Country focus

The initial focus countries include BangladeshIndiaEthiopia and Kenya.

Bangladesh


Our partner in Bangladesh is the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). ICDDR,B plays a lead role in Transform Nutrition's research globally and hosts one of the two joint research directors, Shams El Arifeen. ICDDR,B is also responsible for research uptake in Bangladesh. Find out about the nutrition situation in Bangladesh.

India


Three consortium members work together under the Transfor Nutrition banner in India. These are Public Health Foundation of India, Save the Children India and theInternational Policy Food Research Institute. PHFI is the lead organisation for Transform Nutrition in India. Find out about the nutrition situation in India.

Ethiopia


Save the Children Ethiopia is responsible for research uptake in Ethiopia. The International Food Policy Research Institute provides the research lead role. Co-joint director of Transform Nutrition, John Hoddinott, with his extensive experience in food security in Ethiopia, is responsible for research. Find out about the nutrition situation in Ethiopia.

Kenya


Find out about the nutrition situation in Kenya.

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

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.

Transform Nutrition Learning Journey: Kenaw Gebreselassie, Amref Health Africa, Ethiopia

I am currently working as Communications Manager for Amref Health Africa in Ethiopia, the largest African-led  International NGO which works to ensure health equity by serving women and children and reaching the most disadvantaged and inaccessible communities. Before this, I worked for Save the Children’s Health and Nutrition team  as a Communications and Research Uptake Manager where I disseminated research findings, developed key messages and communications materials on health and nutrition, coordinated the SUN Civil Society Network, and advocated for better health and nutrition services.

However, I wasn’t exposed to nutrition issues until later on in my life. Drought, famine, and the government’s and its partners’ emergency response was all I knew about nutrition issues but I didn’t know about the bigger picture. I started learning more about nutrition at Save the Children, but the first formal training I received was on the Transform Nutrition short course in 2014, where I learnt about the key issues, case studies and country experiences. The short course gave me the confidence I needed to talk about the issues, which had a major impact on my advocacy work at Save the Children and it continues support my communications and advocacy efforts at Amref Health Africa.

For example, I was part of the communications working group at the Ministry of Health so I advised on nutrition advocacy and contributed research uptake materials. As part of this working group, I participated in the development of the nutrition communication section of the National Nutrition Program II, which is currently operational and contributed to Ethiopia’s first 1000 days campaign messaging.  At Save the Children, I coordinated, among other things a radio panel seminar with government representation from the Ministry of Health, Ministry of Agriculture, Ministry of Education, as well as Ministry of Women and Children’s Affair.

I have also used Transform Nutrition course materials to develop a media training programme that I have conducted all around Ethiopia. The media in Ethiopia tend focus on food security when covering nutrition related stories so the course teaches journalists how to spread nutrition related lessons, such as back yard gardening, the importance of diversity in diets, agriculture, and the impact of undernutrition on child development so they can present a more rounded and nuanced message for their audience.

 

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.

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.

Transform Nutrition Learning Journey: Arvind Singh, Matri Sudha, India

Matri Sudha’s mission is to help urban slum children in South East Delhi through social empowerment projects, bringing social change from the grass roots and mobilising people from within the community to uphold their rights.

Putting public health nutrition on the agenda

Public health nutrition is now a key focus area for the organisation but it wasn’t always our approach, nor was it my area of expertise. We came across a government report in 2012 which looked at child malnutrition in Delhi and I started reading more and more journals and learnt about how malnutrition is linked to various other aspects of adolescent health, diarrhoea, pneumonia, and child brain development and we also studied the laws, policies and programmes impacting food security and nutrition in India. It is now my dream, and Matri Sudha’s mission, to improve India’s nutritional status.

We started working at the grass roots level to improve the child and maternal welfare centres usually called ‘Anganwadi centres’ under the government’s Integrated Child Development Services (ICDS) scheme and to strengthen their linkages with the wider health systems. We work with adolescents, pregnant women, lactating mothers and children below the age of six on both preventive and curative aspects of malnutrition in early childhood years.

At Matri Sudha, I lead our work with families to improve their nutritional status, our research work, and our advocacy efforts to improve the nutrition governance issues in Delhi. As a result of Matri Sudha’s research, we filed a Public Interest Litigation in the Delhi High Court to implement the Food Security Act of 2013 and constitution of State Food Commission as an independent body to monitor the nutrition issues in Delhi.

Knowledge, Networks and Nutrition Champions

I enrolled in the Transform Nutrition Short Course in 2015 to deepen my knowledge and I remember on the very first day there was a moment when everyone stood up to introduce themselves – and then it was my turn. I stood up and I said I am neither a public health nutritionist nor a doctor, I am a social worker and I am here for 7 days to understand exactly what public health nutrition is all about.

I knew I wouldn’t understand everything in 7 days but I knew I could take whatever I did learn and incorporate it with my own work to improve our programing at Matri Sudha.

For example, on the third and fourth day of the course we had in-depth discussions about how to evaluate community based programmes. On my return, I discussed with my colleagues in Matri Sudha how our own programme could be revised to make sure the objectives were clear, that we understand why we are implementing the programme and how it can be evaluated. We now have a clear set of goals, objectives, outcomes and outputs so that we can monitor and evaluate its progress, identify challenges, and adapt our approach as we learn.

We have also adopted Transform Nutrition’s approach to supporting Nutrition Champions, who could be the primary care giver, school based nutrition champion or community health worker, or anyone promoting the overall goal of child nutrition within the community. We have developed a programme to identify and highlight the good work of people within the community in order to support their efforts and encourage others to do the same. So far, 12 such Nutrition Champions have been created as our first step toward improving the nutritional status within the community.

One of the key features of the Transform Nutrition course was that it provided a platform to express your views, share your opinions and an excellent opportunity to come into the network of people with different backgrounds and make good friends. For example, I have recently authored a review paper on Infant and Young Child Feeding Practices in India with a colleague I met on the Transform Nutrition short course.