documenting experiences and sharing learning on
how to take these services to scale most effectively.

Importantly, bold initiatives are already underway. The World Health Organization and UNICEF have establishedthe Global Complementary Feeding Collective to foster global and regional cooperation. Technical organisations are providing support to improve the technicaland business capacity of small- and medium-sized enterprises, enabling local foodproduction and fostering sustainable business models. For example, in Cambodia andZambia local initiatives are in place to produce
fish powder, which can be used in homemade
porridges. Egg production hubs have also been
established in Ethiopia, Kenya, Malawi, and India, as another example.
Ultimately, transforming food systems
to deliver safe and nutritious complementary foods through sustainable business models
requires collaborative efforts and innovative
solutions from both public and private sector
actors. Networks and coalitions are set up to
create an ecosystem that supports operational
efficiencies, growth, innovation, and sustainability for small- and medium-sized enterprises. The Scaling Up Nutrition Business Networkand the Alliance for Inclusive and Nutritious
Food Processing are examples of this. Local
food system actors also need access to patient
capital and innovative financing mechanismsthat will ‘de-risk’ their own investments.
The detailed findings of this report are beyond the scope of this summary. However, we
encourage readers to explore the 51-page reportand case studies found within.

Report Summaries

Scaling up severe wasting programming
This is a summary of the following paper: Action Against Hunger, International Rescue Committee,
Save the Children UK, and UNICEF (2023) Scaling up coverage, quality and sustainability of early
detection and treatment of severe wasting programming for children.
https://www.nutritioncluster.net/resources/delivery-systems-scaleChild wasting, a preventable condition, critically impacts children's
ability to survive and thrive. Whileevidence-based approaches to treat
severe wasting exist, the challenge lies in effectively providing these services to the most atrisk children. The 'Delivery Systems for Scale'project (December 2022 to September 2023)
was developed by International Rescue Committee, Action Against Hunger, and Save theChildren, in partnership with USAID and withsupport from UNICEF. The project focused on
three core areas: Country-driven support, coordination and learning, and technical and coordination support.

global targets. Country-level scaling action
was supported through various global and regional activities to address barriers.

A project learning component reviewed
global progress scaling up coverage, quality, and access to detection and treatment programmes for children with severe wasting from2013 to July 2023, building on a 2013 global
stocktake by Action Against Hunger and the
Coverage Monitoring Network (ACF, 2013).

Despite this progress, the report showedthat challenges persist. Health system fragility, inadequate human resources, limited political will, and insufficient funding continue
to hinder scaling efforts. Collaboration between health and nutrition sectors, as well as
engagement with the private health sector, remains critical. Fragmented knowledge management also poses barriers. Improvements in datacollection, analysis, and use have been made,but gaps in data proficiency and accountability persist. The expansion of financing instruments requires better coordination and tracking to optimise resources effectively. Significant
advancements in materials and supplies, particularly with Ready-to-Use Therapeutic Food,highlight the need for optimisation of national supply chains.

Moving forward, a child-centred systems
approach is recommended to integrate prevention, early detection, and treatment ofchild wasting. There are five key recommendations from this analysis which can be taken forward. First, to define and implement
methods to integrate routine detection andtreatment of child wasting within national
health systems. Second, to strengthen knowledge management by investing in retrospective and prospective learning and commit
to simplicity and clarity in communication.
Third, review and update success metrics, including targets, monitoring, and accountability frameworks, aligning them with national
government priorities. Fourth, leverage the2023 WHO Guideline and the 2020 UN Global Action Plan for Wasting rollout, along with
momentum on universal healthcare, to address governance, prioritisation, and resourcing gaps with national actors. Fifth, defineand strengthen collaboration with the private
sector within frameworks that support childhealth and nutrition.

References
ACF (2013) A decade of community-based SAM management 2013. https://www.ennonline.net/ourwork/
othermeetings/communitybasedsam2013© UNICEF/UN022131

Over the past decade, significant progresshas been made through collective efforts bynational governments, NGOs, UN agencies,
civil society, and donors. Increased financing
resulted from joint advocacy and donor engagement, leading to incremental integration
into national systems through expanded policies and resources. Developments in information systems laid the foundation for systematic adoption and tracking of national andKey enablers for this progress included sustained advocacy, predictable technical support, and coordinated research agendas. Country-level technical working groups played acrucial role in mobilising action and addressing
technical and operational shortfalls. The launchof the UN Global Action Plan for Wasting in2020 and the 2023 WHO Guideline for the prevention and management of acute malnutrition
present new opportunities to accelerate prevention and treatment efforts.

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41

Report Summaries

Responding to nutrition in emergencies
within the climate crisis
This is a summary of the following paper: Nutrition in emergencies and the climate crisis:
Global nutrition cluster scoping and options paper (2024).
https://www.nutritioncluster.net/resources/nie-and-climate-crisis-global-nutritioncluster-scoping-and-options-paperClimate change is one of the world’s
most pressing challenges, affecting up to 3.6 billion people in highly vulnerable contexts. The Global Nutrition Cluster (GNC) plays a crucial rolein addressing this crisis within its humanitarian mandate, focusing on climate and weather
shocks and seasonality shifts because of theirimpact on nutrition outcomes and their underlying causes. The GNC also considers environmental impacts and greenhouse gas emissions
in its climate crisis work, given how environmental degradation exacerbates vulnerabilities
and the climate crisis.
The GNC has been refining its approach tonutrition in emergencies (NIE) within the climate crisis, establishing a Climate Crisis Working Group and recognising climate as a strategic priority in 2023. The GNC commissioned
a scoping of evidence, priorities, and opportunities across stakeholders to enhance its approach to supporting country clusters, GNC

global partner agencies, and other global clusters in responding to NIE in the context of climate crisis. This scoping aimed to identify relevant opportunities for the GNC in the face ofthe changing humanitarian landscape due tothe increased frequency and severity of extreme
weather events, emerging risks like disease outbreaks, and the complex relationship between
nutrition and the climate crisis.
The scoping includes an initial articulationof a climate rationale for the GNC’s approach,
identifying action areas for climate crisis and
NIE work and providing an overview of stakeholder needs and capacities. GNC stakeholders
emphasised the importance of addressing thisissue. Critical bottlenecks were identified, including existing challenges in NIE response, low
government priority of the climate crisis, limited capacity to integrate climate predictions into
country planning, and limited programmingand coordination frameworks for climate crisis
and NIE action.

Supporting infants aged undersix months with feeding
difficulties and disabilities
This is a summary of the following paper: ENN, MAMI Global Network(2024). Identifying and supporting infants under 6-months with feeding difficulties and disabilities: An overview of resources and evidence.
Emergency Nutrition Network (ENN), Oxford, UK.
https://www.ennonline.net/identifying-and-supporting-infants-with-feeding-difficulties-and-disabilities

F

eeding difficulties include a wide range
of issues related to eating or drinking that deviate from age-appropriate
norms, often associated with medical,
nutritional, feeding skill, and/or psychosocial
factors. These challenges can increase the riskof malnutrition and infections, as well as theonset or worsening of disabilities in children.
Studies indicate that feeding difficulties affecta substantial proportion of children, with estimates ranging from 25-45% among those without disabilities and between 80-90% amongchildren with disabilities.
Growing concerns about managing children
aged under six months experiencing feeding
difficulties or suspected/confirmed disabilities
highlight a lack of attention and evidence-based
guidance for this vulnerable age group. This has
prompted the compilation of essential resources aimed at supporting both infants and theirmothers. Disabilities are difficult to identify inchildren aged under six months and sometimes

42

only realised when developmental milestones
are not being met. To address this, a documentcompiling key resources focused on children
aged under six months and their mothers wasdeveloped to help consolidate existing guidance
and research for mother–infant pairs. It is divided into four sections, with each providing a linkto and brief description of a relevant suggested/highlighted resource.
First, practical resources on assessment tools
are provided, with an emphasis on the significance of early detection of feeding difficulties ordisabilities in infants. These issues can be overlooked during breastfeeding initiation and before the introduction of semi-solid/solid foods,
when issues are more readily identifiable. Additionally, guidance is offered on providing caregivers with practical support to facilitate safe
and comfortable breastfeeding. The section also
provides general resources available that provide practical support for the feeding of infants
under six months with disabilities and their

FIELD EXCHANGE ISSUE 73, July 2024 www.ennonline.net/fex

To effectively address NIE in the climate crisis, the GNC supports a principled approachrather than a prescriptive one, described underfour key areas. First, climate and environmental justice, anti-oppression, and localisation, ensuring the GNC's work addresses and does notworsen the unequal effects of the climate crisis on people's nutrition status and vulnerability. Second, adopting a NIE climate crisis lens sothat climate crisis considerations are integrated
into existing tools and approaches, for example
strengthening climate risk in nutrition situation
analyses. Third, climate-adapted NIE, whereby
new coordination and programming approaches are developed for emerging climate-relatedrisks, for example promoting sustainable, local solutions for complementary foods for children in emergencies and fragile settings. Finally,
NIE climate and environmental impact mitigation, so that NIE programming mitigates negative climate and environmental impacts, for example in supply chains and waste management.
This approach leverages the GNC’s strategic
advantages, such as its extensive network, global reach, expertise in NIE and the climate crisis, and critical role in facilitating knowledge
exchange and coordination across various levels and clusters. The scoping supports the GNC
Climate Crisis Working Group’s activities, GNC
engagement with other clusters for the rollout of
the IASC Climate Crisis Roadmap, and preparation for the GNC’s next strategy.

mothers. Resources specific to certain
disabilities (e.g., cleft palate, Downs syndrome, etc.) are provided as well.
Secondly, a summary has been provided of some key policy documents related todisability. This includes organisational policies and guidance that have inclusive services and mainstream support in health andnutrition services.
Thirdly, a summary of the Disability Evidence Portal (DEP) is provided. This
portal has been established as “a knowledge exchange platform that seeks to enable and empower decision makers with evidence-based knowledge to make decisions on
how best to improve access, health, education,
livelihood and social outcomes for people withdisabilities worldwide… through acting as a repository of solutions, evidence and tools forstrengthening decision-making within Disability-Inclusive Development.”
This section also calls for more research on
disability inclusion for infants. This group is often excluded from research, which has led to alack of evidence on care required. Some of thereasons why more research is needed for thisage group include the fact that they are more
likely to be malnourished and that there are
long-term nutritional consequences of disability and exclusion of children with disabilities inmalnutrition protocols and guidelines.
The last section of the report provides asummary of ongoing initiatives that highlightthe work that could be relevant to advance
this agenda.

ENN CEO: Nigel Tricks
ENN Directors: Marie McGrath,
Tanya Khara
Operations Team Support:
Emily Cracknell, Hannah Fletcher,
Holly Ruffhead, Laura Delfino, Nicola
Johnstone, Rosaleen Cunningham
Design: Orna O’Reilly
Big Cheese Design.com
Website: Oxford Web Applications

Contributors for this issue:
Alessandro Iellamo
Alice Burrell
Ali Qureshi
Amir Samnani
Andi Kendle
Angelina Nasira Boi
Charles Mumbi
Constance Miller
Diane Holland
Eilise Brennan
Ellyn Yakowenko
Emily DeLacey
Erin McCloskey-Rebelo
Everlyne Adhiambo
Fabrizio Loddo
Fardosa Ahmed Abdullahi
Gina Etheredge
Hatty Barthorp
Hazem Samra
Kelly Thayer
Ketaki Kokil
Kristina Michaux
Leah Richardson
Lenka Blanarova
Lina Muhammad Al-Khatri
Linda Migliorati
Lucy Kinyua
Lucy Maina Gathigi
Luundo Wa Luundo
Manu AdhikariMarie McGrath
Marlene Traore-Hebie
Martha Nakakande
Mohammed Helmi
Mohannad Ibrahim
Nicky Dent
Paul O’Keeffe
Patrizia Fracassi
Sarah Brittingham
Shadrack Oiye
Sumra Kureishy
Tiziana Pirelli
Tomoko Kato
Yussuf Hassan Isaak

CoverMarket at Jaisalmer, India;©Bigstock/Neale Cousland­­­About ENN
Emergency Nutrition Network (ENN) is a UK registered charity that strives to enhance the effectivenessof nutrition policy and programming by improving knowledge, stimulating learning and building evidence.
We are passionate about being field-driven and are globally recognised as thought leadersand conveners in nutrition.
ENN is based in the UK but works globally and is made up of a team of technical experts in nutrition withdecades of collective experience in the field. We work alongside governments, the United Nations, nongovernmental organisations or charities, and research institutions worldwide to look critically at existing
practices, raise awareness of issues and drive change so that those working to tackle malnutrition can do thebest possible job. We do this by:
1. Capturing what works and what is needed to reduce malnutrition – working with people implementing
programmes to help them examine their experiences and document their achievements and challenges.
2. Coordinating technical bodies to increase the global understanding of malnutrition – particularly
focusing on the most nutritionally vulnerable including infants and children, adolescent girls andmothers who are pregnant or are feeding their infants.
3. Supporting global efforts to reduce malnutrition – bringing our knowledge and technical expertise tostrengthen the activities of organisations working to reduce malnutrition at the global level.

Field Exchange Team
Anne Bush
EditorNicki Connell
EditorPhilip James
EditorThomas Stubbs
Content
Coordinator

Gwénola Desplats
French Content
Coordinator

Natalie Sessions
Sub-Editor

Stephanie Wrottesley
Sub-Editor

Amir Samnani
Sub-Editor

Anne Gitari
Sub-Editor

Supported by:

The views expressed in Field Exchange are those of our authors as individuals and our Editorial Team. They do not necessarily
represent the views of these stated donors or organisations featured in the issue, unless otherwise stated.
The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no:1115156) and a company limited by guarantee and not having a share capital in the UK (company
registration no: 4889844). Registered address: 2nd Floor, Marlborough House, 69 High Street,
Kidlington, Oxfordshire, OX5 2DN, UK. ENN Directors/ Trustees: Graham MacKay, Marie McGrath, Jane
Cocking, Harish Jani, Megan Howe, Patrick Webb, Carol Morgan, and Sophie Healy-Thow.

@theennonline@theennonline

ENN Online

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ENN

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