Humanitarian food assistance and nutrition outcomes among refugee children below the age of five years in West Nile region in Uganda: Protocol for food assistance intervention using mixed methods (Preprint)
Authors: Ecega Guli Alfred 
Published: July 2022

BACKGROUND

This study is about the effects of humanitarian food assistance on nutrition outcomes among children under five years old in selected refugee settlements in West Nile, Uganda. Food aid is used to address global nutrition goals, particularly for vulnerable populations of children and reproductive-aged women (Caiafa et al., 2019). Food assistance is a key element of humanitarian aid to conflict-affected populations, intended to promote the survival and growth of infants and young children in vulnerable populations (Gelli & Tranchant, 2018; Mozaffarian et al., 2018). Humanitarian Food assistance is a mandate of the WFP as the largest humanitarian partner responsible for fighting global hunger and malnutrition (WFP, 2017). Humanitarian food assistance is provided to ensure the consumption of sufficient, safe, and nutritious food by conflicted affected populations during or after a humanitarian crisis (European Commission, 2013). Humanitarian food assistance in this study refers to the distribution of food in form of dry rations and cash for refugees. Children under five years are at increased risk of mortality associated with acute malnutrition, micronutrient deficiencies, and stunting (Global Nutrition cluster, 2017). Although food assistance for refugees has been ongoing since 2013, malnutrition is widespread across the refugee settlements with 8% of the children wasted and 20% stunted respectively (WFP, 2017). The majority of the refugees in Uganda depend on food assistance provided by WFP to meet their daily food needs, and without sustained assistance, refugees may face acute food insecurity (USAID, 2019). Out of 1.36 million refugees in Uganda as of June 2018, about 1.1 million were receiving food assistance either in-kind or through cash transfers, however, 18% of refugee households have low food consumption scores and 67% have insufficient access to food in 7 days for all members of the household (UNHCR, 2019b). Although food assistance is the largest part of humanitarian assistance, food aid levels and rations have declined significantly and refugee children are at high risk for nutritional and health disparities (Dawson-Hahn et al., 2016; Iffat Iddris, 2020). Poor food quality, insufficient intake of nutrients such as calories, protein, or micronutrients, and severe or repeated diseases result in malnutrition in children (GoU, 2011; Iffat Iddris, 2020; UNICEF., 2019; WHO, 1997, 2015c). Similarly, poor diets, unfamiliarity with available foods, and socioeconomic influences contribute to nutritional problems among children (Aguayo & Morris, 2020; Rondinelli et al., 2011). Although Uganda boasts of her most favorable and progressive model, the refugee population according to UNHCR is in dire need of humanitarian assistance (Ahimbisibwe, 2019; D. Legason & Dricile, 2018a; WFP, 2019). Despite the support by the humanitarian partners, malnutrition cases continue to be rampant among the refugees, and yet funding for refugees is dwindling, leaving many refugees surviving on basic ration provided by WFP, which many refugees say are inadequate in quantities and quality.

Low funding levels to aid agencies and pipeline break is making for refugees who depend on humanitarian food aid, difficult to access a balanced diet with adequate micronutrients (Krishnamani, 2015). Refugees usually live in extreme poverty and food insecurity situations, incomplete food baskets, food supply pipeline breaks and late delivery of food have all contributed significantly to refugee malnutrition (Nicholas & Kerrie, 2019; van den Briel, 2006). Severe food insecurity is experienced by 7 out of 10 refugee households as compared to the host community with 5 out of 10 host households in Uganda facing food insecurity (Iffat Idris, 2020). Most refugee settlements have inadequate monthly food rations that are monotonous, and of poor quality (IRRI, 2015; Renzaho, 2002). This situation increases a child’s risk of morbidity and mortality and also poor cognitive function and developmental outcomes (Dawson-Hahn et al., 2016; Legason & Dricile, 2018; Ali et al., 2019; Bailey & Hedlund, 2013). Hence, inaccessibility to adequate dietary intake makes refugees prone to malnutrition. An assessment report by WFP has shown that a lack of adequate and diverse diet is the major cause of under-nutrition although the use of cash, as opposed to in-kind delivery, has enhanced dietary diversity (WFP, 2015, 2021). Global acute malnutrition (GAM) prevalence in prevalence in children ranged from 4% to 12% among refugees and 5% to 11% in the hosting population in Uganda (Lazzerini et al., 2020), and the GAM rate for children in settlement areas in Uganda is high, at 7.3 percent, with some of the highest rates found in the West Nile (UNHCR, 2018c). The burden of malnutrition among refugee children as compared to the children in host communities is high (Lazzerini et al., 2020). This is because refugees mainly depend on food rations that are insufficient in quantity and variety. While cash and vouchers have proved effective, there is scanty data on their impact on nutrition outcomes (Global cluster, 2017). Current food and non-food items (NFI) distributions do not meet the full range of refugee needs, making them sell some items including food to compensate for unmet needs (IRRI, 2015). Despite the continued food assistance, malnutrition remains a challenge in most refugee settlements. It is not known whether persistent malnutrition among the refugees is directly related to the humanitarian food assistance (both food in-kind and cash-based transfer) provided, and this is what my study intends to find out. Therefore this study seeks to understand the following specific objectives; (1) to analyze the effects of food in-kind assistance on the nutrition outcomes among children under five years in refugee settlements in West Nile, and (2) to examine the effects of the cash-based transfer on the nutrition outcomes among children under five years in refugee settlements in West Nile, (3) to examine the influence of agricultural inputs support on the nutrition outcomes among children under five years in refugee settlements in West Nile, and (4) to investigate moderating effect of nutritional factors on humanitarian food assistance and nutrition outcomes among children under five years of age in refugee settlements in West Nile.

OBJECTIVE

the major questions underlying the study objectives are;(1) to analyze the effects of food in-kind assistance on the nutrition outcomes among children under five years in selected refugee settlements in West Nile, and (2) to examine the effects of the cash-based transfer on the nutrition outcomes among children under five years in selected refugee settlements in West Nile, (3), to examine the influence of agricultural input support on the nutrition outcomes among children under five years in selected refugee settlements in West Nile, and (4) to investigate the moderating effect of nutritional factors on humanitarian food assistance and nutrition outcomes among children under five years of age in selected refugee settlements in West Nile.

METHODS

Ethics approval
This study received approval from the Gulu University ethics committee (Protocol reference GUREC-2021-108) and Uganda National Council for Science and Technology (UNCST)- reference- HS1912ES. Approval was also obtained from the Office of the Prime Minister (OPM) reference-OPM/R/107, United Nations High Commissioner for Refugees (UNHCR), World Food Programme (WFP), and district local Governments to undertake the study in the refugee settlements and access the research participants. Informed consent will be obtained from all research participants using the approved informed consent protocol and COVID-19 prevention and control mitigation measures will be adhered to.

Research overall design
The study will use a cross-sectional research approach employing a mixed-method research design using both qualitative and quantitative approaches. Both primary and secondary data collection methods will be used for the study focusing on refugee hosting districts of Adjumani, Obongi, and Yumbe. According to Bryman and Bell (2003), triangulation of methodology occurs when more than one research strategy and data source are used in social phenomena. The combination of qualitative and quantitative design strategies has been recommended and used by researchers in situations where one of the approaches is insufficient to reveal all that is required to be known about a phenomenon (Bryman et al. 1996; Wilson and Marlino 2005). The importance of diversifying data sources and methodological approaches is also underscored by Yin, (1994) and Wilson and Marlino (2005) who stipulate that using multiple sources of data is to triangulate evidence to increase the reliability of the data and the process of gathering it and hence corroborate the data gathered from different sources. Both approaches complement each other.

Sample size
The target population of the study is 20,347 refugee households in the selected districts of Adjumani, Obongi, and Yumbe (UNHCR, 2020, 2021). A sample size of 392 participants was obtained using Yamane (1967:886) formula. For the interviews, a sample size of 61 respondents was purposively selected out of a target population of 133 people. The total sample size for the study was 453 research participants.

Data collection
This study will use the following data collection techniques; survey questionnaire, key informant interviews, focus group discussion with respondents, document review, audio recording information, and observation checklist. To ensure validity, questionnaire instruments will be assessed. Quality control will be done by carrying out a pre-test of the research instruments to test its validity using a section of a few targeted respondents. Experts will be asked to review the questionnaire for all forms of errors from grammar, phrases, use of words, and typo errors, scoring on the relevance of the items, and determine whether it is necessary to include additional items or not. Data collectors/enumerators will be trained and unclear concepts will be explained or clarified.

Primary outcomes
The Primary outcomes are; (1) prevalence of malnutrition among under-five children measured using WHO anthropometric measurements, biochemical indicators, and clinical signs of malnutrition, and (2) nutrition quality of children below five years measured using WHO growth reference indicators/curves which are; Z-scores (weight for age (WAZ), height for age (HAZ) and weight for height (WHZ); (3) level of knowledge on nutrition (4) Feeding practices among refugees measured using foo consumption score, dietary diversity and number of meals consumed eaten per day and (5) Food storage and food preparation practices measuring using the WHO golden rules for safe food preparation.

Secondary outcomes
The secondary outcomes of the study include; Food assistance package measured using UNHCR and WFP food assistance standards, (2) humanitarian funding levels measured using UN food assistance standards (3) Livelihood support improvement.
Inclusion criteria
Establishing the inclusion criteria of study participants is important to ensure the right participants are selected. The inclusion criteria will be established based on the characteristics of the study participants as follows; For this study; (1) registered refugees living within the selected refugee settlements, receiving either food in-kind or cash transfer, (2) refugee households with a child below 5 years, (3) active refugee welfare councils, food and cash management committees in the settlements, (4) NGOs implementing food and cash assistance programs in the settlements, and (5) agencies funding refugee food assistance program.

Exclusion criteria
In this case, the main exclusion criteria have been identified as; (1) a household that is not a registered refugee/household but living within the selected settlements, (2) a refugee living in another settlement not selected for this study, (3) refugee households with a child above 5 years getting either food in kind or cash, (4) refugee not receiving any form of food assistance (food in-kind and cash transfer) but leaving within the selected settlements, (5) non-food implementing NGOs operating within the refugee settlements, and (6) a refugee exposed to COVID-19 and tested positive for COVID, 10 days prior to data collection

Data analysis
Quantitative: After data collection, all the data collected will be coded and reviewed for quality, accuracy, consistency, and completeness. The survey data generated from the administration of questionnaires will be subjected to confirmatory statistical analysis techniques. After receiving the filled-in questionnaires from the field, a data entry capture template will be designed in the Statistical Package for Social Scientists (SPSS) version 27 for data entry, cleaning, and analysis. After data entry and cleaning, statistical data analysis using frequency distribution will be carried out to summarize and display the respondents’ views on the questions under study. Confirmatory data analysis using inferential statistics to generate conclusions about the relationships between humanitarian food assistance, nutritional status/outcomes, feeding practices, and knowledge of nutrition will be obtained. To establish the strength of the association between the dependent and independent variables, Pearson's correlation analysis will be used as the data will be categorical with an ordinal scale. Regression analysis (ANOVA) will also be carried out to establish the variation in food assistance and nutritional outcomes. Inferential statistics will use Pearson’s correlation and paired- T-tests regression and path analysis.
Qualitative: Data collected from focus group discussions, observations, and in-depth interviews are categorized into themes and contents based on the commonly occurring data. After the collection of qualitative data, it will be edited and imported into NVIVO through rich text format. Data will be classified and organized into themes using mother and child nodes. Themes that will merge will be modified as meaning will be attached to the data to be analyzed. After editing and importing qualitative data into NVIVO software, the analysis will continue with the review of data collected through coding to obtain a full understanding of the factors that influence food assistance and nutrition outcomes. The coding will result in concepts that will identify the emerging relationships amongst the different variables.
Use of existing data/document review
In this study, I will conduct a secondary data review and analysis of data relevant to the objectives and variables from the available existing literature for triangulation and complementary insights. A documentary review of relevant secondary sources of data will be conducted to collect qualitative information or data from various secondary sources. For this study, Nutrition records/registers or documents from the health facilities, official reports from implementing partners, UN agencies providing food assistance to refugees (WFP, UNHCR), reports from districts, and project documents will be reviewed to collect relevant data on humanitarian food assistance will be reviewed. An extensive document review will use both online and offline approaches. The investigator will draw data directly from health facility registers, reports from refugee supporting agencies, and district records about refugee food assistance and nutrition will be looked at.
Sampling and recruitment of participants.

The study participants will be recruited in the settlements of Adjumani, Obongi, and Yumbe districts (UNHCR, 2021). The research participants will be the heads of households, mothers or caters of children below 5 years from households receiving dry food rations and cash transfers, refuge welfare committees, food management committees, cash management committees, nutrition groups/clubs, implementing and supporting agencies, and district authorities. The research participants will be selected using random sampling for households respondents, purposive sampling for nutrition groups district leaders, implementing partners, and health facility personnel, and a convenient sampling technique for selecting the refugee welfare committees, food management committees, and cash management committees. Observation will be done on children under 5 years, households, and the food distribution process to assess their nutrition status, food distribution exercise, food storage, and food preparation practices, feeding practices, household hygiene, and living environment. Also, an experiment will be done in the Laboratory to analyze the nutrient contents of food provided and procured by the refugees.

Interventions to be measured
The study will measure the prevalence of malnutrition among under five refugees children, the level of knowledge on nutrition, feeding practices, food storage, and food preparation practices of the refugees. The study will understand the food assistance package provided, funding levels to the humanitarian partners, and household food security.
Primary and secondary outcomes to be measured
The primary outcomes to be measured are; Prevalence of malnutrition among under-five children; Nutrition quality of children under five years, level of knowledge on nutrition, feeding practices among refugees, Food storage and food preparation practices. The secondary outcomes include food assistance package review; humanitarian funding levels and livelihood support improvement.

Data analysis and statistical plan
Data collected will be coded, reviewed, and subjected to confirmatory statistical analysis techniques. Statistical Package for Social Scientists (SPSS) version 27 will be used for data entry, cleaning, and analysis. Confirmatory data analysis using inferential statistics to generate conclusions about the relationships between humanitarian food assistance, nutritional status/outcomes, feeding practices, and knowledge of nutrition will be obtained. To establish the strength of the association between the dependent and independent variables, Pearson's correlation analysis will be used and regression analysis will also be carried out to establish the variation in food assistance and nutritional outcomes.

Interview process
The research participants can choose to be interviewed and will be informed about the study. Translated informed consent forms will be provided to participants to ensure they give their fully informed consent.
Household interviews.

Key information interviews
the key informants interview guide will be designed for conducting key informants' interviews with selected informants. In the KII, data will be obtained from the implementing partners (IPs), humanitarian UN agencies (WFP, UNHCR), and district authorities from the refugee hosting districts. A total of 41 key informant interviews will be conducted during the study.

Focus group discussion
A total of 20 focus group discussions will be conducted in all the selected refugee settlements. Focus group discussion (FGD) will be conducted with small groups of 10 to12 members in the selected refugee settlements to gather the experiences and views of recipients of food in-kind and cash on the humanitarian food assistance and nutrition outcomes. The target for the FGD will be food management committees, cash management committees, Refuge welfare committees (RWCs), and Nutrition groups/clubs. The FGD guide will be used to guide the discussions to ensure all members have equal chances to speak. A total of 20 interviews will be conducted during the study. All FGDs will be recorded with the consent of the members and group photos will be taken after the focus group discussions.

Overall data synthesis and dissemination plan
The research participants will be informed of the findings/results of the study including any new information related to the study. During dissemination of findings/results, measures for prevention and control of the risk of spread of COVID-19 will be strictly followed as per the guidelines of the Ministry of Health, World Health Organization standards, and presidential directives on prevention and control measures for COVID-19 pandemic (MOH, 2020; UNCST, 2020). Compliance with the COVID-19 preventive measures will be observed.

RESULTS

The data collection commenced in February 2022 and was completed in May 2022. However, the food samples for proximate food nutrient analysis were collected from 12th to 14th July 2022 and submitted to Food Science and Technology Laboratory at Makerere University. The 392 households’ interviews were conducted, 12 key informant interviews were done, 16 Focus group discussions were done and 2 observations of food distribution were completed. The results of the study will be disseminated and published.

Anticipated findings and potential impact
In conducting this study, the evidence about the experiences of refugees pertaining to the food in-kind and cash-based transfer assistance provided to them will address the gaps. The study mainly focuses on; types of foods, quantity or ration of food, pattern or frequency of food distribution, amount of cash provided and frequency of cash transfer, access to farm inputs, and access to land for farming. In this study, I expect to contribute considerable new knowledge through the use of the mixed method approach. The also considers issues such as the level of education of mothers, parents, and caretakers, the cultural and traditional norms about food storage/preservation, food preparation, food consumption/feeding practices, access to markets and food prices, access to healthcare services, food supply pipeline and funding for humanitarian agencies. In an attempt to tease out the impact of food assistance, the study will explore participants' experiences with the assistance they are receiving, and develop a food Assistance model that is cost-effective to address the nutrition outcomes of refugees. I expect to provide recommendations to implementing agencies, Policy makers, academia, and donors based on the findings.

CONCLUSIONS

The current humanitarian food assistance (food-kind and cash transfer) program is considered inadequate with regard to the number of food rations, cash transfers, and agricultural inputs received by the refugees. The malnutrition rates continue to be higher among the refugees than in the host population. Using a mixed method approach to elicit participants' experiences and views, this study aims to address the gaps in the evidence to help inform changes and improvements in humanitarian food assistance programs and the nutrition status of refugees.