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

2017 Transform Nutrition South Asia symposium report

The Transform Nutrition Research Consortium convened the research symposium ‘Evidence for action in South Asia’ on Saturday 8 July 2017, at the Yak and Yeti Hotel, Kathmandu, Nepal. Over a hundred participants from NGOs (national and international) and academia working on nutrition, health and public health, rural and social development gathered together with government officials from Nepal, India and Bangladesh, donor agency representatives and journalists to discuss the important issue of tackling undernutrition in South Asia

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:

  1. 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.
  2. Second arm: provides the counselling intervention with prenatal supplementation only.
  3. Third arm: combines the same counselling intervention as above with post-natal supplementation for the child from 6-24 months of age.
  4. Fourth arm: pregnant women in this arm receive only the counselling intervention.
  5. 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.

2017 Transform Nutrition East Africa symposium report

The Transform Nutrition Research Consortium convened the research symposium ‘Evidence for action in East Africa’ on Thursday 8 June 2017, at the Southern Sun hotel, Nairobi, Kenya. A hundred participants from NGOs and academia working on nutrition, health, child welfare and development gathered together with government ministers from Kenya and Ethiopia, donor agency representatives and journalists to discuss the important issue of tackling undernutrition in East Africa.

Reflections on the Evidence for Action in South Asia

Patrizia Fracassi, Senior Nutrition Analyst and Strategy Advisor for the Scaling-Up Nutrition Movement Secretariat and member of the Transform Nutrition Consortium Advisory Group gives her reflections.

It has been an incredible privilege to be part of the Transform Nutrition Consortium Advisory Group and to have participated in this Symposium in Kathmandu. The work carried out by Transform Nutrition shows that, in order for the research agenda to be cutting edge, opportunities have to be seized upon and worked with through engagement of key stakeholders, such as academia, research, policy makers, implementers and advocates.

The evidence for action in South Asia generated by Transform Nutrition will help to build bridges in the complex and evolving landscape of nutrition. It highlights with lessons from Bangladesh and India how essential it is to integrate nutrition into health systems. But it also demonstrates that the engagement of frontline workers remains challenging. As illustrated by Kavita Chauhan (PHFI), explaining the story behind the data is vital to increase synergies among people and bring delivery at scale. Findings by Shilpa Deshpande (IDS) were helpful to unravel the identity politics among service providers while the presentation by Rasmi Avula (IFPRI) clarified the incentives that are motivating frontline workers in India. If we want to improve the quality of nutrition services and address challenges of low utilization, we need to understand people and get more of this type of evidence.

We know that Governments invest in social protection programmes. But how do we make them work for nutrition? The results from a study in Bangladesh by Akhter Ahmed (IFPRI) confirm that adding intensive Behaviour Change Communication to cash transfer programmes provides the greatest gains for nutrition. Yet, more research is needed on how this can be replicated at scale. The diagnostic by Suman Chakrabarti (IFPRI) on how big drivers of social spending can be analyzed using a nutrition lens could be applied beyond India. If a large-scale programme fulfills its basic mandate, is it feasible to work with implementers and budget holders to incorporate nutrition goals and actions? This type of assessment is timely to explain the politics of financing and ensure that assumptions are studied before important decisions are made.

I had the privilege to chair the session on the Stories of Change together with Zivai Murira (UNICEF) and to hear from the evidence from Nepal, Bangladesh and the Indian State of Odisha. It was an inspiring and motivating session. The Stories of Change led by Stuart Gillespie (IFPRI) have the greatest potential to reach out to communities beyond nutrition. They link together and explain which factors are important in each context. These factors touch upon different sectors, calls for a variety of stakeholders to get engaged and show that multi-disciplinary teams can help to clarify lessons from the past and highlight future scenarios.

It is encouraging to see how the quantitative work by Derek Headey (IFPRI) to analyze the drivers of nutritional change has been applied and customized in the three countries. The presenters – Kendra Cunningham (Nepal), Masum Billah (Bangladesh) and Neha Kohli (India) – demonstrated that the right enabling environment was the required factor in each country but the triggers were specific to each situation. A key take away for me was that a committed and accountable leadership such as the one in Odisha State and Nepal brought together the evidence and the coherence required to enable the change. This would have not been possible, however, without the championship demonstrated by a wide range of stakeholders in moving the nutrition agenda forward.

Transform Nutrition shows that the evidence for action is there and that people can effectively work together to deliver nutrition. This is the time to reach out to all actors with a stake on nutrition. As highlighted throughout the Symposium, a better understanding of the people, be they mothers, caregivers, frontline workers, advocates or leaders, will enable us to act upon every opportunity and bring the change.

Transform Nutrition Learning Journey: Tomaida Msiska, EU Delegation, Malawi

When I was growing up in Malawi we tended to link marasmus and kwashiorkor to bewitching – we never linked it to malnutrition. However, I gradually learnt more about food groups at secondary school and University. I started to become more interested in the topic when I was working as Food Security and Nutrition Research Assistant alongside nutritionist in the Area Based Child Survival Development Programme at UNICEF. After a stint as a Government Economist I decided to study the subject and I completed a Masters in Medical Science Human Nutrition in 1997. However, it wasn’t until 17 years later that I would eventually take on a role where I could put this knowledge into practice.

I had been working on diversification of agricultural incomes, marketing and food security issues at the EU Delegation in Malawi for 10 years when in the framework of the 2012 London GlobalHunger Event,the EU made a global commitment to tackling undernutrition. We needed to realign our country programming and because of my background I had an opportunity to take on a lead role. However, after so long without practicing nutrition I really needed to reconnect with the issues and refresh my knowledge so I enrolled in the Transform Nutrition Short Course in 2014.

That one week was very helpful. They approached nutrition from a holistic perspective and presented it as a medical issue as well as a developmental issue. This made me more equipped to engage with stakeholders across the board, instead of looking at it from just one perspective.

The key outcome from the course was a realisation that we needed to carry out a mapping exercise in the nutrition sector in Malawi so that our planning and programming could be informed by what is already happening within the sector. We were able to get all the key development partners and the Government to rally behind this idea and as a result of the mapping, we have now developed a holistic multi-sectoral integrated Four Pillar Approach to addressing nutritional issues that scales up successful previous and existing initiatives and provide a platform for discussion between the different partners.

In July 2015 the Government through the National Nutrition Committee adopted the Four Pillars Approach, and now all partners supporting the government use this framework to coordinate and structure their programs in the countryto ensure the national objectives will be achieved.

The Four Pillar Approach

Pillar 1:    Agriculture for food and nutrition security and improved maternal, infant and young child care and feeding

Pillar 2:    Health – primary health care, therapeutic care, support and treatment and WATSAN:

Pillar 3:    Integration of behavioural change and communication for optimal maternal and young child feeding and care (knowledge, attitudes and practices) among communities, learners, professional and frontline workers through nutrition education

Pillar 4:    Governance, human capacity building, research, monitoring & evaluation and fortification.

We have also developed Afikepo, an EU programme to take forward and support the Four Pillar Approach. It translates from the local language as ‘let the children develop to their full potential’ and it has become a moto of some sorts for nutrition programming in Malawi.

Therefore, I took lessons from the 2014 course and applied them in Malawi, which now has the second largest EU nutrition programme in the World. However, I have also enrolled in the 2017 Transform Nutrition Short Course so I can build on my experiences, gain more insights and further improve our programmes and approaches in the country.

Reflections on the East Africa Transform Nutrition Symposium

Grainne Moloney, Head of Nutrition in Kenya for UNICEF and member of the Transform Nutrition Consortium Advisory Group gave her reflections on the day at the end of our meeting in Nairobi on 8 June 2017.

“Thanks to all for coming today and for your excellent participation. I do feel we are all very privileged to have been able to be here today and have access to such important and cutting edge research that we can immediately take back and apply to our work. Most of the time we are all too busy to reflect on the new papers/ evidence being published so today we had the opportunity to come together in our different communities from Government, academia, research, policy makers, programmers all with a common goal of how to improve the nutritional situation of children in Africa. We had time to openly discuss the latest findings and opportunities of application – this is rare. We also must acknowledge that most regions in the world are now seeing reductions in the absolute numbers of stunted children, with the exception of West Central East and Southern Africa so the learning from today is vital to help us all to get the numbers and indicators moving downwards by applying this learning immediately in our day to day work. The fact that you are all still here after 5pm on a weekday given we are now deep in traffic in Nairobi, also shows your interest in today’s meeting and on behalf of you all I would like to specifically thank the Transform team and the local organizing team of Save the Children for arranging and inviting us all to such an interesting and successful day.

So to provide a quick summary of the 4 sessions: Agenda here

o Session one  ~ Stories of Change in Nutrition: Africa set the basis of what works in terms of success stories in stunting reduction based on a review of several case studies- we learned the key common drivers and factors that need to be in place to reduce undernutrition and the case studies illustrated a common theme over and over again. While as a community we have struggled to find the silver bullet to reduce stunting from the quantitative side – now we know the important factors that do have an impact and that it doesn’t have to take generations, that changes in the short term are possible with the right enabling environment – this is something all of us today can carry back to our countries – where we can all write our own story of change and review where we are and what areas we need to focus on more.

o Session two ~ Nutrition sensitive social protection brought the latest evidence on the very topical areas of social protection and nutrition – with 2 solid country examples from Ethiopia and Kenya as well as the review of other studies by John Hoddinott on the potential for its role in stunting reduction. We know the research from Latin America has shown good results – but we have yet to see these same results in Africa – why is that – what are the issues and learning around targeting, monitoring, transfer value and what do we need to consider when we design such programmes. The experience from Ethiopia and Kenya clearly highlighted the evolution of the large Government led programmes for the most vulnerable populations and that over time they are becoming much more nutrition sensitive. It is important to recognize these are dynamic programmes whereby we, as the nutrition community, now need to be more proactive and be at the table to advocate for increased nutrition sensitivity in the design. And let’s generate that evidence for Africa as this is a gap and let’s look at the wider welfare programmes also as an opportunity to influence — and not just cash transfers as ultimately this is the future for support to our vulnerable communities.

o Session three ~ Transform Nutrition research from Kenya and Ethiopia then highlighted several innovative research studies supported by Transform Nutrition that aim to improve nutrition outcomes. The studies ranged from technological innovation in terms of using handheld devices in nutrition programmes which looked not just at the time saving side but also on efficiency and quality assurance to new approaches in using Social Returns on Investment (SROI) and giving a new importance and value to people’s perceptions of caring for their children. Finally we heard 2 case studies that reinforced some of the earlier learning on social protection, that if we don’t make that connection to the household and the behaviors and needs of that household in the design of our programme and only focus on the supply side such as increased production, we will not have an impact on improving nutrition outcomes.

o Session four ~ Leadership in nutrition was a highly inspiring and motivating session where we had the privilege to learn from Transform’s nutrition champions who through their commitment energy and belief in their work- have made extraordinary influence and gains in their sector. Again common themes emerged through each of the stories- and we can all take something from them. The role of leader also was highlighted but not always in the traditional sense of a senior Government official but in all the work we do – we can all be champions to improve the agenda , also the stories highlighted it is not always easy , there are often conflicts of interest that we have to manoeuver but some of the key learning was the importance of getting people together, having a common vision, dealing with the challenges and being self aware of what is possible- so let’s all take inspiration from these great women and do our bit to get nutrition on the agenda in our countries.”

Transform Nutrition Event: Evidence for action in South Asia

From 2011-2017 Transform Nutrition has been strengthening the content and use of nutrition-relevant evidence, to accelerate the reduction of undernutrition.

On the 8th July 2017 in Kathmandu, Nepal, it will host a regional meeting; ‘Evidence for action in South Asia the day before the joint ANH Academy Week and Feed the Future Innovation Lab for Nutrition Agriculture-Nutrition Scientific Symposium, to highlight experiential learning from South Asian countries on key drivers to improve nutrition status.

It will feature evidence on what works in nutrition-sensitive interventions, presented to policymakers from Nepal and international donors and NGOs in the South Asia region. The meeting aims to inform and equip attendees in order to address the particular challenges of tackling child undernutrition in their current contexts. See agenda.

Back to the storyboard

by Stuart Gillespie

What knowledge is needed to ride a bike? Is it enough to have a manual?  Of course not… you need to get on the bike, fall off, get back on again… and eventually you’ll figure it out. The manual may provide information on “what” to do, but knowledge of “how” to do it is tacit knowledge that can only be acquired from experience.  This important distinction was made in “The Concept of Mind” (1949) by Gilbert Ryle, a British philosopher – between “knowing that” and “knowing how”. In nutrition, as in many development arenas, we have a wealth of knowledge products (guidelines, toolkits, checklists) that focus on “what to do” but not enough documented experience of attempts (some successful) of how to do it. [Read more...]