Scaling Up Nutrition Research Articles

A strategy for scaling up vitamin A supplementation for young children in a remote rural setting in Zimbabwe

Background. Vitamin A deficiency is a public health problem in Zimbabwe. Addressing vitamin A deficiency has the potential to enhance resistance to disease and reduce mortality especially in children aged <5 years. Objective. To describe a vitamin A supplementation outreach strategy implemented in one of the remote rural districts in Zimbabwe, which increased coverage after being implemented in difficult circumstances in a remote rural region. Methods. We implemented and adapted a vitamin A supplementation outreach strategy within the national immunisation days (NIDs) and extended programme of immunisation in a remote rural district in Zimbabwe. The strategy involved supplementating children at prescheduled outreach points once per month for the whole year. Despite usual operational challenges faced at implementation, this approach enabled the district to increase delivery of vitamin A supplements to young children in the district. Results. The strategy covered 63 outreach sites, with two sites being covered per day and visited once per month for the whole year. Coverage reached 71% in an area in which previous coverage rates were around <50%. Conclusion. Implementing a vitamin A supplementation outreach strategy increased vitamin A supplementation coverage among children living in a remote rural region. This strategy can potentially be used by Scaling Up Nutrition (SUN) member states. However, we recommend further exploration of this strategy by others working in similar circumstances.

Strengthening strategic capacity for nutrition in four African countries (632.14)

Undernutrition has received significant attention at global and national levels in recent years, as evidenced by the Scaling Up Nutrition (SUN) movement with 43 participating countries and a G8 commitment of $4.2 billion to the Nutrition for Growth initiative, among others. The translation of this attention into effective action at the country level poses many challenges, as documented previously. Here we describe the results of an on‐going action research effort to address these challenges by strengthening strategic capacity in four Africa countries: Burkina Faso, Mali, Ethiopia and Uganda. All four of these countries have developed multisectoral national nutrition policies and/or plans of action, created coordinating committees and identified SUN focal points. Further multisectoral progress faces challenges seen elsewhere, such as the dominance of sectoral goals and incentives, uneven understanding of multisectoral roles, responsibilities and leadership; uneven participation and ownership; weak human and institutional capacities; lack of effective sub‐national multisectoral platforms; and the persistence of unaligned donor‐ and NGO‐driven approaches. Initial efforts to address these challenges by facilitating informal strategic and adaptive management approaches reveals second order constraints such as high turnover of key staff in and out of government, heavy workloads, rigidity and risk avoidance. Ongoing work focuses on formation of strategic alliances, leadership development, the strengthening of sub‐national experiences to inform the design of multisectoral strategies at the national level and strengthening linkages with global initiatives.Grant Funding Source: Supported by UNICEF

Differential Risk Perceptions toward Illness guide development of a prevention of stunting intervention in rural Mozambique (LB477)

Objective: To inform the behavior change communication (BCC) component of a stunting prevention program in Cabo Delgado, Mozambique, the World Food Programme (WFP) supported the government’s Scaling Up Nutrition (SUN) movement to understand how community members perceive the risk of young children’s illnesses associated with poor nutritional status.Methods: Among community leaders and caretakers of children under 2 years in Macua and Mwani cultural groups, data were collected in a three‐phase, iterative process from May ‐ August 2013 using free listing (n = 80), pile sorting (n = 67), and in‐depth interviewing (n = 34). Free list illness terms were analyzed for statistical salience and pile sort data were analyzed using multi‐dimensional scaling (MDS). Interview data were coded inductively using a Grounded Theory approach.Results: Biomedical nutrition illness terms are largely absent from the cultural domains of the groups studied. The most important illnesses to the Macua group include malaria, stomachache, and headache, whereas the most salient illnesses to the Mwani group are cough, stomachache, and fever. Community members do not associate the causes of these illnesses with food and nutrition, but do categorize their signs and symptoms in relation to perceived severity. Stunted growth, wasted or emaciated appearance, and slowed cognitive development are perceived to be less severe than other disease signs and symptoms.Conclusion: Behavior change models posit that a person’s perceived susceptibility and severity of a health problem are important for his or her behavior change. Because our results indicated that among these cultural groups, illnesses associated with poor nutritional status were not considered important threats to a child’s health, WFP supported the government to develop a BCC strategy that appeals to other core cultural values of the ethnic groups rather than solely focusing on the program’s potential impact upon nutritional status. Widespread sensitization efforts were also made around chronic malnutrition prior to intervention roll out.

Approaches to Enhanced Political Will for Achieving Nutrition-Related Millennium Development Goals in Nigeria

Background: The year 2015 was set as the target to achieve the Millennium Development Goals (MDGs),including those that are directly linked with nutrition in Nigeria. However, the chances of meeting this target appear very slim as 2015 is here. Efforts geared towards meeting these targets have recorded little success due to myriads of challenges of which weak political ownership takes a vantage position; coupled with lack of specificity in coordination of nutrition programmes. This has contributed to low level of nutrition development because all the government ministries/agencies where nutrition programmes have been domiciled have their specific goals and nutrition is usually considered as add-on Programme. Objective: To examine tested approaches to achieving nutrition-related MDGs in Nigeria. Method: Review of literature and relevant national documents using a desk-review guide, which was developed in line with the goal of this presentation. Results: International agencies including the World Bank are becoming more involved in nutrition programmes and are passionate of the pivotal role of nutrition in the scheme of national development. However, learning from the success story of nutrition programmes in some sub-Sahara African countries, it is certain that proper coordination of nutrition programmes by an agency solely created by the national government is the missing link in the equation for enhanced nutrition development. Conclusion: Establishment of a full-fledged National Nutrition Council under the Office of the President will be an impetus required to kick-start effective coordination and mainstreaming of nutrition into all developmental agenda. This is in line with the global practice of scaling-up nutrition programmes at the national level.

‘FAN the SUN brighter’: Fortifying Africa nutritionally (FAN) – the role of public private partnership in scaling up nutrition (SUN) in West Africa

The scaling up nutrition (SUN) policy framework requires extensive public–private partnership (PPP). Malnutrition is multi-dimensional and should engage multi-sectoral platforms. The SUN policy however did not fully embrace the dynamics of harnessing PPP. The objectives of the present paper are to highlight the reasons for the apprehension around PPP and illustrate how effective coordination of PPP in West Africa has contributed to implementing large-scale food fortification with micronutrients as a complementary nutrition intervention. The experience of Helen Keller International (HKI) in scaling up food fortification was emphasised with understanding of the factors contributing to indifference by the international community to private sector contribution to SUN. The roles of different stakeholders in a PPP are elucidated and the process linked to who, why and how to engage. The private sector provides direct nutrition services while the public sector creates the enabling environment for the private sector to thrive on social values. Through this approach fortified vegetable oil and wheat flour are now reaching over 70% of the population in West Africa. As a neutral broker HKI coordinated and facilitated dialogue among the different stakeholders. The core competencies of each stakeholder were harnessed and each partner was held accountable. It concludes that multi-sectoral relationship must be transparent, equitable and based on shared mutual interests. The rules and values of PPP offer opportunities for SUN.

Commentary: Foetal growth, preterm birth and childhood undernutrition

The application of the World Health Organization (WHO) Child Growth Standards released in 2006 showed that in many lowand middle-income countries (LMICs), a child’s length is already compromised at birth. In this issue of the IJE, Christian and colleagues make an important contribution to understanding the extent to which foetal growth restriction contributes to childhood stunting and other indicators of nutritional status. The consortium of researchers, pooling data from 19 birth cohorts from LMICs, show that childhood undernutrition has its origins in the foetal period. Relative to children born adequate size-for-gestational age (AGA) and at term, the odds ratios of childhood (12–60 months) stunting associated with AGA and preterm; smallfor-gestational age (SGA) and term; and SGA and preterm; are 1.93, 2.43 and 4.51, respectively. A similar magnitude of risk is observed for wasting and underweight. Importantly, despite the large variation in the prevalence of both SGA and preterm birth, the risk of undernutrition associated with being born too small or too soon is comparable across populations and regions, reflecting common underlying causes of either foetal growth restriction or preterm birth. The results indicate a stronger association between SGA and stunting than between preterm and stunting. In contrast, preterm birth – which affects a smaller number of neonates – is associated with a higher risk of neonatal mortality, with relative risk ranging from 6 to 9 vs. SGA alone, which was consistently associated with a 3-fold increased risk. In 1998 we reported a first attempt to estimate the burden of intrauterine growth restriction in LMICs. Knowledge has evolved and today we are better able to estimate the large number of babies born each year too small or too soon. In other respects, however, past challenges remain. An important one is accurately assessing gestational age in LMICs in the context of antenatal care programmes. Furthermore, the definition of what constitutes ‘normal’ foetal growth continues to be hotly debated. At present, there is no classification system that incorporates both the clinical heterogeneity and the multi-causality of foetal growth disturbances reflecting the lower and upper ends of the distribution, including describing the different phenotypes associated with disturbed foetal growth. Ideally, a unified classification should be developed that is consistent with the definitions and terminology commonly used in postnatal life so that there is a harmonized approach to classifying disturbances in human growth from early pregnancy to childhood. An important component of such a system will be the availability of international standards for foetal growth and neonatal weight, length and head circumference for gestational age. Such standards should follow the prescriptive conceptual approach used to construct the WHO Child Growth Standards currently used worldwide. However, their utility depends on accurate measurement of weight, length and head circumference at birth, which is rare in LMICs. In these settings, in which either a large proportion of pregnant women do not have access to antenatal care or many births occur in the home, valid estimates of gestational age and accurate anthropometry birth measurements are difficult or impossible to obtain. Nevertheless, in an ideal world, their availability would enable us to move beyond the traditional maternal and child health indicator of low birthweight (<2500 g) which, as shown by Lee and colleagues, fails to identify most babies who are born either too small or too soon. The new evidence from Christian and colleagues is both timely and important. Timely, because it comes at a moment when international mobilization around malnutrition has never been stronger, in particular with the Scaling Up Nutrition (SUN) movement (http://scalingupnutrition.org). Important, because it shows that efforts to tackle the scourge of undernutrition and its perverse effects on human health and development will not succeed without paying Published by Oxford University Press on behalf of the International Epidemiological Association

The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction

Advocacy represents an intervention into complex, dynamic and highly contextual socio-political systems, in which strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback. For this reason, the practice of advocacy is often considered more art than science. However, capacities and practices for advocacy can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. Nutrition is a particular context for advocacy, but to date, there has been little systematic analysis of experiences. The purpose of this paper is to illustrate and draw lessons from the practice of nutrition advocacy, especially in relation to stunting and complementary feeding, and suggest ways to strengthen capacities and practices in the future. The strategies and tactics, achievements and lessons learnt are described for three case studies: Uganda, Vietnam and Bangladesh. These cases, and experience from elsewhere, demonstrate that concerted, well-planned and well-implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through the SUN (Scaling Up Nutrition) movement and other initiatives, there is now a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity-building.

Delivery platforms for sustained nutrition in Ethiopia

The revised national nutrition programme spanning 2013-15 will address these challenges by emphasising the first 1000 days of life with a focus on children younger than 2 years pregnant and lactating women and adolescent girls to break the intergenerational cycle of malnutrition. Furthermore the revised programme will emphasise actions for acceleration of stunting reduction by focusing on nutrition-sensitive interventions in other development sectors such as education agriculture social protection and women’s affairs and civil society organisations and the private sector. The role of health extension workers and the health development army will continue to be central to achievement of equitable access of all vulnerable women and children to both curative and preventive services and to ensure that targets specified in the health sector development plan IV of Ethiopia are met. Ethiopia’s actions have enabled development workers to engage people at risk in an integrated manner using a unified Health Extension Programme enabling achievement of great gains in child survival and nutrition. The Government of Ethiopia on the basis of experiences in the past 10 years of this programme and the substantial improvements in nutritional status believes that even greater efforts can be made to reduce stunting. The government will continue to optimise the revised national nutrition programme and the global efforts on nutrition such as Scaling Up Nutrition (SUN) and Renewed Efforts Against Child Hunger (REACH) which are mechanisms to catalyse further multisectoral nutrition-sensitive actions beyond the health sector. Nutrition as one of many crucial indicators of health status should be used for close programmatic linkages and synergies between targeted social protection interventions. These synergistic actions across social services will contribute towards increased resource allocation for the national nutrition programme and ensure that sustainable interventions are scaled up to improve food and nutrition security. (Excerpt)

ASEAN: Insights and Considerations toward Nutrition Programs

In July 2011 the Global Alliance for Improved Nutrition (GAIN) and the World Food Programme (WFP) held a symposium to discuss important nutrition issues in the Association of Southeast Asian Nations (ASEAN) countries. With a focus on micronutrient deficiencies and stunting stakeholders ranging from Ministry of Health participants to leaders of local nongovernmental organization elaborated on pressing nutrition issues in the region and debated strategies to tackle the prevalence of malnutrition. The region still faces high prevalence rates of micronutrient deficiencies and stunting despite Southeast Asia’s progress in reducing mortality rates and its economic growth over the past few decades. Failure to achieve recommended daily intakes of at least some micronutrients (most commonly vitamin A iron calcium riboflavin and iodine) is documented by survey data from almost every part of the region. Stunting and micronutrient deficiencies have detrimental impacts on childhood development and morbidity and according to experts the situation is unlikely to drastically improve in the long term due to food supply shortages. In this context health and nutrition interventions need to synchronize with national government policies to reduce malnutrition as well as obesity. The 1000 Day Window of Opportunity Initiative and the Scaling up Nutrition (SUN) movement provide important strategic framework for these kinds of interventions. The role of the private sector is an integral part of the SUN movement to which some ASEAN countries have already signed up. This supplement highlights some of the pressing issues important for nutrition programming and shares highlights and experiences from ongoing programs addressing malnutrition and micronutrient deficiencies. In mirroring the diverse and rapidly changing ASEAN region the topics of the papers range widely from highlighting the problem of stunting to presenting models of more effective food fortification.

Ensuring optimal breastfeeding and improvements in complementary feeding to improve infant and young child nutrition in developing countries

Ensuring optimal breastfeeding and improvements in complementary feeding to improve infant and young child nutrition in developing countries

The elephant moves into the sunlight: progress in childhood malnutrition

Beginning with a historical summary of investigative work into protein-energy malnutrition, now termed ‘severe acute malnutrition’, this review ends by summarizing recent initiatives to tackle the global problem of malnutrition, specifically Scaling-Up Nutrition (SUN). In early years, macronutrient deficiency or imbalance was considered the principal cause of complex metabolic disturbances, including kwashiorkor, whereas, now, micronutrient deficiency infections, including HIV, and a background of deprivation are implicated. Different approaches to management are reviewed. The rehabilitation of individual children by protocolised-phased feeding has largely given way to community-based therapeutic feeding. Despite sporadic successes, the overall impact on morbidity and mortality has been so disappointing that the global community now plans a new initiative, viz. SUN. Its focus on the critical window of 1000 days (from conception to 2 years) is similar to the earlier focus on early childhood vulnerability which inspired the under-5 clinics and their integration into maternal and child health programmes. ‘Targeted’ interventions, recently more prominent than integrated community-based primary care, often undertaken by NGOs, have been effective, although sometimes imperfectly accountable. Will SUN, aiming for a broad approach, and the participation of recipient communities finally succeed in integrating nutrition into child health?