Transform Nutrition has produced a Guidance note for donors and national government based on our 6 years of research on Frontline Health Workers:
pivots for mass behaviour change
Behavioral change for Improved Nutrition among Pastoralists in Ethiopia
Pastoralists in Ethiopia
Ethiopia is one of the countries who managed to meet the nutrition target of MDG 1 by reducing the rate of stunting from 58% in 2000 to 40% in 2014 and wasting from 12% in 2000 to 9% in 2014.[1] Currently, the country is working towards the nutrition targets of SDG2. As of 2016, 38% of children in Ethiopia are chronically malnourished and 10% are acutely malnourished. [2]
However, the picture in pastoral areas like Somali Region of Ethiopia shows that the under-served and hard to reach segments of the population of the country need tailored ways to address the still prevailing situation of undernutrition. In Somali Region of Ethiopia, the prevalence of stunting (chronic malnutrition) is 27.4% as of 2016. In addition, the region has the highest proportion of children with acute malnutrition from all regions of Ethiopia having 22.7% wasting rate. Somali Region also has the highest prevalence of anaemia in children with a rate of 82.6% as compared to the national prevalence of 56%. Moreover, 12.8% of children in Somali region have severe anaemia. The highest prevalence of anaemia in women is also seen in Somali Region with 59% prevalence compared to 23% nationally. [3]
Nutrition sensitive interventions by VSF-Suisse in Ethiopia
To contribute to addressing the need to nutrition interventions in pastoral areas as Somali Region of Ethiopia, VSF-Suisse has implemented different nutrition sensitive interventions in the region. Linking agricultural and livestock interventions to community-based nutrition has been a flagship activity of the VSF-Suisse (and of the Ethiopia Programme in particular). Owing to the fact that the nutrition needs of under-served communities cannot be addressed by direct nutrition interventions alone, VSF-Suisse had nutrition sensitive livestock based interventions where animal source foods sourced from local markets like meat and milk were availed to households hosting children recurrently affected by acute malnutrition and recurrently admitted to therapeutic feeding centers. These interventions have proven to show changes on the availability of animal source foods at the household level.
To showcase one of these interventions in Kebriderhar and Shilabo Woredas of Somali region of Ethiopia in 2013, where 9 milking goats were provided to households hosting children affected by recurrent malnutrition, change was observed in the targeted households in terms of acute malnutrition, measured through MUAC (Mid-Upper Arm Circumference). A decreased percentage of children with MUAC <11cm from 33% before the intervention to 0% at 4 months after the provision of milking goats was observed. The percentage of children with MUAC for age <-3 SD, showing signs of acute malnutrition, had decreased from 56.8% before the intervention to 12.3% after the intervention.
Availing Animal Source Food was not Sufficient
In the intervention mentioned above, even though change was observed on one of the nutrition indicator of the targeted children, MUAC for age, it was noteworthy to observe that after they were provided with milking goats, none of the mothers were breastfeeding (from 12% before the intervention). This was one of the signals that availing animal source foods for households does not necessarily ensure the improvement of the overall nutrition situation and optimal nutrition practices. The main lesson drawn was that nutrition sensitive interventions are beyond linking specific livestock relief interventions with nutrition outcomes. This ignited the idea of thinking on optimal behavioral change communication interventions which suits pastoral areas like Somali Region of Ethiopia. The option lies on whether to integrate the conventional nutrition education or IEC/BCC interventions to our nutrition sensitive interventions or to look for other sustainable means of channeling our important message on optimal maternal, infant and young child nutrition practices.
Pastoral Community Platforms
Among the rural pastoral communities of Ethiopia’s Somali Regional State, VSF-Suisse has used the community platforms of Pastoral Field Schools (PFS) and Village Community Banks (VICOBAs) to improve communities’ resilience to recurring episodes of drought and other emergencies. The PFS approach is an adaptation of the interactive Farmer Field Schools (FFS) approach developed by the UN-FAO in Indonesia in 1989. They are groups of community members who meet periodically to pool their observations on livestock production and on rangeland management and to experiment new production systems. VICOBAs, meanwhile, comprise groups of mainly women who are trained and then meet regularly to organise collective saving and loans for times of emergency or crisis.
Given that both of these pastoral community platforms are now integrated features of their communities, they have shown to have tremendous cumulative benefit by equipping them with critical nutrition-related messages.
The BCIN-Action Research
The action research entitled ‘Behavioral Change for Improved Nutrition among pastoralists in Ethiopia’ (BCIN) thus intended to bridge the knowledge gaps by providing the scientific evidence on the outcome of integrating Behavioral Change Communication (BCC) interventions into the routine activities of the existing pastoral platforms, the PFS and VICOBA groups.
BCIN was a quasi-experimental research conducted in two pastoralist districts, Moyale and Mubarek of Somali Region of Ethiopia. The action research evaluated both intervention communities and comparison communities where the intervention did not take place with the aim of appraising the impact of channeled messages on key nutrition practices. In line with this, a total of 942 mothers having children 0-23 months were interviewed, 471 of them were in each study leg.
As a result, the number of mothers who heard about exclusive breastfeeding, optimal young child feeding practices, food safety and personal hygiene through the PFS and VICOBA were higher for the intervention communities compared to the comparison communities.
One of the main findings of the action research shows that exclusive breast feeding, food safety and hygiene are influenced by the mother’s age, educational status, income, and prior information on the issues. It is also observed that 85.5% of the mothers in the intervention groups reported receiving the information through the community platforms compared to 14.2% from other sources. Also, the action research found out that pastoral- community platforms have potential for channeling messages on key maternal, infant and young-child nutrition practices.
[1] MDG report of Ethiopia, 2014
[2] Ethiopian Demographic Health Survey, 2016
[3] Ethiopian Demographic Health Survey, 2016
Agriculture for improved nutrition and health
Our project partners Egerton University, Kenya convened a workshop Agro-biodiversity and Dietary diversity for optimal nutrition and health on Tuesday 22nd August, 2017 at the ARC Hotel Egerton University, Kenya. Forty-Five participants from academia, Ministry of Health, Ministry of Agriculture and NGOs working on Agriculture, nutrition and health gathered together with representative from County Government to discuss the important issue of tackling malnutrition and links between agriculture and Nutrition. See workshop report.
They have also written a blog Agriculture for improved nutrition and health
Guidance note on Nutrition sensitive social protection and agriculture
Transform Nutrition has produced a Guidance note for donors and national government based on our 6 years of research mainly in Bangladesh and Ethiopia on Nutrition sensitive social protection and agriculture. This note highlights 3 key areas for action.
Enabling environments for nutrition
We have been working with Eldis to produce a key issues guide on Nutrition leadership and Capacity. The guide summarises all of Transform Nutrition research which has sought to answer the question – how can we build commitment to, and accountability for, scaling up nutrition-relevant actions? Eldis key issues guide : Enabling environments for nutrition
The role of social protection and agriculture in tackling chronic undernutrition
We have been working with Eldis to produce a ‘key issues guide’ which summarises all of the research Transform Nutrition has done on How to maximize the impacts of investments in agriculture, social protection and women’s empowerment on nutrition. Eldis key issues guide : The role of social protection and agriculture in tackling chronic undernutrition
Nine key ingredients for transforming nutrition delivery
We have been working with Eldis to produce a ‘key issues guide’ which summarises all of the research Transform Nutrition has done on how to choose the best interventions and delivery strategies to scale up nutrition. Nine key ingredients for transforming nutrition delivery- Lessons from a series of country-level case studies.
The right nutrition intervention bundle in the first 1000 days for a fair start to life
Blog by Masum Billah and Mohd Anisul Karim, icddr,b
In current times, human capital is regarded as essential to the growth and development of nations. Factors that impede investment in the development of human capital hinder national development, arrest economic progress and deprive the country the benefits of globalization. One such adverse factor is stunting – a condition where an individual does not grow in length as they should in utero and over the first 5 years of life.
The first 1000 days encompasses the period from conception up until the child is 2 years of age. The height of the child at this age is the single best indicator of how well-off, cognitively and economically, a person will be down the road. Nutrition during this critical period is crucial to influence stature and later life outcomes. However, intuitively, many people think that everyone would have different growth trajectories during this period and that this would be influenced heavily by our genetic make-up. In reality, provided optimal environmental conditions, all children, regardless of where they live, were found to grow at similar rates in utero.
This makes research on what interventions work, can be delivered to everyone, are cost-effective and can bring about changes in a single generation – of utmost importance. To fill the evidence gap on an appropriate combination of preventive nutrition interventions, a cluster randomized trial is being conducted in a food-insecure zone of Bangladesh. The policies underpinning investments based on this research is expected to be transformative in developing counties with a high undernutrition burden. This research, funded by Transform Nutrition and led by researchers at icddr,b –attempts to explore how the right nutrition interventions can be delivered at scale to optimize human growth as capital for national and global development.
Large-scale community-based trials and their systematic reviews have demonstrated what works when implemented at scale. We know that awareness of the problem is important to drive care-seeking behaviour, and being educated makes people more likely to seek the right help. We also know that mothers appropriately counselled tend to adopt healthier practices during and after pregnancy. Counselling for exclusive breastfeeding and weaning at the right time result in a significant increase in these practices. We also understand that in resource-poor settings, nutritional supplements may improve dietary diversity. Thus, a more pertinent question, perhaps, is what combination of counselling (during and after pregnancy) and supplement (or absence of it) gives us the best value for money. This “bundling of nutrition interventions trial” currently taking place in Bangladesh is an attempt to answer a) the combined effect of the different intervention combinations, and b) if there is any evidence of synergy between prenatal and complementary feeding supplement on stunting prevention.
The TN Bundling study has 3 interventions bundled in different combinations in 4 arms with the 5th arm being the comparison group:
- First arm: delivers a validated counselling strategy to promote maternal nutrition during pregnancy, exclusive breastfeeding and complementary feeding, along with prenatal nutrition supplement for pregnant women and complementary food supplement for the child from 6 to 24 months of age.
- Second arm: provides the counselling intervention with prenatal supplementation only.
- Third arm: combines the same counselling intervention as above with post-natal supplementation for the child from 6-24 months of age.
- Fourth arm: pregnant women in this arm receive only the counselling intervention.
- Fifth arm: where participants will continue to follow existing practices as is.
All interventions are being delivered door-to-door by community health workers. Pregnant women are enrolled in early pregnancy and are followed up until the children reach their second birthday. The child’s height for a given age will reflect the effectiveness of the intervention bundle in each of the 4 arms compared to the comparison arm.
We will also be exploring changes in mother and child’s dietary and hygiene practices, and childhood gut infections that have huge impact on health. A comparatively novel approach used in this project is a bespoke electronically guided (tablet-based) intervention delivery and data collection platform for all staff, and a web-based real-time monitoring system for supervisors. Further details of the study can be accessed here.
The preliminary results of the trial are due in 2018. Choosing the right combination of interventions, based on the trial findings, will help policymakers in Bangladesh and other developing countries to make data-driven budgetary decisions. This will ultimately build on the demographic dividend Bangladesh has already achieved and accelerate our progress towards a middle income country.
Public-Private Partnerships and undernutrition: Examples and future prospects
In recent years, political commitment to reducing undernutrition has risen globally. Nutrition features prominently on development agendas, in prime ministerial speeches,
in international development discourse and in the media. The multisectorality of nutrition is better recognised with the corresponding need for engagement by multiple actors in different sectors and at different levels. While this has thrown a spotlight on the issue of private sector engagement in nutrition-relevant actions, looming over new initiatives that engage the private sector is a deeply suspicious nutrition sector. This research brief from Transform Nutrition Public-Private Partnerships and undernutrition: Examples and future prospects examines this issue.
New approaches to accountability in nutrition
Getting governments and others to step up to the challenges of undernutrition requires concerted efforts to build commitment, increase responsiveness and to hold these actors to account for their progress or its lack. For the past six years Transform Nutrition has been at the forefront of research and conceptual development on accountability and nutrition. This brief New approaches to accountability in nutrition describes the research, tools and approaches developed by the consortium to build, monitor and increase commitment, responsiveness and accountability in nutrition
