Nutrition program design and planning
6 likes4,576 views
This document summarizes the Nutrition Program Design Assistant tool, which was created by CORE Group and partners to help program planners design community-based nutrition programs. The tool includes a reference guide and workbook. The reference guide provides guidance on analyzing the nutrition situation, identifying appropriate program approaches, and selecting a combination of approaches based on the situation, resources, and objectives. It outlines six steps for using the tool: 1) gathering and synthesizing nutrition data, 2) determining program goals and objectives, 3) reviewing existing health services, 4) preliminary prevention program design, 5) preliminary recuperation program design, and 6) finalizing the programming plan including costing. The tool was developed with input from many organizations to help
![ESSENTIAL NUTRITION ACTIONS
11
The ENA encompass a menu of recommendations for key optimal infant and young child feeding behaviors, maternal nutrition
behaviors and micronutrient intake for women and children to be promoted at facility services, and during community‐based
activities and home‐based care.
12
Pre‐lacteal feeds include any food or liquid other than breast milk given to a child in the first three days of life.
13
International guidance on optimal feeding of children 6‐23 months can be found in PAHO. 2003. “Guiding Principles for
Complementary Feeding of the Breastfed Child 6‐23 months:
http://www.who.int/child_adolescent_health/documents/a85622/en/index.html and WHO. 2005, Guidance for Feeding non‐
breastfed children 6‐24 months: http://whqlibdoc.who.int/publications/2005/9241593431.pdf
7
KEY CONCEPTS
The ENA are seven affordable and evidence‐based nutrition interventions delivered at
health facilities and communities to improve the nutritional status of women and
children.11 The ENA provide a holistic framework on which to base nutrition programming.
The ENA framework maximizes coverage of these interventions by delivering key messages
and services through multiple contact points in relevant nutrition, health and social sector
programs, and especially focuses on six critical contact points: prenatal visits, delivery
care, postpartum care for mothers and infants, immunization, sick‐child visits and well‐
child visits (including counseling and growth monitoring and promotion [GMP]). The seven
ENA are:
1. Promotion of optimal breastfeeding during the first six months
Promote early initiation of breastfeeding (i.e., within one hour of birth); do not give
pre‐lacteal feeds12
Promote exclusive breastfeeding (EBF) for the first six months of life (i.e., no other
liquids or foods)
Promote breastfeeding on demand, day and night (i.e., usually 8‐12 times per day) for
an adequate time at each feeding; offer the second breast after infant releases the first
Practice correct positioning and attachment of infant at the breast
Promote good breast health care
2. Promotion of optimal complementary feeding starting at 6 months with continued
breastfeeding to 2 years of age and beyond13
Continue frequent, on‐demand breastfeeding through 24 months of age and beyond
Introduce complementary foods at 6 months of age
Prepare and store all complementary foods safely and hygienically
Increase food quantity as child gets older
o 6‐8 months: 200 kcal/day from complementary foods
o 9‐11 months: 300 kcal/day from complementary foods
o 12‐23 months: 550 kcal/day from complementary foods
Increase frequency of feeding complementary foods as child gets older
o 6‐8 months: 2‐3 meals per day
o 9‐23 months: 3‐4 meals per day, 1‐2 snacks per day (as desired)
Increase food consistency and variety gradually as child gets older
Feed a variety of foods daily to ensure adequate nutrient intake, including animal
products, fortified foods and vitamin A‐rich fruits and vegetables](https://image.slidesharecdn.com/nutritionprogramdesignandplanning-131114072229-phpapp01/85/Nutrition-program-design-and-planning-14-320.jpg)
![Good quality local information will come from a KPC if one has been recently done in the
target area. Unfortunately, a KPC may not be available to you in the early program design
stage since it is generally conducted following the award of a grant. Excellent resources for
conducting a KPC with information on sampling, indicators, tabulation and survey tools
can be found at: www.mchipngo.net/controllers/link.cfc?method=tools_kpc_modules.
Ministry of Health (MOH) National Health Management Information System (HMIS)
Local MOH data can be useful, but interpretation must take into account that some health
facilities may not regularly provide reports and/or that data come from only those children
and women who actually use available health services and may not include more
vulnerable women and children with barriers to access. MOH data provides information
on health service delivery, but does not provide a complete picture of the health and
nutrition situation for all women and children (both users and non‐users). In addition,
MOH systems rarely gather important data on maternal and child feeding practices, which
is critical for designing any nutrition approach.
Other Local Surveys
There may be other surveys that have been conducted in the local target area by UNICEF
(or other United Nations [UN] agencies), national campaigns, NGOs, research institutions
and/or donor agencies.
STEP 1 PART II. GATHERING QUALITATIVE
INFORMATION
Step 1 Part II begins on page 12 of the Workbook.
Qualitative data will further your understanding of the implications of the quantitative
data and is key to understanding local practices, beliefs and cultural norms. Information
gathered at this stage for identifying appropriate interventions will help to tailor the
program to the local context and to develop implementation strategies. However,
programs will likely need to gather more detailed qualitative data during program
implementation.
The Food Consumption Summary Table in Step 1 Part II of the Workbook helps to
summarize the qualitative food consumption information that they team gathers. NPDA
users are encouraged to modify this table, using the MS Excel file available at
www.coregroup.org and www.fanta‐2.org, or you may use other formats. Program
planners should also keep a separate notebook to document additional qualitative data
that they collect (described on the next page).
16
GUIDE STEP ONE
Knowledge, Practice and Coverage Survey
1](https://image.slidesharecdn.com/nutritionprogramdesignandplanning-131114072229-phpapp01/85/Nutrition-program-design-and-planning-23-320.jpg)
![Qualitative data will assist the program in better understanding the quantitative data. The
list here summarizes broad categories of qualitative data that can help in nutrition
program development, and much of the information will be used in Step 3. The team
should include other pertinent qualitative data as appropriate.
Categories of qualitative information include:19
Food consumption practices: Which food groups are consumed by various target
groups, their availability in the market, and their accessibility to people of low
socioeconomic status. There is a Food Consumption Summary Table on page 12 of the
Workbook to record data.
National policies and protocols (This information will be needed in Workbook Step 3):
Key elements of nutrition‐related policies that the government has established (e.g.,
national nutrition policy, community health policy, guidelines on management of SAM,
infant and young child feeding [IYCF] policy, nutrition and HIV, micronutrient
supplementation)
Health services: Available services, distance to services, explanations of why people do
or do not use the health services, staffing, community perceptions of the health
services, quality assessments
Description of communities: Social structure of community and families,
infrastructure, including existence of and access to water and sanitation facilities,
government (committees, councils, leadership), community buildings, markets,
agricultural activities, information on community decision‐making process
Cultural beliefs and practices: Can cover a range of topics, including child care,
women’s and men’s roles in family and community, health and health care,
education/schooling
Livelihood sources and patterns: How people provide for themselves and their
families; where people access food (home production, purchase, food assistance),
seasonality of income and food access
Vulnerable groups: In many communities, there are often groups of people who are
more vulnerable than others because of ethnic discrimination, socioeconomic status,
geographic location, sex or age of household head, illness, sex, age or education level;
It will be important to find out who are the most vulnerable in any given community
and make sure the program is able to meet their needs
External context: Relative political stability, conflict, and/or natural disaster risk profile
Sources of Qualitative Data
You may have some recent and good‐quality qualitative data to draw upon that has
already been collected and summarized, which will save time and resources. Extensive
qualitative research resources exist and should be consulted. The resource section at the
19
Many of these categories were drawn from Nutrition Essentials: A Guide for Health Managers.
http://www.basics.org/documents/pdf/NutritionEssentials_English.pdf and Schoonmaker‐Freudenberger, Karen.
1999. Rapid Rural Appraisal (RRA) and Participatory Rural Appraisal (PRA): A Manual for CRS Field Workers and
Partners. Baltimore, MD: Catholic Relief Services.
17
GUIDE STEP ONE
Qualitative Data to Collect
1](https://image.slidesharecdn.com/nutritionprogramdesignandplanning-131114072229-phpapp01/85/Nutrition-program-design-and-planning-24-320.jpg)
![
Medical referral and treatment to address underlying disease burden, routine
deworming (mebendazole/albendazole), micronutrient supplementation (vitamin
A and iron) and vaccinations
Daily supplemental meals with a minimum number of calories and protein based
on WHO guidance64
Education, training and/or cooking demonstrations on how to prepare the food, if
supplemental foods are unfamiliar
A mechanism for follow‐up and monitoring weight gain
Medical referral, treatment, and nutrition support and counseling for children who
are not gaining appropriate weight or are losing weight in recuperative services
Behavior change and nutrition counseling to improve feeding and care practices
If the prevalence of SAM is of public health significance, a program to directly address
children with SAM is needed in addition to a program that incorporates the components
to address children with MAM. Ideally, the program would be community based with
strong links to health services including inpatient and outpatient management of SAM.
Any program for treatment of SAM should follow the national protocol for the
management of acute malnutrition and/or international WHO or CMAM protocols.
Incorporate the following minimum elements:
Community outreach for active case‐finding, referral and follow‐up at the
community level
Initial medical evaluation for diagnosis of medical complications, danger signs and
assessment of appetite
Routine treatment of children according to standard medical and nutrition
protocols for managing SAM 65
o Medical protocols include: Amoxicillin or second‐line antibiotic, vitamin A
supplementation for children with no edema who have not received a dose in
the previous 30 days, deworming after week one of treatment, measles
vaccination and malaria treatment in malarial areas
o Nutrition protocols include: Therapeutic feeding (RUTF for children 6‐59
months of age with no medical complications, therapeutic milk [F75 or F100]
for children with medical complications, no appetite or under 6 months of age)
Outpatient care provided using established national protocols or CMAM protocols
(if no national protocols exist) for children with SAM and no medical complications
Referral to inpatient facilities with 24‐hour care and staff trained in the
management of SAM, according to established national guidelines or WHO
guidelines (if national guidelines do not exist) for children with SAM with medical
complications, IMCI danger signs or a failed appetite test, or who have not gained
weight in outpatient care
64
Current WHO guidance suggests that supplemental feeding rations for the treatment of MAM should provide 1000 – 1200
kcal/person/day if there is a take‐home ration to account for family sharing. There are ongoing discussions about the best
treatments for MAM and guidance may evolve. The Management of Nutrition in Major Emergencies. 2000. Geneva: WHO.
65 FANTA Project, Concern Worldwide, UNICEF, and Valid International. Training Guide for Community‐based Management of
Acute Malnutrition. November 2008. http://fanta‐2.org/; and Valid International. Community‐based Therapeutic Care: A Field
Manual. 2006.
65
GUIDE STEP FIVE
Severe Acute Malnutrition
5](https://image.slidesharecdn.com/nutritionprogramdesignandplanning-131114072229-phpapp01/85/Nutrition-program-design-and-planning-72-320.jpg)
Nutrition program design and planning
- 1. Nutrition Program Design Assistant: A Tool for Program Planners Reference Guide April 2010 FANTA 2 FOOD AND NUTRITION T E C H N I C A L A S S I S TA N C E
- 4. Table of Contents ACKNOWLEDGMENTS ............................................................................................................. I INTRODUCTION ..................................................................................................................... 1 Background ............................................................................................................................... 1 Purpose ..................................................................................................................................... 2 Use ............................................................................................................................................ 2 . Nutrition Approaches Included ................................................................................................. 3 KEY CONCEPTS ....................................................................................................................... 4 Nutrition Concepts .................................................................................................................... 4 Essential Nutrition Actions ........................................................................................................ 7 HOW TO USE THE NPDA ...................................................................................................... 10 Use of Icons ............................................................................................................................. 10 Assumptions Made ................................................................................................................. 10 . Key Steps ................................................................................................................................. 11 STEP 1. GATHER AND SYNTHESIZE INFORMATION ON THE NUTRITION SITUATION .............. 14 Step 1 Part I. Gathering Quantitative Information ............................................................... 14 Step 1 Part II. Gathering Qualitative Information ................................................................ 16 Step 1 Part III. Synthesizing Data .......................................................................................... 19 STEP 2. DETERMINE INITIAL PROGRAM GOAL AND OBJECTIVES ........................................... 29 Forming Program Goals and Objectives .................................................................................. 29 STEP 3. REVIEW HEALTH AND NUTRITION SERVICES ............................................................ 31 Gathering Data on Health and Nutrition Services ................................................................... 31 Other Resources ...................................................................................................................... 32 STEP 4. PRELIMINARY PROGRAM DESIGN: PREVENTION ...................................................... 34 Step 4 Section A. Cross‐Cutting Approaches to Improve Nutritional Status ........................ 35 Step 4 Section B. Infant and Young Child Feeding ............................................................... 47 . Step 4 Section C. Maternal Nutrition ................................................................................... 54 Step 4 Section D. Micronutrient Status of Children ............................................................. 57 Step 4 Section E. Underlying Disease Burden ...................................................................... 61 STEP 5. PRELIMINARY PROGRAM DESIGN: RECUPERATION .................................................. 64 Develop and Strengthen Referral Systems ............................................................................. 64 STEP 6. PUTTING IT ALL TOGETHER ...................................................................................... 71 Costing Out the Nutrition Programming Plan ......................................................................... 71 ANNEX 1. TERMINOLOGY..................................................................................................... 74 ANNEX 2. RESOURCES .......................................................................................................... 79 REFERENCE GUIDE ACRONYMS AND ABBREVIATIONS ........................................................................................ III
- 9. PURPOSE The NPDA is a tool to help program planning teams, including those designing USAID Child Survival and Health Grants Program (CSHGP) or Title II food security program proposals, design the nutrition component of their programs and select the most appropriate community‐based nutrition approaches for their specific geographic target areas. A simple reference guide and workbook, the NPDA is best used in collaboration with a range of partners, including ministry staff, community leaders and representatives, and local organizations. The NPDA focuses on the design of preventive programs and is intended for use in areas where there is a high prevalence of stunting and/or underweight in children. The NPDA also provides guidance on recuperative approaches that may be included in preventive programs in areas that also have a high prevalence of acute malnutrition and a very high prevalence of underweight in children. USE The NPDA: Assists in developing programs and/or proposals, and can also be used in program reviews to reassess the design of nutrition programs that are not making progress Provides guidance based on the most recent consensus by experts on recommended interventions, approaches, protocols, and indicators for community‐based nutrition programming Focuses primarily on preventive programs that address stunting and underweight and may incorporate recuperative approaches to address acute malnutrition when necessary Emphasizes local community participation and ownership as part of the program design process: Community ownership and participation ‐‐ and community‐based participatory data collection and assessment tools ‐‐ are critical to the program design process. A technically “perfect” intervention or approach can be derailed if it does not address a community priority or value. Not only is it critical to build in sufficient time and resources for meaningful community participation and community mobilization as part of program implementation, it is important to incorporate the observations and recommendations from community members, local ministries and implementing 2 INTRODUCTION Working Group, local community‐based partnership organizations, United States Agency for International Development (USAID) technical experts and USAID technical assistance projects as well as the literature. The tool’s guidance on approaches, protocols and cutoff points is based on expert consensus documents such as joint statements made by United Nations Children’s Fund (UNICEF) and World Health Organization (WHO) because nutrition recommendations, protocols and best practices evolve and continually improve. Some of the recommendations might change over time, but the principles of using data to design programs based on nutrition needs, applying interventions and approaches that have a strong evidence base, and building the evidence base by continually testing, refining and documenting new/improved approaches will continue to be applicable.
- 14. ESSENTIAL NUTRITION ACTIONS 11 The ENA encompass a menu of recommendations for key optimal infant and young child feeding behaviors, maternal nutrition behaviors and micronutrient intake for women and children to be promoted at facility services, and during community‐based activities and home‐based care. 12 Pre‐lacteal feeds include any food or liquid other than breast milk given to a child in the first three days of life. 13 International guidance on optimal feeding of children 6‐23 months can be found in PAHO. 2003. “Guiding Principles for Complementary Feeding of the Breastfed Child 6‐23 months: http://www.who.int/child_adolescent_health/documents/a85622/en/index.html and WHO. 2005, Guidance for Feeding non‐ breastfed children 6‐24 months: http://whqlibdoc.who.int/publications/2005/9241593431.pdf 7 KEY CONCEPTS The ENA are seven affordable and evidence‐based nutrition interventions delivered at health facilities and communities to improve the nutritional status of women and children.11 The ENA provide a holistic framework on which to base nutrition programming. The ENA framework maximizes coverage of these interventions by delivering key messages and services through multiple contact points in relevant nutrition, health and social sector programs, and especially focuses on six critical contact points: prenatal visits, delivery care, postpartum care for mothers and infants, immunization, sick‐child visits and well‐ child visits (including counseling and growth monitoring and promotion [GMP]). The seven ENA are: 1. Promotion of optimal breastfeeding during the first six months Promote early initiation of breastfeeding (i.e., within one hour of birth); do not give pre‐lacteal feeds12 Promote exclusive breastfeeding (EBF) for the first six months of life (i.e., no other liquids or foods) Promote breastfeeding on demand, day and night (i.e., usually 8‐12 times per day) for an adequate time at each feeding; offer the second breast after infant releases the first Practice correct positioning and attachment of infant at the breast Promote good breast health care 2. Promotion of optimal complementary feeding starting at 6 months with continued breastfeeding to 2 years of age and beyond13 Continue frequent, on‐demand breastfeeding through 24 months of age and beyond Introduce complementary foods at 6 months of age Prepare and store all complementary foods safely and hygienically Increase food quantity as child gets older o 6‐8 months: 200 kcal/day from complementary foods o 9‐11 months: 300 kcal/day from complementary foods o 12‐23 months: 550 kcal/day from complementary foods Increase frequency of feeding complementary foods as child gets older o 6‐8 months: 2‐3 meals per day o 9‐23 months: 3‐4 meals per day, 1‐2 snacks per day (as desired) Increase food consistency and variety gradually as child gets older Feed a variety of foods daily to ensure adequate nutrient intake, including animal products, fortified foods and vitamin A‐rich fruits and vegetables
- 15. 14 Current WHO guidelines include iron supplementation for children, and all supplementation should be in line with national guidelines. However, guidelines for supplementation of children in areas where malaria is highly prevalent may be modified. A randomized, controlled trial in Pemba, Zanzibar, where malaria is highly endemic, showed that daily iron supplementation of all children resulted in a statistically significant increase in hospitalization. The adverse outcomes appear to have occurred in children who were iron replete prior to supplementation. Further research needs to be done, and iron supplementation recommendations 8 KEY CONCEPTS Practice responsive feeding (i.e., feed infants directly and assist older children, encourage children to eat, do not force feed, minimize distractions, show love to children by talking and making eye contact) 3. Promotion of optimal nutritional care of sick and severely malnourished children Continue feeding and increase fluids during illness o Child under 6 months of age: increase frequency of EBF o Child 6‐24 months: increase fluid intake, including breast milk, and offer food Increase feeding after illness until child regains weight and is growing well For diarrhea: provide zinc supplementation for 10‐14 days, according to WHO protocol For diarrhea: provide low osmolarity oral rehydration solution (ORS) to children over 6 months For measles: provide vitamin A treatment, according to WHO protocol Refer severely malnourished children for treatment according to WHO protocol, through community‐based management of acute malnutrition (CMAM), inpatient care, or other appropriate program 4. Prevention of vitamin A deficiency in women and children Breastfeed children exclusively for the first 6 months, and continue breastfeeding until the child is 24 months or older Treat xerophthalmia and measles cases with vitamin A, according to WHO guidelines Provide high‐dose vitamin A supplementation to children 6‐59 months of age, every six months according to WHO guidelines Provide post‐partum high‐dose vitamin A supplementation to women as soon as possible after delivery: o If breastfeeding, within eight weeks of delivery o If not breastfeeding, within six weeks of delivery Promote consumption of vitamin A‐rich foods, including liver, fish, egg, red palm oil, dark yellow or orange fruits (e.g. mango ripe and dried, papaya ripe and dried, apricots fresh and dried, persimmon), dark green leafy vegetables, and orange or dark yellow‐ fleshed vegetables, roots and tubers (carrots, pumpkin, squash, sweet potatoes). Promote consumption of vitamin A‐fortified foods, where available 5. Promotion of adequate intake of iron and folic acid and prevention and control of anemia for women and children Promote intake of iron‐rich foods, especially animal products and fortified foods Provide iron/folic acid (IFA) supplementation to all pregnant women; continue supplementation for three months post‐partum in areas with anemia prevalence greater than 40 percent Provide IFA supplementation for children14
- 16. in malarious zones may change. (Sazawal et al. 2006. Lancet Vol 367: 133). www.who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf 15 http://www.who.int/nutrition/publications/micronutrients/WHOStatement__IDD_pregnancy.pdf 16 WHO/UNU/UNICEF. 2001. Iron Deficiency Anaemia: Assessment, Prevention and Control. There is a chart on page 58 that indicates the recommended IFA dosages for different target groups. http://whqlibdoc.who.int/hq/2001/WHO_NHD_01.3.pdf 17 Ibid. 9 KEY CONCEPTS Deworm children over 12 months of age, pregnant women after the first trimester and lactating women according to WHO protocol in areas where parasitic worms are a common cause of anemia Prevent and control malaria o Intermittent preventive treatment for pregnant women o Long‐lasting insecticidal nets (LLINs) for women and children 6. Promotion of Adequate intake of iodine by all members of the household Promote consumption of iodized salt Supplement pregnant and lactating women and children 6‐24 months of age with iodized oil capsules when iodized salt is not available, according to WHO‐recommended doses15 7. Promotion of optimal nutrition for women Consume more food during pregnancy and lactation o Pregnancy: 285 extra kcal/day (one additional small meal each day) o Lactation: 500 extra kcal/day (1‐2 additional small meals each day) Increase protein intake during pregnancy and lactation (e.g., beans, lentils, legumes, animal source foods, oilseeds) Provide IFA supplementation for all pregnant women, according to WHO protocol16 Treat and prevent malaria Deworm during pregnancy (after first trimester) in areas where parasitic worms are a common cause of anemia Provide post‐partum vitamin A supplementation Promote consumption of iodized salt Supplement pregnant and lactating women with iodized oil capsules when iodized salt is not available, according to WHO recommended doses17
- 18. Geographic Targeting KEY STEPS Step 1. Gather and Synthesize Information on the Nutrition Situation Step 1 provides guidance on gathering and synthesizing data to: 1) determine whether implementation of a community‐based nutrition program is warranted in the setting; 2) identify potential causes of undernutrition and key intervention areas; and 3) decide whether the program will focus on prevention‐only or prevention and recuperation. Step 1 reviews data on: A. Nutritional status: Anthropometry B. Infant and young child feeding C. Maternal nutrition D. Micronutrient status of children E. Underlying disease burden The Workbook provides space for recording the data on each of the relevant indicators, conclusions on level of public health significance based on the tables in the Reference Guide, answers to additional questions for interpreting the data, and your final decisions on whether the specific intervention area should be a priority. Later analysis will help you determine whether you will attempt to address all of the priority areas. Result: Determination of program focus (prevention only or prevention + recuperation) and indication of priority intervention areas for addressing woman, infant and child nutrition Step 2. Determine Initial Program Goal and Objectives Step 2 guides the user to draft initial program goals and objectives based on the conclusions in Step 1, and to note information on other issues such as the funding available, community priorities, donor interests and organizational strengths. The goal and objectives drafted in Step 2 will be revisited in Step 6 after collecting and reviewing additional information. Result: Initial program goal and objectives 11 HOW TO USE This tool can be used to develop program approaches for any geographic level –local community, district, province or national. The level your team chooses should be based upon what is most useful for your planning purposes. The Quantitative Data Collection Tables at the beginning of the Workbook provides columns for geographic disaggregation of data in case you want to do an initial comparison of needs in making your final decision on the target area. The tool does not provide any additional guidance in geographic targeting, but assumes that your team already has substantial experience in choosing a geographic target area.
- 19. Result: Mapping of the existing capacity of local health and nutrition services at the community and facility level to inform subsequent decision making on appropriate nutrition approaches Step 4. Preliminary Program Design: Prevention Step 4 provides information on potential preventive approaches to deliver the priority interventions selected in Step 1. Information and guidance on various program approaches is provided in the Reference Guide. Summary tables of common approaches are included for rapid comparison and review. Questions are provided in the Workbook under this step to guide your thinking about assets, gaps and opportunities. Result: Listing of all potential preventive approaches that could be considered based on an analysis of the needs and assets in the target area Step 5. Preliminary Program Design: Recuperation Step 5 provides information on potential recuperative approaches that can be added to the preventive program, as necessary. The Reference Guide describes key components of recuperative interventions to address MAM, SAM and underweight and summary tables of common approaches that meet key criteria. The Workbook provides questions to guide team discussions and selection of recuperative approaches. Result: Listing of potential recuperative approaches that could be added to the preventive program, based on the situation in the target area 12 HOW TO USE Step 3. Review Health and Nutrition Services Step 3 guides the user through mapping what currently exists in terms of: National policy Service availability, access, and uptake Quality of services Availability of materials and equipment, to include information, education and communication (IEC) and behavior change communication (BCC) materials The Reference Guide provides guidance on collecting this information and the Workbook provides detailed questions and space for recording a summary of the national policy environment and a review of local services.
- 21. STEP 1. Gather and Synthesize Information on the Nutrition Situation GUIDE STEP ONE 1 Step 1 begins on page 1 of the Workbook. In Step 1 you will identify the areas of key public health significance to ensure that the approaches you select address the areas of greatest need. At the end of this step, your team will reach consensus regarding the overall program focus (prevention or prevention+recuperation) and intervention areas indicated as key public health concerns. In subsequent steps, you will decide whether your team will actually attempt to address each intervention area you prioritize in this step. This step provides guidance on gathering and synthesizing data in five areas of public health significance: A. Nutritional status: Anthropometry B. Infant and young child feeding C. Maternal nutrition D. Micronutrient status of children E. Underlying disease burden The guidance in this section covers: Part I. Gathering quantitative information Part II. Gathering qualitative information Part III. Synthesizing data STEP 1 PART I. GATHERING QUANTITATIVE INFORMATION Any good analysis starts with good data. Doing an analysis to determine appropriate nutrition interventions is no different. What is often challenging is sorting through the many potential indicators and types of information to determine which ones your team will use during decision making. Too much data can be as confusing as too little. Step 1 Part I of the Workbook helps your program to document necessary data. Quantitative Data Collection Tables A‐E identify which data are essential to use when prioritizing nutrition intervention areas (the numbered indicators). The tables also include additional indicators that programs may find useful to consider, but that are not 14
- 24. Qualitative data will assist the program in better understanding the quantitative data. The list here summarizes broad categories of qualitative data that can help in nutrition program development, and much of the information will be used in Step 3. The team should include other pertinent qualitative data as appropriate. Categories of qualitative information include:19 Food consumption practices: Which food groups are consumed by various target groups, their availability in the market, and their accessibility to people of low socioeconomic status. There is a Food Consumption Summary Table on page 12 of the Workbook to record data. National policies and protocols (This information will be needed in Workbook Step 3): Key elements of nutrition‐related policies that the government has established (e.g., national nutrition policy, community health policy, guidelines on management of SAM, infant and young child feeding [IYCF] policy, nutrition and HIV, micronutrient supplementation) Health services: Available services, distance to services, explanations of why people do or do not use the health services, staffing, community perceptions of the health services, quality assessments Description of communities: Social structure of community and families, infrastructure, including existence of and access to water and sanitation facilities, government (committees, councils, leadership), community buildings, markets, agricultural activities, information on community decision‐making process Cultural beliefs and practices: Can cover a range of topics, including child care, women’s and men’s roles in family and community, health and health care, education/schooling Livelihood sources and patterns: How people provide for themselves and their families; where people access food (home production, purchase, food assistance), seasonality of income and food access Vulnerable groups: In many communities, there are often groups of people who are more vulnerable than others because of ethnic discrimination, socioeconomic status, geographic location, sex or age of household head, illness, sex, age or education level; It will be important to find out who are the most vulnerable in any given community and make sure the program is able to meet their needs External context: Relative political stability, conflict, and/or natural disaster risk profile Sources of Qualitative Data You may have some recent and good‐quality qualitative data to draw upon that has already been collected and summarized, which will save time and resources. Extensive qualitative research resources exist and should be consulted. The resource section at the 19 Many of these categories were drawn from Nutrition Essentials: A Guide for Health Managers. http://www.basics.org/documents/pdf/NutritionEssentials_English.pdf and Schoonmaker‐Freudenberger, Karen. 1999. Rapid Rural Appraisal (RRA) and Participatory Rural Appraisal (PRA): A Manual for CRS Field Workers and Partners. Baltimore, MD: Catholic Relief Services. 17 GUIDE STEP ONE Qualitative Data to Collect 1
- 28. In practice, programs seek to achieve targets of at least 80 percent or more of the target population practicing a recommended behavior. Any recommended behavior practiced below an 80 percent cutoff is generally considered to be a nutrition priority. Any negative behavior (e.g., pre‐lacteal feeding) would be considered to be a nutrition priority if practiced by more than a 20 percent cutoff.23 When several behaviors are classified as nutrition priorities and the program does not have the resources to address all of them, design teams will prioritize them relative to each other, considering which behaviors will have the largest impact on children’s health and nutrition and are most feasible to change, and focus on those higher priorities during program design. Discuss as a group whether to designate behaviors as low, medium, high or very high public health significance. An example of data synthesis, based on DHS data, is included in the Country Example below. The comments, level of public health significance and subsequent synthesis of data provide a model for the level of information and agreement that should come out of your group discussion. After recording your rationale and answer in the Workbook in Section B, proceed to Section C. Maternal Nutrition. Country Example of Prioritizing Indicators of IYCF Practices INDICATOR: BREASTFEEDING DATA COMMENTS ON DATA LEVEL OF PUBLIC HEALTH SIGNIFICANCE B1. % of children born in the last 24 months who were put to the breast within one hour of birth 35.1% Most were to the breast within 24 hours HIGH B2. % of children 0‐23 months of age who received a pre‐lacteal feeding 67.5% Strong local beliefs and HIGH practice of giving herbal tea B3. % of infants 0‐5 months of age who 60.1% are fed exclusively with breast milk Plain water is the most common item consumed in addition MEDIUM/HIGH INDICATOR: YOUNG CHILD FEEDING COMMENTS ON DATA LEVEL OF PUBLIC HEALTH SIGNIFICANCE DATA B4. % of children 12‐15 months of age not who are fed breast milk avail‐ able Median duration: 21 months Unknown at this time – will need to conduct further investigation as part of formative research B5. % of infants 6‐8 months of age who not receive solid, semi‐solid or soft foods avail‐ able Introduction of foods is often Unknown – will need to do delayed, according to key further investigation as part informants of formative research 23 ENA approach aims to achieve at least 80% coverage at national or sub‐national scale (Acharya K, Sanghvi T, Diene S, Stapleton V, Seumo E, Srikantiah S, Aminu F, Ly C, Dossou V. 2004. Using ENA to Accelerate Coverage with Nutrition Interventions in High Mortality Settings. Washington, DC: BASICS II Project). 21 GUIDE STEP ONE Guidance for Data Synthesis 1
- 29. 6‐11 months: 28% 12‐27 months: 43% 18‐23 months: 47% B7. % of children 6‐23 months of age who receive foods from four or more food groups Majority of diet is staple food HIGH 48.7% B8. % of children 6‐23 months of age 32% who receive a minimum acceptable diet INDICATOR: FEEDING OF SICK CHILDREN DATA HIGH HIGH COMMENTS ON DATA LEVEL OF PUBLIC HEALTH SIGNIFICANCE B9. % of children aged 0‐23 months of 32.3% age with diarrhea in the last two weeks who were offered more fluids during the illness (Note: fluid is breast milk only in children under 6 months) HIGH B10. % of children 6‐23 months of age not with diarrhea in the last two weeks who avail‐ were offered the same amount or more able food during the illness Unknown, but based on the small number offered more fluids, this practice may be a problem SYNTHESIS OF DATA ON INFANT AND YOUNG CHILD FEEDING Do any of the indicators or trends concern you? If so, which and why? All of the indicator results in the table above fall significantly below the 80 percent cutoff and highlight that poor IYCF is a cause for concern and a likely contributor to high levels of undernutrition in the area. The very important practices of early initiation and exclusive breastfeeding are definitely suboptimal. While we do not know how many children 12‐15 months of age are still fed breast milk, we do know that median duration is 21 months, so it looks like many women continue breastfeeding. The age of introduction of complementary foods is unknown, but key informant data indicate that complementary foods are introduced later than 6 months of age. Finally, practices regarding feeding of sick children seem to be lacking overall and there is opportunity to improve these practices. Formative research will be important to determine the barriers to optimal practices in this area. What further insight does disaggregated data provide? (Note: This detail would be found in the Quantitative Data Collection Tables and is not listed above) The sex‐disaggregated data show little difference between boys and girls. However, in the DHS report there are geographic differences, with the southern districts having much lower rates of exclusive breastfeeding and higher rates of pre‐lacteal feeds than the eastern districts. Cultural differences may explain this, as the districts are of different ethnic groups. Additionally, the southern area is more urban, so this may reflect mothers leaving their children while they work outside the home. Finally, practices do vary a bit by socioeconomic group, with poorer mothers much less likely to provide the minimum number of solid or semi‐ solid foods than wealthier mothers. Formative research will need to focus on better understanding these differences. Which are the most vulnerable groups? Why? In the aftermath of the war, there are many households that are female‐headed or youth‐headed that have less access to resources than those headed by an adult male. Women, in general, have fewer rights than men and are frequent victims of violence. 22 GUIDE STEP ONE B6. % of breastfed and non‐breastfed 39.2% children 6‐23 months of age who receive solid, semi‐solid or soft foods the minimum number of times or more 1
- 30. Are there gender issues to consider? Yes. Drawing from qualitative data collected by our data team, we have learned that women are vulnerable and tend to have little voice, and as mentioned above have fewer legal rights than men and are subject to frequent violence. In households, women have many responsibilities, yet need permission (from the male head or other designated male family leader) to take their children to health services or attend the market. The program will need to be sensitive to these challenges. Other thoughts? In terms of early initiation, most babies were at the breast within 24 hours, so there is hope to improve this practice to have them feeding sooner – closer to one hour. The two geographic areas are a bit different and the strategy will need to be tailored. 1 CONCLUSION on the synthesis of data on Infant and young child feeding Are interventions in IYCF indicated? Check all areas that apply: Breastfeeding Young child feeding Feeding of sick children SUMMARY OF RATIONALE FOR THE CONCLUSION ON THE SYNTHESIS OF DATA ON INFANT AND YOUNG CHILD FEEDING At a glance, the information in this table indicates that sub‐optimal infant and young child feeding practices are a serious issue and that the project’s design should include interventions and approaches to improve these practices. More in‐depth formative research will follow in the program. All of the IYCF indicators in the table above are significant. Although exclusive breastfeeding in children 0‐5 months of age is relatively higher at 60.1 percent, it is such an important and life‐saving practice for child nutrition that the team gave this a medium/high level of priority for emphasis. As it appears that the ENA of providing sick children with increased fluid during illness is very low (32 percent) feeding practices during illness should be looked at very carefully when formative research is being carried out in the program. Because feeding of sick children is problematic, we reviewed data on key childhood illnesses and found high rates of diarrhea in both districts, meaning that optimal feeding of the sick child, in addition to preventing diarrhea, will be crucial to improving children’s nutritional status. DHS survey results indicated that in the eastern districts, EBF and pre‐lacteal feeds will be of higher priority than they are in the south, and the program, in general, must reach those who influence and support women’s decisions on how to feed their children. In researching barriers to optimal feeding, we will need to carefully examine socioeconomic status and see how this affects feeding decisions. Because there does not seem to be one key practice of concern to focus on, but rather many, it looks like a comprehensive IYCF strategy focused on multiple behaviors at multiple contact points may be developed for this project. However, to truly achieve behavior change, the program will focus on key priority behaviors in which improvements are achievable, including: exclusive breastfeeding, avoidance of pre‐lacteal feeds, quality and quantity of complementary foods, and feeding of sick children. 23 GUIDE STEP ONE
- 31. Step 1 Part III Section C begins on page 23 of the Workbook. At this point, the team will discuss the data gathered on the nutritional status of newborns and women and determine whether this is a priority intervention area. Guidance for Data Synthesis WHO Classification of Public Health Significance of Low Birth Weight Indicator: Anthropometry Public Health Significance IF PREVALENCE IS… ≥15% 24 C1. % of newborns with low birth weight (<2500 grams) Alternate Indicator: % of newborns with low birth weight (mother’s report of baby being “very small at birth”)25 Data Synthesis Note: Data on the prevalence of low birth weight may be difficult to interpret because it often represents only those children born in local health facilities. If available, complement with the percent of hospital‐based deliveries. DHS also asks mothers interviewed to retrospectively categorize the size of their last born as being “very small,” “smaller than average” or “average or larger.” If possible, program planners should look at information from both indicators. WHO Classification of Public Health Significance of Low Body Mass Index26 and Stunting27 Level of Public Health Significance Indicator: Anthropometry Low Medium High Very High C2. % of non‐pregnant women of reproductive age (15‐49 years) with low BMI (<18.5 kg/m2) 5‐9.9% 10‐19.9% 20‐39.9% ≥ 40% C3. % children stunted (HFA < ‐2 Z‐scores) <20 20‐29 30‐39 ≥ 40 WHO Classification of Public Health Significance of Vitamin A Deficiency28 Indicator: Vitamin A Level of Public Health Significance Normal C4. % of women of reproductive age (15‐49 years) with vitamin A deficiency (serum retinol values ≤ .70µmol/l) Low Medium High < 2 % 2.0‐9.9% 10.0‐19.9% ≥ 20% 24 WHO Expert Committee. 1995. Physical Status: The Use and Interpretation of Anthropometry WHO Technical Report Series #854. Geneva: WHO. 25 Ibid. 26 Ibid. Note: the above is based on BMI in adult population and is applied here to women. 27 Ibid. 28 World Health Organization. 1996. Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programs. WHO/NUT/96.10. Geneva: World Health Organization. 24 GUIDE STEP ONE Section C. Synthesizing Data on Maternal Nutrition 1
- 33. Section D. Synthesizing Data on Micronutrient Status of Children Step 1 Part III Section D begins on page 27 of the Workbook. At this point, the team should discuss the data gathered on micronutrient status in children and determine whether micronutrients are a priority intervention area. Guidance for Data Synthesis The WHO, UNICEF and Micronutrient Forum provide guidance on interpreting the prevalence of micronutrient deficiencies and ranking their level of public health significance. Classification of Public Health Significance of Vitamin A Deficiency Indicator: Vitamin A D1. % of children 6‐59 months with vitamin A deficiency (serum retinol values ≤ 0.70μmol/l)34 Level of Public Health Significance Low Medium ≥ 2 ‐ 9.9% ≥10 ‐ 19.9% High ≥ 20% Classification of Public Health Significance of Access to Vitamin A Supplementation Indicator: Vitamin A Public Health Significance D1. Alternate Indicator: % of children 24‐71 months with night blindness35 > 1% D2. % of children 6‐59 months who have received vitamin A supplement in previous 6 months36 < 80% Although the guidance in the next table refers to the percentage of anemia in the general population instead of specifically for children 6‐59 months, please use this table to rate the public health significance related to children. Classification of Public Health Significance of Anemia Indicator: Iron Level of Public Health Significance Normal/Adequate D3. % of anemia in the population37 Low Medium High ≤ 4.9% 5.0‐19.9% 20.0‐39.9% ≥ 40% 34 WHO. 1996. Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programmes, WHO/NUT/96.10. Geneva: World Health Organization. 35 Sommer, Alfred. 1995. Vitamin A Deficiency and its Consequences: A field guide to detection and control. Third Edition. Geneva: World Health Organization. 36 Coverage of 80% for delivery of several micronutrient interventions were selected based on the idea that ENA approach aims to achieve at least 80% coverage at national or sub‐national scale (Acharya K, Sanghvi T, Diene S, Stapleton V, Seumo E, Srikantiah S, Aminu F, Ly C, Dossou V. 2004. Using ENA to Accelerate Coverage with Nutrition Interventions in High Mortality Settings. Washington, DC: BASICS II. 37 WHO. 2001. Iron Deficiency Anemia: Assessment, Prevention, and Control. A Guide for Program Managers. Geneva: World Health Organization. (WHO/NHD/01/3) http://whqlibdoc.who.int/hq/2001/WHO_NHD_01.3.pdf 26 GUIDE STEP ONE 1
- 38. STEP 3. Review Health and Nutrition Services Mapping existing health and nutrition policies, programs and activities is an important part of program design. This information will guide your team to consider which activities can be strengthened or built upon, the local capacity for response, and the best use of limited available resources. The mapping information gathered in Step 3 of the Workbook (pages 39‐48) will be used throughout the rest of this tool for making programmatic decisions. This information is a minimum set to facilitate discussion and program planning and does not replace a comprehensive health facility assessment or gap analysis, which can be conducted as part of subsequent program design or program implementation. NDPA users also may find opportunities to coordinate and integrate with other sectors beyond health (e.g., agriculture, microenterprise, food security). A review of health and nutrition services is divided into the following areas:42 National policies Service availability, access and uptake Quality of service delivery Availability of health and nutrition IEC materials GATHERING DATA ON HEALTH AND NUTRITION SERVICES National Policies for Nutrition Programming Gather information on existing national policies and protocols for health and nutrition services and advocacy activities. Existing policies or plans to update policies may affect the program design or the overall effort required by a program to implement a nutrition approach. Provide brief summaries of key elements of the policies that are likely to influence a nutrition program and consider if there is a particular policy barrier that will limit the program. Information on policies should be available from the national MOH. 42 Marsh, D.R., Alegre, J.C., and Waltensperger, K.Z. 2008. A results framework serves both program design and delivery science. The Journal of Nutrition Symposium: From Efficacy Trial to Public Health Impact: Improving Delivery and Utilization of Nutrition Programs. 31 GUIDE STEP THREE Step 3 begins on page 38 of the Workbook. 3
- 42. STEP 4 SECTION A. CROSS‐CUTTING APPROACHES TO IMPROVE NUTRITIONAL STATUS After reviewing your answers to the questions in Steps 1‐3 in the Workbook, discuss potential cross‐cutting program approaches with your team. Record your conclusions in the Workbook in Step 4 Section A. There are a number of proven cross‐cutting approaches that advance and support multiple intervention areas in nutrition programs. Four cross‐cutting approaches are described here and will be referred to often in the intervention‐specific sections (Sections B‐E): Social and behavior change approaches (including community mobilization) Food‐based approaches (FBAs) Growth monitoring and promotion (GMP) Linking to health services Social and Behavior Change Approaches SBC approaches are critical to increasing the adoption and use of the nutrition interventions covered in this tool. Many of the nutrition outcomes are related to individual practices of caregivers in a household and community context. It is almost impossible to develop an effective community‐based nutrition program that does not include SBC approaches in its design. This section provides guidance on approaches related to SBC that apply to all of the intervention areas. Its purpose is to help program planners envision what will be necessary to include in a comprehensive SBC approach during the program design phase so that design opportunities are not overlooked, adequate staffing and coverage of community health workers (CHWs), community health volunteers (CHVs) or community nutrition volunteers (CNVs) is planned for and that the budget (e.g., for trainings, development of materials and supervision) is realistic. A more thoughtful, detailed SBC strategy would need to be developed during the initial phases of program implementation. This section will cover only a few pointers and approaches related to SBC to support decision making about overall program design. Many tools exist to guide program staff in conducting formative research and developing effective messages and SBC strategies. Please see the Resource Guide’s Resources section (page 80). In general, NGOs can develop SBC programs that: Ensure that key nutrition messages are incorporated into all counseling and counseling materials at key contact points Provide nutrition education and counseling to caregivers and women of reproductive age 35 GUIDE STEP FOUR Step 4 Section A begins on page 51 of the Workbook. 4
- 43. Train and provide supportive supervision to counselors, CHWs and health care providers Promote health and nutrition behaviors through multiple channels and contact points, including traditional birth attendants and community sources of information Mobilize women, caregivers and communities to access the services provided Establish a supportive household and community environment that facilitates behavior change Work with the challenges and barriers that caregivers face When developing a comprehensive SBC approach, program planners should discuss these four key decisions:43 Whose behavior needs to change to bring about the desired health outcomes? Who are the audiences? (E.g., parents, neighbors, health workers.) What do you want to help them to do? Is it technically correct? Is it feasible (can they do it)? Is it an effective practice? Why are they not doing it now? How can you best influence and support those behaviors? What barriers exist to people adopting an improved behavior? Consider both internal and external barriers. What incentives and factors (in the broadest sense) exist that would help motivate people to change their behavior? Why are some people currently doing it and others not? What makes the difference? What approaches can you include in your program that would help you to address those factors that you’ve identified as most influential in changing the behavior? (See description of SBC approaches below.) Do you need materials or trainings to support those approaches? Potential SBC Approaches There are many potential SBC approaches and a good program will incorporate a combination of these. A general rule related to behavior change is that there should be a limited number of messages transmitted through multiple channels. Community mobilization should be considered an essential aspect of all effective, sustainable child nutrition programs. The first table on the next page summarizes this approach and provides several resources for more information. There are several other SBC approaches to be considered: Counseling at key contact points Home visits Support groups Mass media Care groups Community “infotainment”, e.g., drama, community theatre 43 From Technical Reference Materials on Behavior Change Interventions. 2007. Child Survival Technical Support Plus Project/USAID. 36 GUIDE STEP FOUR 4
- 44. In addition to the approaches listed here, consider any other approaches or contact points that have been successful in the program area. Community Mobilization44 A capacity‐building process through which community members, groups, or organizations plan, carry out and evaluate activities on a participatory and sustained basis to improve their health and other conditions, either on their own initiative or stimulated by others Build greater community participation, commitment and capacity for improving child nutrition Strengthen civil society Target Group Everyone in the community Criteria Community members most affected by and interested in child nutrition are involved from the very beginning and throughout the process Defining Builds on social networks to spread support, commitment, and changes in social Characteristics norms and behaviors Builds local capacity to identify and address community needs Helps to shift the balance of power so that disenfranchised populations have a voice in decision‐making and increased access to information and services while addressing many of the underlying social causes of poor nutrition and health Motivates communities to advocate for policy changes to respond better to their real needs Plays a key role in linking communities to health services, helping to define, improve on, and monitor quality of care, thereby improving the availability of, access to, and satisfaction with health and nutrition services Needed Staff training in community mobilization techniques Elements for Organizational and political commitment and support Quality Adequate time: It will generally take 2‐3 years to begin to see improvements in Programming nutrition and several more years to strengthen community capacity to sustain improvements Community participation, ownership and collective action Organizational values and principles that support empowering people to develop and implement their own solutions to health and other challenges Resources Demystifying Community Mobilization ‐‐ An Effective Strategy to Improve Maternal and Newborn Health http://www.savethechildren.org/publications/technical‐resources/saving‐newborn‐ lives/publications/ACCESS_DemystCM.pdf How to Mobilize Communities for Health and Social Change http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/pdf/index.php 44 Adapted from Demystifying Community Mobilization: An Effective Strategy to Improve Maternal and Newborn Health. 37 GUIDE STEP FOUR Brief Summary Description Objectives 4
- 45. Counseling at Key Contact Points Counseling is provided by a health care provider to a caregiver during the delivery of health services. Counseling messages can be personalized to the needs of the mother/caregiver or child. Within this approach, consider opportunities to improve the quality and timeliness of the counseling, in addition to reinforcing the same message across various contact points. Contact points include: IMCI or sick‐child visits Well‐child visits Immunizations PMTCT clinics Antenatal or prenatal care visits Baby delivery (potentially via traditional birth attendants) Post‐partum care GMP sessions Child health days Recuperative feeding sessions Schools or community meetings for mother and father involvement Rally points Mobile clinics Local shops, wells and marketplaces Objectives Improve care and feeding practices for pregnant and lactating women and children under 5 years of age Target groups Pregnant and lactating women Mothers/caregivers of children 0‐23 months or up through 59 months Influencers of caregivers of children under 5 Criteria Time available for counseling Adequate coverage: community where women access services at the health facility Defining Messages targeted to the child’s developmental stage when the mother/caregiver Characteristics seeks the service Individually tailored guidance Needed Training on counseling and negotiation skills Elements for Counseling materials developed through formative research, appropriate for a low‐ Quality literate population, if necessary Programming Time and space available for counseling Continuous supportive supervision Resources Diene, Serigne, Kinday Samba and Ismael Thiam, Training Manual for Health and Social Workers in sub‐Saharan Africa: Implementation of Essential Nutrition Actions http://www.basics.org/publications/Training_Manual_Implementation_of_ENA.pdf#sea rch="counseling" Home Visits (e.g., Auxiliary Nurses, CHWs, Care Groups) Summary Objectives Home visits, conducted by CHWs, auxiliary nurses, or specialized community CNVs, provide an opportunity for one‐on‐one, personalized counseling, outreach, follow‐up and support to pregnant women, lactating women, caregivers of children and their families. Visits may include checking on the health of a baby, counseling caregivers, or following up with a child who has experienced growth faltering, acute malnutrition and/or illness. Ensure child’s health or growth is improving Improve care and feeding practices Support family 38 GUIDE STEP FOUR Brief Summary Description 4
- 46. Target group Criteria Defining Characteristics Needed Elements for Quality Programming Pregnant and lactating women, mothers/caregivers of children 0‐23 or up to 59 months Willing and available volunteers Community where homes are located a short distance of each other Opportunity to tailor messages to individual needs and to engage in dialogue to negotiate change Community members provide support and counseling Individually tailored guidance and support Counseling materials developed through formative research, appropriate for a low‐ literate population, if necessary Training on counseling and negotiation skills Continuous supportive supervision Brief Summary Description Support groups provide comfortable, respectful environments where peers can learn from and support each other to practice optimal child care and feeding practices. Support groups may build on existing groups within the community or be organized for specific purposes. Common support groups include breastfeeding support groups, women’s groups and grandmother’s groups. Support groups may be facilitated by a member of the group, a health care provider or other community member. Objective Promote optimal child care and feeding behaviors Target groups Mothers of young children (<2, <3 or < 5 years of age) Pregnant women First‐time mothers Adolescent mothers Criteria Group members willing and able to meet and share with each other Community mobilized Defining Groups are composed of peers Characteristics Safe environment for mothers to learn and share Research shows the level of influence of peers on behavior change is strong45 Requires minimal outside resources Needed Group leader must have strong facilitation skills Elements for Training may be necessary Quality Variation in methodology from very interactive to lecture driven Programming Can link into the non‐health sector Resources Linkages. Training of Trainers for Mother to Mother Support Groups http://www.linkagesproject.org/media/publications/Training%20Modules/MTMSG.pdf Freedom from Hunger. Freedom from Hunger integrates microfinance with health and life skills services to equip very poor families to improve their incomes, safeguard their health, and achieve lasting food security through a range of group‐based models. For more information visit: http://ffhtechnical.org/ La Leche League. Mother‐to‐Mother Support Handbook www.lalecheleague.org La Leche League International Peer Counseling Program http://www.llli.org/ed/PeerAbout.html#pc 45 Linkages and World Health Organization. 2003. Community‐based Strategies for Breastfeeding Promotion and Support in Developing Countries. 39 GUIDE STEP FOUR Support Groups (e.g., Mothers/Grandmothers, Other Community Affinity Groups) 4
- 47. Mass Media Objective Target Group Criteria Defining Characteristics Needed Elements for Quality Programming Mass media includes options such as radio, billboards, bus advertising and posters in addition to community gatherings such as health fairs or market days. Mass media can transmit messages to a wide audience and educate and entertain them, but will generally not change behavior by itself. Since it is generally an expensive strategy, a program may want to consider collaborating with others conducting mass media efforts to align messages for greater repetition and support. To create awareness of specific behaviors or draw attention to ongoing activities or health issues Communities in area ‐‐ can target all members with broad messages People need access to the media being used Simple messages ‐‐ can generate discussion High inputs at beginning and then message carried by advertising channel Can reach many people in little time Careful selection of appropriate messages Good understanding and pilot testing of the message Creativity Care Groups Brief Summary Description Objectives Target group Criteria Defining Characteristics Needed Elements for Quality Programming Resources Care groups are an approach for organizing community health volunteers. It is a community‐based strategy for improving coverage and behavior change through building teams of women who each represent, serve and promote health and nutrition among women in 10‐15 households in their community. Volunteers meet weekly or bi‐ weekly with a paid facilitator to learn a new health message, report on the incidence of disease and support each other. Care group members visit the women for whom they are responsible, offering support, guidance and education to promote behavior change. Improve coverage of health programs Sustainable behavior change Mothers of children 0‐59 months of age Community with houses close enough together so that volunteers can walk between them and to meetings Need a sufficient volunteer pool Trained “leader mother” volunteers provide support to other mothers Small number of paid staff reach large population (through leader mothers) Peer support Can support multiple health initiatives Time available – leader mothers must have 5 hours per week to volunteer Comprehensive and ongoing training of leader mothers Long start‐up time (due to training) – program should be of 4‐5 year duration Supervisor‐to‐promoter ratio should be 1:5 A Guide to Mobilizing Community‐Based Volunteer Health Educators: The Care Group Difference http://www.coregroup.org/diffusion/Care_Manual.pdf www.CareGroupInfo.org 40 GUIDE STEP FOUR Brief Summary Description 4
- 49. Food Fortification Food fortification is one approach to improve the micronutrient content of foods. Fortification of commonly consumed foods, such as flour, sugar, oils and salt, can be an effective approach for reducing micronutrient deficiencies in populations. Guidelines for mass production of centrally processed fortified foods are not covered in the NPDA. Many countries have a policy on food fortification; others have fortified foods on the market, even without a policy. If there are fortified foods available, your team may consider: Promoting the consumption of vitamin A‐, iron‐ or multiple micronutrient‐fortified foods within a larger behavior change approach Promoting the use of home‐based fortification methods and products, such as Sprinkles, that permit the fortification of local foods in the home to increase the content of multiple micronutrients, including iron, folic acid, zinc, vitamin A and vitamin C: The home‐based fortification methods are most appropriate in contexts where centrally fortified foods are not available to the target population or do not meet their nutritional needs (e.g., for young children). Moreover, there is ongoing research testing the formulations and outcomes of using lipid‐based nutrient supplement (LNS) as an effective home‐based (or “point of use”) fortification method in various contexts. If fortified foods are not available, consider: Advocating to the specific country’s government to promote food fortification with needed nutrients Partnering with the private sector to promote food fortification: The private sector could be an important partner either for marketing fortified foods or for increasing the availability of fortified foods in the marketplace. Fortification can be done at a large or medium scale. Setting up community facilities may also be possible. Establishing food fortification, with mass production of a quality‐controlled fortified product is possible, though it requires a high level of specialized skill Iodine deficiency is also addressed through a fortification strategy. Universal salt iodization is recommended and salt iodization is the major approach to reduce iodine deficiency disorders. If iodized salt is available: Promote consumption of iodized salt and (if possible) seafood by the entire household within a larger behavior change approach. During monitoring and evaluation activities, consider simple tools to test the level of iodization in household salt. This is useful when complemented with other activities for the advocacy of reliable salt iodization. If iodized salt is not available, consider: Partnering with other organizations to conduct advocacy efforts. Increasing the bioavailability of micronutrients to improve the quality of the diet includes approaches such as home processing methods (e.g., fermentation, germination) and use of dietary food combinations that promote absorption/increase the bioavailability of 42 GUIDE STEP FOUR 4
- 50. certain micronutrients (e.g., consumption of citrus foods with iron rich foods) or reduce consumption of dietary inhibiters (e.g., drinking tea will reduce absorption of dietary iron when taken soon before or with a meal). Animal flesh is among the best sources of heme iron, which is the most absorbable form of iron, and enhances the absorption of non‐heme iron. Programmers should research the available/common sources of heme iron in the community and look for ways to incorporate more of these foods into the diet. GMP is a preventive strategy focused on improving child growth that incorporates elements of community mobilization, SBC, IYCF, micronutrients, underlying disease burden and links to health services. The table on GMP and subsequent text provide considerations that should be reviewed in deciding whether to include or leverage a GMP component in your program. GMP can be conducted at facilities and/or in communities. Because the NPDA focuses on community‐based strategies, we will focus on community‐based growth monitoring and promotion (CBGMP) here. GMP has a mixed evidence base and was not listed among the effective approaches in the 2008 Lancet Series on Maternal and Child Undernutrition.47 However, growth monitoring, in various forms, is conducted in a number of national nutrition programs48 and thus has potential as a useful contact point for nutrition counseling messages focused on the improved growth of the child. Community‐Based Growth Monitoring and Promotion (CBGMP) Brief Summary Description Approach implemented at the community level to prevent undernutrition and improve child growth through monthly monitoring of child weight gain, although there is growing consensus that monitoring height/length gain may be more critical, one‐on‐one counseling and negotiation for behavior change, home visits, and integration with other health services. Action is taken based on whether a child has gained adequate weight, not by a nutritional status cutoff point, and then identifying and addressing growth problems before the child becomes malnourished. A major benefit of high‐quality programs includes that caregivers witness their child’s weight gain and thereby receive reinforcement for improving their practices. Additionally, CBGMP provides an opportunity for advocacy with community leaders and other persons of influence to become involved in seeking local solutions to the problem of growth faltering and undernutrition. Objectives Improve child growth Prevent undernutrition Early detection of growth faltering and undernutrition Target Group Children 0‐23 months Criteria (when Best used in communities with high prevalence of mild or moderate underweight or to use this stunting approach) Defining Creates community motivation/sensitization to reduce underweight Characteristics Uses trained community‐selected volunteers 47 “What Works? Interventions for Maternal and Child Undernutrition and Survival.” Lancet 371 (9610): 417‐40. Ashworth, A, et al., Growth Monitoring and Promotion: review of evidence and Impact. Journal compilation. 2008 Blackwell Publishing Ltd. Maternal and Child Nutrition (2008), 4, pp. 86–117. 48 43 GUIDE STEP FOUR Growth Monitoring and Promotion 4
- 51. Community‐Based Growth Monitoring and Promotion (CBGMP) Uses “inadequate weight gain” as early indicator of growth faltering Referral and counter‐referral system with health posts/centers Uses counseling and negotiation specific to the individual child Home visits Active community involvement in problem solving and planning Potential contact for MUAC and edema screening and SAM referral Addresses many causes of poor growth, not just the symptoms, and is closely tied to promoting evidence‐based interventions Needed For the individual child: Elements for Routine monthly assessment of growth status Quality Feedback on growth and on assessment of health and feeding Programming Individualized counseling on feeding and child care practices and negotiating adoption of by improved practices Implementers Follow‐up and referral following program standards Across the whole program: Quality counseling Analysis of causes of inadequate growth with guidelines for taking actions A large network of community‐based workers or volunteers (2‐3 community workers per 20 children) to be effective Supportive and quality monitoring and supervision Community participation in planning Caretaker involvement in monitoring the child’s weight gain A central location within a reasonable walk for most community members Resources Griffiths, Marcia, Kate Dickin and Michael Favin. 1996. Promoting the Growth of Children: What Works. Rationale and Guidance for Programs. Tool #4, The World Bank Nutrition Toolkit. Washington, DC: The World Bank. http://www.worldbank.org (Search for “Nutrition Toolkit”) Fiedler. 2003. A cost analysis of the Honduras Community‐based Integrated Child Care Program. Washington, DC: World Bank HNP Discussion Paper. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627‐ 1095698140167/Fiedler‐ACostAnalysis‐whole.pdf Ashworth, et al. 2008. Growth Monitoring and Promotion: A Review of the Evidence. Maternal and Child Nutrition (February 2008). http://www3.interscience.wiley.com/journal/119424907/abstract?CRETRY=1&SRETRY=0 Participation: If there is adequate access but low participation (less than 80 percent of the target population participating regularly in the program), an NGO can work to mobilize the community to increase participation. Consistency of service: The standard frequency for CBGMP is monthly sessions, although it is done less frequently in some locations. CBGMP should be done consistently, and NGOs can work with stakeholders to increase the frequency and quality of sessions, as necessary. Materials: NGOs can assist governments by ensuring that the appropriate scales, growth charts, registers and counseling materials are available in both facility‐ and community‐ based services. 44 GUIDE STEP FOUR 4
- 54. approaches, including cross‐cutting approaches, you are considering. Please remember, a much more thoughtful and complete SBC strategy will be developed during the initial phases of program implementation. STEP 4 SECTION B. INFANT AND YOUNG CHILD FEEDING Use this section if your data show that prevalence of some or all of the IYCF indicators are at less than 80 percent (or greater than 20% for negative behaviors) and need to be addressed to improve childhood nutritional status. IYCF approaches are specifically targeted to the age range of 0‐24 months and are composed of the ENA practices of immediate, exclusive and continued breastfeeding, and a number of child feeding practices for well and sick children. Improving IYCF practices contributes to reduced child morbidity, stunting and mortality. Breastfeeding is recognized as the most effective of the preventive public health interventions for child survival and has the potential to reduce child mortality by 13 percent.51 Where children are undernourished, one or more aspects of IYCF practices will most likely be suboptimal and a contributing factor to undernutrition. After reviewing your answers to the questions in Steps 1‐3 and Step 4 Section A in the Workbook, discuss the options in this section with your team. Record your conclusions in the Workbook in Step 4 Section B. The approaches addressed in this section in this section are: Training health providers Social and behavior change o Influencing caregiver practices o Strengthening family and community support o Organizing peer support groups o Building IYCF messages into other programs Increasing the nutritional adequacy (quantity and quality) of complementary foods Addressing water and hygiene issues Resource Transfer Advocacy and policy environment 51 Black, RE et al. 2008. Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences. The Lancet Maternal and Child Undernutrition Series. January 2008. 47 GUIDE STEP FOUR Step 4 Section B begins on page 54 of the Workbook. 4
- 55. Health care providers at the facility and community level provide a valuable source of counseling and advice to caregivers. Consider the potential contact points for pregnant women and caregivers and how training and provision of counseling cards can help providers deliver and reinforce the same message across various contact points. Essential IYCF messages can delivered through variety of providers in addition to training specific providers as IYCF counselors. For more information, please refer to the section on counseling at key contact points within Step 4 Section A, Cross‐Cutting Approaches, Social and Behavior Change. Additionally, health providers at both the facility and community levels are critical allies in addressing issues related to the feeding and care of sick children. Programmers should ensure that the following services for sick children are available and accessible: Promoting recommended feeding practices during illness, including continued breastfeeding (see Key Concepts, ENA #3 on page 8) ORS and zinc treatment for diarrhea Antibiotics for pneumonia Antimalarials for malaria Vitamin A treatment for measles Social and Behavior Change Many of the practices to improve IYCF rely on SBC approaches. SBC is covered in more detail in Step 4 Section A, but several relevant approaches are mentioned here, including: a) influencing caregiver practices; b) strengthening family and community support; c) organizing peer support groups; and d) building IYCF messages into other programs. Influencing Caregiver Practices According to the WHO/UNICEF Global Strategy for Infant and Young Child Feeding, caregivers have a right to have “access to objective, consistent, and complete information, free from commercial influence. Specifically, they need to know about the recommended period of exclusive and continued breastfeeding, timing of introduction of complementary foods, what types of food to give, how much and how often, and how to feed these foods safely.”52 Step 4 Section A, Cross‐Cutting Approaches includes more information on influencing caregiver knowledge and practices. One important step is conducting good formative research to gain a better understanding of the barriers to successful nutrition practices in program implementation. Several potential approaches to formative research include Trials of Improved Practices, Positive Deviance Inquiries (PDIs), Doer/Non‐Doer 52 WHO. 2003.Global Strategy for Infant and Young Child Feeding. http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html. 48 GUIDE STEP FOUR Training Health Providers 4
- 57. Applying lessons learned in the field leads to more effective programs and helps researchers identify the key issues that need to be addressed during consultative research and program planning. The following points summarize conclusions drawn from reviews of efforts to improve child feeding practices in Africa and other parts of the world. 1. Formative research has shown that age‐specific feeding problems are similar in most countries, despite individual and regional variation in foods given. Being aware of the particular problem for an age group helps to focus the formative research and the program actions. 2. Programs should emphasize improving child feeding practices rather than only the foods consumed by young children. 3. Feeding a child who is sick or anorexic is a major problem that requires different solutions for improved feeding of the child. Do not omit this aspect. 4. Motivations for feeding practices must be understood before behavior can be changed. In most cultures feeding has meanings and purposes beyond simply nourishing the body: practices may be related to social organization, religious beliefs and family dynamics. Promoting improved practices should reference the important motivations reported by families with young children. 5. Common constraints that may limit willingness or ability to change behavior must be addressed. Programs must be realistic about what can be accomplished if, for example, economic constraints are great or mothers feel they have no time to do more. 6. The influence of family members and knowledgeable community members on child feeding practices should be assessed. These individuals should be considered in the formative research and the program. 7. Methods of counseling and communication are as important as the messages conveyed, so attention must be paid to facilitating the development of counseling skills and providing the time to apply them. Formative research also needs to assess the knowledge, motivations and constraints of service providers. From: Dickin, Kate, Marcia Griffiths, Ellen Piwoz. 1997. Designing by Dialogue: A Program Planners’ Guide to Consultative Research for Improving Young Child Feeding. The Sara Project. Addressing Water and Hygiene Issues If there are water and sanitation programs operating in the same area, consider how you can work together to promote clean water, handwashing and hygiene. Poor water and sanitation are the cause of a significant proportion of diarrhea cases in young children. For more information, refer to Step 4 Section E, Underlying Disease Burden. 50 GUIDE STEP FOUR Programs to Improve Child Feeding Practices: Lessons Learned 4
- 58. If food availability and access are limited in the program area, SBC alone may not be sufficient to achieve impact. It may be appropriate to consider additional resource transfers54 within the program through actions such as adding food supplementation (see table below)55 or CCTs56 to the behavior change approach. These approaches work to improve IYCF by conditionally transferring and ensuring resources to households with children under 2 years of age, providing short‐term support to protect and ensure adequate consumption and requiring participation in essential health and nutrition activities that will improve nutrition in the long‐term. The conditions may include participation in SBC programs, accessing essential health and nutrition services, or other activities deemed essential to improving nutrition. No child under 6 months of age should be the direct recipient of targeted food assistance. Rather, programs should take actions to support and promote immediate and exclusive breastfeeding and, when appropriate, provide pregnant and lactating mothers with food assistance until the child is 6 months of age. In food insecure contexts, programmers can consider assisting children 6‐23 months of age and their vulnerable households with food supplementation/food assistance. Guidelines are provided in the table below. Food Supplementation/Food Assistance: Prevention Brief Summary In food‐insecure environments, programs may choose to supplement the diets of women, Description children and/or households to help them meet their macro and micronutrient needs. Food supplements may be in the form of international food aid, including fortified blended foods and vitamin A‐fortified oil, or locally or regionally purchased foods. The food rations are generally distributed on a monthly basis. To be most effective, food supplementation should be accompanied by essential health and nutrition services and SBC programming. One food supplementation program, the Preventing Malnutrition in Children Under 2 Approach (PM2A) is a specific, tested package of actions aimed at preventing undernutrition. Although PM2A has been found to be more effective in reducing chronic malnutrition than recuperative programs, it may not be appropriate in all program contexts. There is also a great deal of experience with the use of food supplementation to meet gaps in the diet in emergency situations; some lessons are applicable in developing contexts. Objective Reduce prevalence of chronic malnutrition Target Groups All children 6‐23 months of age Pregnant women Lactating women from delivery until the child is 6 months of age Households of the participant women and children Criteria Food‐insecure environment Evidence that the area can absorb the quantity of food supplementation needed and 54 Gentilini, U. 2007 Cash and Food Transfers: A Primer. Rome, Italy: World Food Program. Please refer to the FANTA website (www.fanta‐2.org) for information on the Preventing Malnutrition in Children Under Two Approach. 56 Both food supplementation and conditional cash transfer programs with nutrition education are identified as interventions with sufficient evidence to implement in specific situational contexts in Bhutta, Z. A., T. Ahmed, R. E. Black, S. Cousens, K. Dewey, E. Giugliani, and others. 2008. “What Works? Interventions for Maternal and Child Undernutrition and Survival.” Lancet 371 (9610): 417‐40. 55 51 GUIDE STEP FOUR Resource Transfer 4
- 59. Defining Characteristics Needed Elements for Quality Programming Resources that the food supplementation will not displace local food production. (Bellmon Estimation for Title II is a resource for this) Logistical capacity for transport, storage and management of food commodity Health services available (or ability to work to strengthen health services) Child stunting and/or underweight should be high (>30% or 20%, respectively) Food is provided to vulnerable people who could not otherwise access it Opportunity to link with agriculture and livelihood sectors and improve food access while also improving utilization Food supplementation may also be targeted on a seasonal basis, when the food needs are the greatest Provision of or access to basic essential health services Complementary SBC programming focused on maternal nutrition, IYCF, hygiene and health‐seeking behaviors Close coordination with health, nutrition and food security programs and services Formative research to adapt program to local conditions, including a seasonal calendar of when food needs are greatest USAID Office of Food for Peace: http://www.usaid.gov/our_work/humanitarian_assistance/ffp/ FANTA‐2: www.fanta‐2.org World Food Programme: www.wfp.org Conditional Cash Transfers (CCTs)57 Brief Summary CCT programs provide cash payments to poor households that fulfill program‐mandated Description requirements, such as participation in certain nutrition programs (e.g., BCC, GMP, supplementation, attending health services). CCTs aim to alleviate poverty in the short‐ and long‐term through simultaneous cash transfers and investments in health, education, social services and women’s empowerment. The cash payment given to the household encourages participation in health and nutrition programs, reduces resource constraints/improves purchasing power, and encourages long‐term investment in human capital. Program evaluations have found that CCT programs have improved nutritional status in children (stunting) and school enrollment, and have reduced illness. CCT programs tend to be large‐ scale, government‐run programs. Results are very dependent on the quality of program implementation and targeting. Administering and monitoring CCT can be costly. Objectives Break the intergenerational cycle of poverty Provide incentive to participate in essential health and nutrition services Promote behavior change Target groups Poor households with children under age two Women are generally the recipients of the cash because they are more likely to invest it in the well‐being of their family Criteria Nutrition and health services/programs that beneficiaries must participate in are in place, accessible and of good quality Government/community support the program Program takes place in areas where families are unlikely or unable to invest their own resources in children’s long‐term human capital (e.g., health services are available and of good quality, but underutilized) 57 Bassett, Lucy. 2008. Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition? SP Discussion Paper No. 0835, Social Protection and Labor. Washington, DC: The World Bank. 52 GUIDE STEP FOUR Food Supplementation/Food Assistance: Prevention 4
- 60. Defining Resource transfer is cash Characteristics Conditions for receiving the cash Comprehensive program addressing resource constraints, poverty, health‐seeking behaviors and behavior change Needed Close monitoring of program operations, targeting and conditionality Elements for Strong administrative supervision Quality Links between all related sectors (health, education, social services) Programming Formative research to understand reasons why people do or do not participate in health and nutrition services Health system strengthening to support increased demand from CCT Resources Bassett, Lucy. 2008. Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition? SP Discussion Paper No. 0835, Social Protection and Labor. Washington, DC: The World Bank. October 2008. http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/SP‐Discussion‐ papers/Safety‐Nets‐DP/0835.pdf Son, Hyun H. 2008. Conditional Cash Transfer Programs: An Effective Tool for Poverty Alleviation? Asian Development Bank, Economics and Research Department Policy Brief Series No 51. July 2008. http://www.adb.org/Documents/EDRC/Policy_Briefs/PB051.pdf Lindert, Kathy et al. 2007. The Nuts and Bolts of the Bolsa Familia Program: Implementing CCTs in a Decentralized Context. SP Discussion Paper No. 0709. Washington, DC: The World Bank. May 2007. http://siteresources.worldbank.org/INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamili aDiscussionPaper.pdf Advocacy and Policy Environment If there are significant policy barriers to implementing the above approaches, it may be necessary to get involved in advocacy efforts. One influencer of breastfeeding practices is the promotion of breastfeeding in the hospitals and the level of influence by health care providers or mass media promoting formula feeding. In Step 3, you determined if the country had signed the International Code for the Marketing of Breastmilk Substitutes, if they had Baby Friendly Hospitals and if they have the Baby Friendly Communities Initiative. If the answer to any of these questions is no, consider partnering with other organizations working to influence key decision makers. Which approaches will you use? Fill out your thoughts in the boxes in Step 4 Section B of the Workbook. 53 GUIDE STEP FOUR 4
- 61. STEP 4 SECTION C. MATERNAL NUTRITION After reviewing your answers to the questions in Steps 1‐3 and Step 4 Section A in the Workbook, discuss the options in this section with your team. Record your conclusions in the Workbook in Step 4 Section C. There are several maternal nutrition approaches to be considered: SBC related to maternal nutrition Food‐based approaches to improve the diet Micronutrient supplementation of women Complementary maternal health services for anemia prevention Develop and strengthen referral systems Social and Behavior Change Related to Maternal Nutrition SBC to support women and families in practicing optimal nutrition behaviors is essential to achieving improved maternal nutritional status. Some of the key practices have already been briefly mentioned above within food‐based strategies. This section describes some topics that may be incorporated into the SBC strategy to improve maternal nutrition status. Refer to Step 4 Section A for more guidance on potential SBC approaches and contact points, including community mobilization, care groups, mass media, support groups, home visits, counseling and community “infotainment”. Some key maternal nutrition SBC topics include: Increase calorie and protein consumption for pregnant and lactating women based on national recommendations Promote dietary diversity: o Nutrition education to promote consumption of local, nutrient‐rich food sources, especially those high in vitamin A, iron and iodine o Promoting consumption of foods that enhance absorption of iron such as citrus fruits or other foods with vitamin C Promote consumption of fortified foods: o Advocate for the increased availability of and access to these foods at the community level 54 GUIDE STEP FOUR Step 4 Section C begins on page 56 of the Workbook. Use this section if you have determined that the maternal health and nutrition indicators are at a level of public health significance and need to be addressed to improve maternal, newborn and child nutritional status. Step 1 focused on both maternal and newborn indicators in the target area to determine their importance in an approach to address childhood nutrition. This section is focused on potential approaches for maternal nutrition that support infant and childhood nutrition. Users should also refer to Step 4 Section A. 4
- 62. o Work with community to create demand for fortified foods (identify what the barriers to consumption might be) Promote uptake of key maternal nutrition services, including: o Antenatal care o Nutrition counseling o Micronutrient supplementation o Malaria prevention and treatment o Prevention and treatment of parasitic worm infections Promote other community/household support for pregnant/lactating women, including: o Reduced workload o Care seeking A key strategy to improve maternal nutritional status is to improve the quality of women’s diets by improving access to and consumption of protein and micronutrient‐rich foods. These include approaches to increase production and seasonal availability of nutrient‐rich foods, to promote consumption of nutrient‐rich foods (including fortified foods), and to improve the bioavailability of nutrients in foods consumed. Details on these approaches were discussed in Step 4 Section A, Cross‐Cutting Approaches, Food‐based Approaches. Micronutrient Supplementation for Women Vitamin A: Many countries have policies and/or programs for large‐scale, preventive, high‐ dose vitamin A supplementation of post‐partum women (within six weeks of delivery). Some women may also need therapeutic treatment for xerophthalmia or Bitot’s spots. Iron: As part of a minimum package of maternal care during pregnancy, most countries have protocols in place for the provision of IFA supplements to pregnant and post‐partum women (especially in settings where anemia prevalence ≥ 40 percent). If your country of operation has a micronutrient supplementation policy in place, consider including some or all of the following: Community organization and awareness promotion to increase participation Logistical support and transportation for outreach from health facilities Support to address any micronutrient supply issues Activities may be also needed to strengthen therapeutic supplementation of iron for women with severe anemia. This treatment is complicated and requires access to and referral mechanisms to skilled technical assistance and/or clinical care. If there is not a policy in effect, consider partnering with other organizations to conduct advocacy efforts. 55 GUIDE STEP FOUR Food‐Based Approaches to Improve the Diet 4
- 63. In some locations, recurring bouts of malaria or a high prevalence of hookworm infection may be key causes of maternal anemia.58 In these areas, programs should look at approaches for the prevention and treatment of malaria and hookworm infection to reduce the prevalence of anemia. Governments often have policies or programs in place regarding: Intermittent preventive treatment of malaria (IPT) during pregnancy in endemic areas Providing access to LLINs Deworming after the first trimester of pregnancy If there are policies in place, consider: Promoting the services Providing training to health service staff Community mobilization and awareness campaigns Supporting health facilities to address supply issues Social and Behavior Change Related to Maternal Nutrition SBC to support women and families in practicing optimal nutrition behaviors is essential to achieving improved maternal nutritional status. Some of the key practices have already been briefly mentioned above within food‐based strategies. This section describes some topics that may be incorporated into the SBC strategy to improve maternal nutrition status. Refer to Step 4 Section A for more guidance on potential SBC approaches and contact points, including community mobilization, care groups, mass media, support groups, home visits, counseling and community “infotainment”. Some key maternal nutrition SBC topics include: Increase calorie and protein consumption for pregnant and lactating women based on national recommendations Promote dietary diversity: o Nutrition education to promote consumption of local, nutrient‐rich food sources, especially those high in vitamin A, iron and iodine o Promoting consumption of foods that enhance absorption of iron such as citrus fruits or other foods with vitamin C Promote consumption of fortified foods: o Advocate for the increased availability of and access to these foods at the community level o Work with community to create demand for fortified foods (identify what the barriers to consumption might be) 58 R. Galloway. 2003. Anemia Prevention and Control: What Works? Part 1 and Part 2. USAID, World Bank, PAHO/WHO, Micronutrient Initiative, FAO and UNICEF. http://siteresources.worldbank.org/NUTRITION/Resources/281846‐1090335399908/Anemia_Part1.pdf http://siteresources.worldbank.org/NUTRITION/Resources/281846‐1090335399908/anemia_Part2.pdf 56 GUIDE STEP FOUR Complementary Maternal Health Services for Anemia Prevention 4
- 64. Promote uptake of key maternal nutrition services, including: o Antenatal care o Nutrition counseling o Micronutrient supplementation o Malaria prevention and treatment o Prevention and treatment of parasitic worm infections Promote other community/household support for pregnant/lactating women, including: o Reduced workload o Care seeking Even with preventive activities in place, some women will require treatment for nutritional deficiencies. NGO programs can provide guidance and training to traditional birth attendants, counselors and CHWs on when and where to refer women for specific services. More detailed guidance on linking with health systems is provided in Step 4 Section A, Cross‐Cutting Approaches, Linking with Health Systems. Which approaches will you use? Fill out your thoughts in the boxes in Step 4 Section C of the Workbook. STEP 4 SECTION D. MICRONUTRIENT STATUS OF CHILDREN Step 4 Section D begins on page 58 of the Workbook. Use this section if you determined that micronutrient status of children may be a priority issue in the program area and you are considering incorporating micronutrient approaches. After reviewing your answers to the questions in Steps 1‐3 and Step 4 Section A in the Workbook, discuss the options in this section with your team. Record your conclusions in the Workbook in Step 4 Section D. Much like the detailed approaches covered in other sections of this tool, there are several child micronutrient approaches to be considered: Social and behavior change related to child micronutrients Food‐based approaches for children Micronutrient supplementation Delayed cord clamping 57 GUIDE STEP FOUR Develop and Strengthen Referral Systems 4
- 65. Social and Behavior Change Related to Child Micronutrients SBC efforts to promote consumption of locally‐available and accessible micronutrient‐rich food sources should be part of a comprehensive nutrition behavior change strategy for long‐term and sustainable improvements. If vitamin A‐rich foods are available, consider: Working with communities to develop a food calendar of locally‐available foods rich in vitamin A Promoting consumption within the overall SBC approach, with special targeting to change behaviors of vulnerable groups: o Consumption of animal‐source vitamin A, especially for children 6‐23 months of age as part of complementary feeding messages for behavior change o Consumption of diets and recipes that include foods that are dark green, yellow and orange If vitamin A‐rich foods are not available, consider food‐based approaches within a SBC strategy such as promoting vitamin A rich food production in home gardens, with a focus on consumption at the household level. Iron If iron‐rich foods are available, consider: Working with communities to develop a food calendar of locally‐available foods rich in iron and vitamin C Promoting the consumption of foods high in iron in such a way to maximize absorption within a larger behavior change approach Promoting the consumption of foods with vitamin C along with foods high in iron, which promotes absorption Promoting hot beverage options other than tea and coffee, the ingestion of which inhibits absorption Promoting the consumption of animal‐source foods by children, especially 6‐24 months of age If iron‐rich foods are not available, consider introducing an animal husbandry project with a focus on consumption at the household level. Zinc Animal products are the best source of zinc. Inhibiters, such as foods with high‐phytate content including grains, limit zinc absorption. Consider adding food‐based approaches such as cooking, fermentation and sprouting to improve the bioavailability of zinc (and reduce phytic acid) within the SBC strategy. 58 GUIDE STEP FOUR Vitamin A 4
- 66. Food‐Based Approaches for Children FBAs59 are made up of a combination of approaches to improve dietary quality and dietary diversity, a common measure of dietary quality. The most common approaches can be organized around those that will increase the production and availability of micronutrient rich foods; dietary intake of micronutrient rich foods, including the promotion and support of breastfeeding, recommended IYCF practices, and consumption of iodized salt; and bioavailability (ability of the body to better absorb) of micronutrients. For more information on food‐based approaches, please see Step 4 Section A, Cross‐Cutting Approaches, Food‐based approaches. Micronutrient Supplementation Many countries where child mortality rates are high (> 70 deaths/1,000 live births) have policies for twice‐yearly vitamin A supplementation of children 6‐59 months of age. Successful implementation of this level of supplementation should result in an average 23 percent reduction in child mortality. Large‐scale supplementation is often combined with outreach efforts for immunization with periodic campaigns conducted by all health services. This approach may be called the “Child Health Day” or “Child Health Week”. If the country has a micronutrient supplementation policy in place, only a modest level of effort will be needed to provide support for the policy. Consider providing: Community organization and awareness promotion to increase participation Logistic support, including the coordination of transportation for outreach from health facilities Support and advocacy to address any micronutrient supply issues If there is no policy in effect, consider partnering with other organizations to conduct advocacy efforts in micronutrient supplementation Even with the above approaches, some children will need therapeutic treatment for potentially complicated illnesses, such as xerophthalmia or Bitot’s spots. Additionally, therapeutic vitamin A supplementation is also provided to address measles and other severe infections. Activities may be needed to strengthen clinical care use of therapeutic supplementation. This treatment is complicated and requires access to skilled technical assistance and/or clinical care. Iron Whether there are periodic campaigns for deworming and iron supplementation of children 6‐59 months of age varies by country. In areas endemic for malaria, WHO does 59 Much of this section on food‐based strategies draws from Ruel, MT and Levin, C. 2000. Assessing the Potential for Food‐Based Strategies to Reduce Vitamin A and Iron Deficiencies: A Review of Recent Evidence. IFPRI. FCND Discussion Paper No. 92. 2000. For more background information, please see http://www.ifpri.org/sites/default/files/publications/fcndp92.pdf. 59 GUIDE STEP FOUR Vitamin A 4
- 67. not recommend routine iron supplements (including point‐of‐use fortificants like Sprinkles) for children under 2 years of age. Iron (or IFA) supplements in endemic areas should be targeted to children with anemia or at risk of iron deficiency anemia. These children should also receive concurrent protection from malaria and other infectious diseases. Therapeutic supplementation with iron for cases of malaria in children under five in endemic areas is under review due to potential adverse outcomes. Giving children 1‐5 years of age routine, twice‐yearly deworming treatment improves nutritional status for a number of micronutrients, including iron; improves child development; and reduces undernutrition. If the country has an iron supplementation policy in place, only a modest level of effort will be needed to provide support for the policy. Consider providing: Community organization and awareness promotion to increase participation Individual counseling to mothers of individual children receiving iron supplements to ensure children receive the entire course of supplementation Logistic support for outreach from health facilities Support to address any micronutrient supply issues Ensuring training and job aids are available to assist health workers with correctly identifying and screening for anemia If there is not a policy in effect, consider partnering with other organizations to conduct advocacy efforts. Zinc The Lancet Series on Maternal and Child Undernutrition60 has reported that there is sufficient evidence for recommending large‐scale supplementation of zinc for infants and children. Check for recent policy developments with relevant ministries before pursuing any efforts. Note that to‐date, data are not routinely gathered on zinc status and the use of preventive zinc supplementation. The Micronutrient Initiative tracks progress and posts recent developments on its website.61 The use of zinc to address diarrhea is addressed in the section related to the underlying disease burden. The Countdown to 2015: Maternal, Newborn, and Child Survival Reports track policy adoption of zinc protocols for the management of diarrhea. Iodine In countries with iodine deficiency disorder, supplements (iodized oil capsules) may be targeted to children 7‐24 months of age, especially where iodized salt is not available. Check national policies. 60 “What works? Interventions for maternal and child undernutrition and survival.” The Lancet, Vol. 371, February 2, 2008. http://www.micronutrient.org/english/view.asp?x=1 61 60 GUIDE STEP FOUR 4
- 68. Delayed Cord Clamping Delaying cord clamping during childbirth has been found to prevent infant anemia. If you are working with birth attendants, consider incorporating training on the proper cord clamping procedure. The correct technique is to wait to clamp the cord until the pulsing has stopped and the maximum amount of blood (and therefore iron) has passed to the newborn. Child Health Weeks/Days They should occur every six months to deliver vitamin A supplements and other preventive health services to children at the community level. In addition to vitamin A, services have included: catch‐up immunization, providing IFA to pregnant women, deworming, iodized salt testing, distribution of LLINs and promotion of infant and young child nutrition. Target Group Criteria Defining Characteristics Needed Elements for Quality Programming Increase coverage of vitamin A supplementation Increase coverage of other nutrition approaches Provide deworming Children 0‐59 months of age Vitamin A program in‐country High coverage rates Feasible in diverse settings Community census and social mobilization Best suited for areas with high prevalence of vitamin A deficiency Requires coordination with district health plan Need to assure adequate supply Volunteers and supervisors need to be trained Substantial social mobilization Follow‐up/record‐keeping important Part of a larger nutrition strategy Which approaches will you use? Fill out your thoughts in the boxes provided in Step 4 Section D of the Workbook. STEP 4 SECTION E. UNDERLYING DISEASE BURDEN Step 4 Section E begins on page 60 of the Workbook. Use this section if you have determined that the levels of illness such as diarrhea, ARI, malaria, and HIV are at a level indicating that there must be a focus on prevention and treatment of underlying disease to address childhood undernutrition rates. A comprehensive review of programming approaches to diarrhea, ARI, malaria, HIV, and water and sanitation is beyond the scope of this tool; however, the Resource Guide’s Resource section provides some references for more information. 61 GUIDE STEP FOUR Brief Summary Description Objectives 4
- 69. After reviewing your answers to the questions in Steps 1‐3 and Step 4 Section A in the Workbook, discuss the options in this section with your team. Record your conclusions in the Workbook in Step 4 Section E. In general, programs should consider incorporating the following approaches to address the underlying disease burden: Linking nutrition programming with existing health programming to ensure that nutrition aspects of the underlying disease burden are addressed Implementing community‐based health programs, such as C‐IMCI or CCM, to address the underlying disease burden Providing training to community‐ and facility‐based health workers on prevention and treatment of common illnesses and nutrition management of common illnesses Incorporating SBC approaches to promote healthy practices and health‐seeking behavior within both nutrition and health services activities Promoting timely identification of danger signs for childhood illnesses and when and where to seek treatment Water and sanitation improvements to prevent diarrhea Referring for treatment Advocacy if there are clear policy barriers to implementing priority interventions The following hygiene practices should be promoted in nutrition programs: Safe storage and treatment of water at the point‐of‐use Optimal handwashing techniques Sanitary disposal of human feces in basic, low‐cost sanitation facilities With a high prevalence of HIV in a population, the ENA still apply, but the messages need to be modified to focus on the needs of HIV‐infected individuals. Programs should follow national HIV and IYCF guidelines and consult the most recent WHO guidance.62 The following table provides a summary of two approaches to addressing the underlying disease burden, C‐IMCI and CCM. Nutrition Community Integrated Management of Program Childhood Illness (C‐IMCI) Brief Summary Community‐based program to address Description diarrhea, malaria, undernutrition, measles and pneumonia. Four key elements are: facility/community linkages; care and information at the community level; promotion of16 key family practices; and coordination with other sectors. Community Case Management (CCM) CCM is an approach to deliver community‐based, life‐saving curative interventions for common, serious childhood infections including: pneumonia, diarrhea, malaria and newborn sepsis. It relies on trained, supervised community members to provide health services. The interventions are: antibiotics for pneumonia, dysentery and newborn sepsis; oral rehydration therapy (ORT); antimalarials; zinc; and vitamin A. 62 WHO. HIV and Infant Feeding: Revised Principles and Recommendations. November 2009. Geneva: World Health Organization. http://www.who.int/child_adolescent_health/news/archive/2009/30_11_09/en/index.html 62 GUIDE STEP FOUR 4
- 70. Community Integrated Management of Community Case Management (CCM) Childhood Illness (C‐IMCI) Reduce morbidity and mortality of Reduce mortality from common childhood children under 5 years of age illnesses among children 0‐59 months of age Address diarrhea, malaria, undernutrition, Improve access to curative services measles and pneumonia Address pneumonia, diarrhea, newborn sepsis Improve access to curative services and malaria Target Groups Children 0‐59 months of age Children 0‐59 months of age Criteria National IMCI policies and protocols High mortality from illnesses treated by CCM Collaborating health facility implementing Lack of continual access to curative IMCI for patient referral interventions Cadre of available community health Low use of health facilities workers or volunteers Policy environment supports CCM (e.g., CHWs able to administer medications) High prevalence of common childhood illnesses: undernutrition, diarrhea, Treatment protocols available malaria, pneumonia and/or measles Defining Integrated approach focuses on whole Uses trained, supervised community members Characteristics child, not individual diseases to deliver the services Community‐level prevention and Designed to respond to local needs ‐‐ is seldom treatment a national program Linked with health facilities Focus on areas with limited access to health facilities Evidence‐based protocols for prevention and treatment Used to improve access, quality and demand of treatment at the community level Addresses interrelationships among illnesses All ENA messages are part of IMCI key family practices Mostly applied to children who present at health facilities or to CHWs with illness Needed Involvement and commitment of the Requires sound training and supervision Elements for health sector needed Strong links with functional health facilities for Quality Training of health staff training, supervision and referral Programming Refresher courses Requires access to supply of curative products: medicines, ORT, vitamin A and zinc Supplies Promotion of timely care‐seeking and Supervision improved feeding during illness Resources Household and Community IMCI. Community Case Management Essentials. 2010. Washington, DC: CORE Group Washington, DC: CORE Group. Available: Available: http://207.226.255.123/working_groups/im http://www.coregroup.org/storage/documents/C ci_c‐imci.cfm CM/ccm%20essen%20final%20dec%2009.pdf Which approaches will you use? Fill out your thoughts in the boxes provided in Step 4 Section E of the Workbook. 63 GUIDE STEP FOUR Nutrition Program Objectives 4
- 72. Medical referral and treatment to address underlying disease burden, routine deworming (mebendazole/albendazole), micronutrient supplementation (vitamin A and iron) and vaccinations Daily supplemental meals with a minimum number of calories and protein based on WHO guidance64 Education, training and/or cooking demonstrations on how to prepare the food, if supplemental foods are unfamiliar A mechanism for follow‐up and monitoring weight gain Medical referral, treatment, and nutrition support and counseling for children who are not gaining appropriate weight or are losing weight in recuperative services Behavior change and nutrition counseling to improve feeding and care practices If the prevalence of SAM is of public health significance, a program to directly address children with SAM is needed in addition to a program that incorporates the components to address children with MAM. Ideally, the program would be community based with strong links to health services including inpatient and outpatient management of SAM. Any program for treatment of SAM should follow the national protocol for the management of acute malnutrition and/or international WHO or CMAM protocols. Incorporate the following minimum elements: Community outreach for active case‐finding, referral and follow‐up at the community level Initial medical evaluation for diagnosis of medical complications, danger signs and assessment of appetite Routine treatment of children according to standard medical and nutrition protocols for managing SAM 65 o Medical protocols include: Amoxicillin or second‐line antibiotic, vitamin A supplementation for children with no edema who have not received a dose in the previous 30 days, deworming after week one of treatment, measles vaccination and malaria treatment in malarial areas o Nutrition protocols include: Therapeutic feeding (RUTF for children 6‐59 months of age with no medical complications, therapeutic milk [F75 or F100] for children with medical complications, no appetite or under 6 months of age) Outpatient care provided using established national protocols or CMAM protocols (if no national protocols exist) for children with SAM and no medical complications Referral to inpatient facilities with 24‐hour care and staff trained in the management of SAM, according to established national guidelines or WHO guidelines (if national guidelines do not exist) for children with SAM with medical complications, IMCI danger signs or a failed appetite test, or who have not gained weight in outpatient care 64 Current WHO guidance suggests that supplemental feeding rations for the treatment of MAM should provide 1000 – 1200 kcal/person/day if there is a take‐home ration to account for family sharing. There are ongoing discussions about the best treatments for MAM and guidance may evolve. The Management of Nutrition in Major Emergencies. 2000. Geneva: WHO. 65 FANTA Project, Concern Worldwide, UNICEF, and Valid International. Training Guide for Community‐based Management of Acute Malnutrition. November 2008. http://fanta‐2.org/; and Valid International. Community‐based Therapeutic Care: A Field Manual. 2006. 65 GUIDE STEP FIVE Severe Acute Malnutrition 5
- 73. Appropriate counseling and behavior change Mechanism to monitor weight gain and follow‐up to ensure continued weight gain Clinical program supervision and medical expertise Linkages with other nutrition, health or food security initiatives Underweight There is recognition by nutrition practitioners that a wasted child participating in a recuperative nutrition program is more likely to recover than a stunted child participating in the same program (see Terminology), and this is an important consideration for resource allocation and motivation of caregivers. The evidence for programmatic solutions for the recuperation of stunted children is extremely weak at this time. Hence, it is recommended that programmers identify and track in program monitoring plans not only underweight rates as a part of program enrollment but stunting and wasting rates (or MUAC) as is feasible. Having this information will enable programmers, researchers and policy makers to better understand program trends and more effectively allocate resources. If the prevalence of underweight is of public health significance, you will need a program that incorporates the following elements: A mechanism for active case finding, referral and follow‐up at the community level A mechanism for monitoring weight gain and follow‐up to ensure continued weight gain Screening to measure the height of enrolled children identified as underweight to determine if the underweight is a result of stunting, wasting or both (see text box) Community outreach for active case‐finding of children with SAM and referral of these children to therapeutic services Medical referral and treatment to address underlying disease burden, deworm children, provide micronutrient supplementation, and address children who are not gaining appropriate weight or are losing weight in recuperative services A daily supplemental meal (Hearth) with a minimum of 500‐700 kilocalories/beneficiary/day and 15‐25 g of protein for two weeks or until the child has gained 400 g and is continuing to gain weight66 Behavior change and nutrition counseling to improve feeding and care practices Links to Existing Services If appropriate recuperative services are available and accessible (see Workbook, Step 3, Service Availability Access and Uptake: Focus your efforts on strengthening existing services through partnerships where needed. Ensure that the nutritional status of children is regularly monitored. Refer malnourished children to available recuperative services, and ensure a medical evaluation for diagnosis and referral. 66 Nutrition Working Group, CORE Group, Positive Deviance / Hearth Essential Elements: A Resource Guide for Sustainably Rehabilitating Malnourished Children (Addendum). June 2005. Washington, DC: CORE Group. 66 GUIDE STEP FIVE 5
- 74. Ensure that a follow‐up mechanism is in place that provides for follow‐up and family support, such as home visits, if necessary. If services are not available: Incorporate approaches below for rehabilitating malnourished children into program design. Focus program efforts on advocacy and capacity strengthening to ensure that services and supplies will be available in the future. Potential Recuperative Approaches There are a number of potential recuperative approaches, several of which are listed below. The key point is to ensure that whichever approach you use includes the relevant list of elements above. To address MAM or underweight, consider: Positive Deviance (PD)/Hearth Recuperative Supplementary Feeding Programs with behavior change programming Other approaches that contain the listed elements To address SAM, consider: CMAM67 in areas of >1 percent prevalence of SAM in children 6‐59 months of age Referral combined with training to improve facility‐based care Other approaches that contain the listed elements Positive Deviance (PD)/Hearth Brief Summary PD/Hearth is an approach to rehabilitate underweight children. PDIs identify successful Description practices and strategies of poor local families that have healthy children. In a two‐week intensive behavior change initiative (Hearth sessions), volunteers and caregivers prepare and feed a recuperative meal of locally available foods and learn and practice affordable, acceptable, effective and sustainable PD care practices. The meal ingredients are provided by participating families so that they learn that they can afford the foods, where to acquire them and how to use them. Families are followed up with home visits after graduating from the Hearth session to ensure continued growth. Objectives Rehabilitate moderately underweight children68 Enable families to maintain child’s improved nutritional status Prevent undernutrition among other children born in the family Improve care and feeding practices Avoid community dependence on supplemental food programs Target Group Children 6‐36 months of age with moderate underweight (WFA < ‐2 Z‐scores) Note: Children under 6 months of age should be exclusively breastfed and if malnourished, need to be referred to a health center 68 Recent evidence indicates that PD/Hearth is most effective in rehabilitation where underweight is reflecting wasting rather than stunting. 67 GUIDE STEP FIVE 5
- 75. Positive Deviance (PD)/Hearth Consider PD/Hearth if you can answer yes to the following questions: Are at least 30 percent of children 6‐36 months moderately or severely underweight (WFA <‐2 Z‐scores)? Is nutrient‐rich food available and affordable? Are homes located within a short distance of each other? Is there is a community commitment to overcome undernutrition? Is there access to basic complementary health services such as deworming, immunizations, malaria treatment, micronutrient supplementation and referrals? Is there a system (or can a system be created) for identifying and tracking malnourished children? Defining Caregivers contribute local foods Characteristics Community‐level rehabilitation Uses locally available foods and feasible practices Engages community in addressing undernutrition Recuperation and prevention of future undernutrition Follow‐up home visits Intensive behavior change Needed PDI done in every community Elements for Growth monitoring or screening mechanism to identify malnourished children Quality SBC strategies for Hearth participants and larger community Programming Health services to address common childhood diseases Community mobilization Qualitative skill sets to engage community in conducting and analyzing PDI Skills in anthropometric measurement Ability to identify children with SAM for referral Ability to identify children who are stunted only, who are less likely to benefit from the program, and screen them out Technical assistance from someone skilled in the PD/Hearth approach Good supervision skills Access to basic complementary health services (immunization, deworming, micronutrients) Resources CORE Nutrition Working Group. 2002. Positive Deviance / Hearth: A Resource Guide for Sustainably Rehabilitating Malnourished Children. Washington, DC: CORE Group. Available: http://www.coregroup.org/working_groups/pd_hearth.cfm Food Supplementation/Food Assistance: Recuperation Brief Summary In a recuperative food supplementation program, children (usually 6‐59 months of age, but Description target ages vary) with moderate underweight or MAM receive a supplementary food ration along with health services and BCC for a set period of time or until recovery. Recent research has found that a preventive program that targets all children under 2 and pregnant and lactating women with the same services is more effective at reducing prevalence of undernutrition than a recuperative program that only targets the malnourished. Objectives Target Group Criteria Supplementary feeding programs are also often established in emergencies to fill dietary gaps, protect lives and protect nutritional status of women and children. Manage MAM Manage moderate underweight Children 6‐59 months of age with MAM Lactating mothers of malnourished children < 6 months of age Food‐insecure environment 68 GUIDE STEP FIVE Criteria 5
- 76. Food Supplementation/Food Assistance: Recuperation Community‐Based Management of Acute Malnutrition (CMAM)69 Brief Summary Community‐based approach for managing SAM cases, which includes outpatient care for SAM Description without medical complications, inpatient care for SAM with medical complications and infants < 6 months, and community outreach. Community workers are trained to use MUAC and assess edema to actively seek and refer SAM cases to the CMAM program. Based on a medical evaluation and using routine medication and RUTF, CMAM treats the majority of SAM cases at home. SAM cases with medical complications are referred to inpatient care for stabilization before being released to outpatient care for full recovery. CMAM programs may also include a component to manage MAM with routine medications and supplementary feeding, often with fortified‐blended foods. Objectives Treat acute malnutrition in the community Reduce morbidity and mortality of children with acute malnutrition Target Group Children 6‐59 months of age with SAM (MUAC < 115 mm, WFH < ‐3 Z‐scores and/or bilateral pitting edema) Children 6‐59 months of age with MAM (MUAC < 125 but > 115 mm, WFH < ‐2 Z‐scores) may be included if there is a supplementary feeding program Children under 6 months of age with SAM (inpatient care) Criteria Availability of national protocols for the management of acute malnutrition Availability of RUTF, therapeutic milk (F75/F100) and routine medication Availability of trained staff Prevalence of SAM in children under 5 exceeds 1 percent of population of children 6‐59 months Communities with > 10 percent wasting among children 6‐59 months 69 CMAM originated as an emergency care model known as Community‐based Therapeutic Care (CTC). 69 GUIDE STEP FIVE Evidence that food supplementation will not displace local production Logistical capacity for transport, storage and management of food commodity Very high prevalence of underweight (> 30 percent) or high prevalence of MAM (> 10 percent , >5 percent with aggravating factors) Defining Opportunity to link with agriculture and livelihood sectors and improve food access while Characteristics also improving utilization Food supplementation may also be targeted on a seasonal basis, when the food needs are the greatest Food is provided to children 6‐59 months of age with MAM Needed Provision of or access to basic essential health services (and treatment of SAM if Elements for appropriate) Quality Complementary preventive SBC programming focused on maternal nutrition, IYCF, hygiene Programming and health‐seeking behaviors Close programmatic coordination with health, nutrition and food security programs and services Formative research to adapt program to local conditions, including seasonal calendar of when food needs are greatest Resources USAID Office of Food for Peace: http://www.usaid.gov/our_work/humanitarian_assistance/ffp/ FANTA‐2: www.fanta‐2.org World Food Programme: www.wfp.org 5
- 77. May be considered for use in post‐emergency communities or with frequent periodic emergencies in addition to development contexts Defining Community‐based approach for treating acute malnutrition on an outpatient basis Characteristics Use of RUTF instead of milk‐based formulas for cases of SAM with no medical complications and children over 6 months of age Community outreach for active case‐finding and referral to catch children with SAM or MAM as early as possible Needed Active community case‐finding using MUAC and assessment of edema Elements for SBC strategies for sustainable prevention Quality Health services to address common childhood diseases Programming Skills in anthropometric measurement Trained community members who can identify cases of severe or complicated acute malnutrition for referral Technical assistance from someone skilled in the CMAM approach Resources (financial, in‐kind) for a supply of RUTF and medications Trained clinical staff to conduct medical evaluation, identify medical complications, refer and treat cases Inpatient services available Resources FANTA, Concern Worldwide, UNICEF, and Valid International.2008. Training Guide for Community‐based Management of Acute Malnutrition. Washington, DC: AED. Available: http://www.fanta‐2.org/ What approach will you use? Fill out your thoughts in the boxes provided in Step 5 of the Workbook. 5 70 GUIDE STEP FIVE
- 79. 72 6 Staffing Needs What tasks and responsibilities will program staff have? Consider needs for SBC, nutrition, monitoring and evaluation, and community mobilization. What number and skill sets of staff are needed to implement the program effectively? What tasks and responsibilities will CHWs or CHVs have? How many hours per week or month are needed? How many volunteers or workers are needed? What are the supervisory needs? How are volunteers or community workers currently compensated or incentivized? Do staff need capacity building in the skills needed to implement the program approach? Technical Assistance Needs Will external technical assistance be needed? Consider needs for SBC, monitoring and evaluation, community mobilization, formative research and documentation. Can technical assistance be secured from home/regional office? Can technical assistance be secured from local or international consultants? Does the health system (national or local) or other organization or partners have individuals with strong skills that can contribute to training others in specific nutrition approaches? Direct Program Implementation Needs What activities will you carry out (e.g., trainings, support groups, SBC strategy, advocacy, health days)? Where will they take place? What vehicle or fuel costs will be needed to support outreach and program efforts? How many communities will be involved? How many people will be involved in activities? Program Supply Needs What inputs and materials will need to be purchased and distributed? Does the MOH or other organization or partner have appropriate nutrition educational materials which can be used or modified? Will you need: o Scales and measuring boards o MUAC tapes o Child growth cards o SBC materials o Food supplements o Medications o Micronutrient supplements o Record‐keeping/monitoring materials o Office equipment GUIDE STEP SIX Costing Considerations
- 84. Classifications of Undernutrition for Individuals76 Cut‐off Undernutrition Classification < ‐1 to ≥‐2 Z‐scores Mild < ‐2 to ≥‐3 Z‐scores Moderate < ‐3 Z‐scores Severe Anthropometry Summary Type of Undernutrition Detected Indicator77 Height‐for‐Age (HFA) Stunting/Chronic Malnutrition Failure to grow adequately in height or length Reflects chronic, long‐term undernutrition or poor health % of children 0‐59 months with HFA < ‐2 Z‐scores Weight‐for‐Height (WFH) Wasting/Moderate Acute Malnutrition (MAM) Failure to gain sufficient weight relative to height or length, or weight loss Reflects more recent undernutrition or weight loss % of children 0‐59 months with WFH < ‐2 Z‐scores Weight‐for‐Age (WFA) Underweight Failure to gain sufficient weight relative to age, or weight loss Reflects stunting, wasting or both but does not distinguish between the two % of children 0‐59 months with WFA <‐2 Z‐scores Body Mass Index (BMI) Body Thinness/Chronic Energy Deficiency Failure to gain sufficient weight, or weight loss Associated with body fat and protein stores % of women 15‐49 years with BMI < 18.5 kg/m2 Mid‐Upper Arm Circumference (MUAC) Acute Malnutrition Failure to gain sufficient weight, or weight loss Reflects wasting GAM: % of children 6‐59 months with MUAC < 125 mm MAM: % of children 6‐59 months with MUAC < 125 mm and ≥ 115 mm SAM: % of children 6‐59 months with MUAC < 115 mm 76 Cogill, Bruce. 2003. Anthropometric Indicators Measurement Guide. Washington, DC: Food and Nutrition Technical Assistance Project, Academy for Educational Development. 77 Note: Age ranges for which data are available can and will vary. 77 GUIDE ANNEX ONE Measure
- 92. The Nutrition Program Design Assistant: A Tool for Program Planners helps program planning teams select appropriate community-based nutrition approaches for specific target areas. The tool has two components: 1) a reference guide that provides guidance on analyzing the nutrition situation, identifying program approaches and selecting a combination of approaches that best suits the situation, resources and objectives and; 2) a workbook where the team records information, decisions and decisionmaking rationale. www.coregroup.org CORE Group fosters collaborative action and learning to improve and expand community-focused public health practices. Established in 1997 in Washington D.C., CORE Group is an independent 501(c)3 organization, and home of the Community Health Network, which brings together CORE Group member organizations, scholars, advocates and donors to support the health of underserved mothers, children and communities around the world. Photo Credits Top left: Laura Lartigue, Courtesy of Photoshare Second: Save the Children Third: Judiann McNulty Fourth: Save the Children Fifth: Save the Children Sixth: International Relief & Development Seventh: Save the Children Bottom: International Relief & Development