Models for Strengthening the Community-based Management of Acute Malnutrition_Geraldine McCrossan_5.6.14
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Models for Strengthening the Community-based Management of Acute Malnutrition_Geraldine McCrossan_5.6.14
- 1. Nutrition Impact & PositiveNutrition Impact & Positive Practice (NIPP) ProjectPractice (NIPP) Project GOALGOAL Spring 2014 Global Health Practitioner Conference Date: 5th – 9th May 2014 Presentation Prepared By: Hatty Barthorp, GOAL Global Nutrition Advisor hbarthorp@goal.ie Presentation Presented By: Geraldine McCrossan, GOAL Global Health Advisor
- 2. Why we chose to create a new approach? Offers an alternative to food hand outs for community based MAM treatment and prevention in non-emergency settings Supports: The treatment of mild or moderate MN in the community Prevents future episodes of acute MN To reduce the prevalence and thus burden of chronic MN Ø 2
- 3. Rationale: Other Approaches not addressing the underlying causes of MN ØTSFP: Treat MAM - impact on the prevalence of SAM & associated mortality ØBSFP: Prevent MAM - impact on the prevalence of SAM & associated mortality, and partial role in reducing MAM ØSignificant issues around plausibility & sustainability of SFPs in chronic or cyclical emergencies
- 4. How do NIPPs attempt to achieve their outcomes? By using a grass-roots based approach, tackling a multi- sectoral package of underlying behavioural causes of acute & chronic MN, through changing community norms and targeting infants, children, PLW &/or CI. Despite having a nutrition focus, NIPPs have been designed to be sensitive to pre-identified health, hygiene-sanitation and nutrition security causes of MN, in addition to addressing problematic care and feeding practices. Objective: To achieve positive and sustained Behaviour Change through a holistic approach 4
- 5. 555
- 6. Structure of the project “Macro-circles” are comprised of a female circle, a male circle & a community circle The focus is around replicable, peer-led education and practical demonstrations, in attempts to support positive behaviour change in communities where inappropriate behaviours are known to contribute to MN. As knowledge does not necessarily translate into action, sessions use: participatory methods, positive reinforcement and repetition. The circles focus on 3 main components which are repeated during each session: 1. Behaviour Change Communication & Counselling 2. Micro-gardening 3. Cooking demonstrations 6
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- 8. How do we maximise outcomes? Formative research -household analyses, understanding of barriers and market assessments Specific activities designed based on findings. Note: different messages & activities can be promoted in different settings, dependent on causes identified. How do we monitor whether it’s working? a) LQAS to assess chronic and acute MN - indication of the ‘impact’ b) Longitudinal data collection– indication of ‘outcomes’ 8
- 9. Activities Incorporated Construction of fuel efficient stoves & Cooking demonstrations after market assessment Fuel-efficient stove building Cooking demonstration items, South Sudan 999
- 10. Kassala State, Sudan Use of Food Flash Cards to teach participants about food groups, diet diversity and help design their own recipes 101010
- 11. Micro-gardening (eating produce at home) The garden at the HH of a NIPP circle beneficiary in Baliet County, South Sudan 111111
- 12. Produce from the Micro-garden Harvesting tomatoes/ eggplant in Ulang County, South Sudan 121212
- 13. Participatory, activities on food processing, preservation & storage Food preservation in Garbia, Sudan 131313
- 14. Construction of basic hygiene-sanitation hard-ware to address related causes of MN Tippy taps for hand washing, South Sudan Household latrines Drying rack 141414
- 15. Where is GOAL implementing NIPPs Geographic coverage of the intervention at present: South Sudan (4 field sites) – Baliet & Ulang in Upper Nile State, Twic in Warrup State and Abyei Administrative Area, all sites direct oversight by GOAL Sudan (3 field sites) – Kutum in N.Darfur, oversight by GOAL, Kassala in East Sudan, oversight by local partner WOD and Mayo in Khartoum, oversight by local partner ALMANAR Zimbabwe 3 districts – Hurungwe, Makoni and Nyanga districts, all direct oversight by GOAL Malawi in the process of transitioning from PD Hearth to full NIPP approach in two districts, Balaka and Nsanje 151515
- 16. Why do we think it works? 16
- 17. 171717
- 18. Results Admission data from 130 circle cycles Graduation data from 59 circle cycles From Sudan & SS we have been able to show: Ø79.7% (419 cases) of children/PLW admitted graduated ØFollow- up on-going 18
- 19. 19 To give an idea of scalability: DFID Roll-out plan for Zimbabwe 19
- 20. 20 MoH, local CBOs or national NGOs could run the project. As M&E can be downscaled and operational costs are purposefully kept to a minimum. • Volunteer incentives are limited to non-expensive means • • The only hand out to participants – is a starter seed pack: everything else is sourced by the participants locally. • Thinking long-term: 2020
Notas do Editor
- Needed an alternative means ofcommunity based, moderate acute malnutrition (MAM) treatment and preventionto food hand-out style nutrition programs (SFPs) in non-emergency settings To Help treat mild or moderate MNin the community To Prevent future episodes of acute MNincluding low birth weight (LBW) due to intrauterine growth restriction through treatment/prevention of pregnant/lactating women (PLW); and thus To Help to reduce the prevalence and thus burden of chronic MN
- TSFP: Used to treat MAM for those with identified MAM will only have a potential impact on the prevalence of SAM & associated mortality, but will in no way impact the rates of MAM and thus overall GAM. This is because treatment is focussed on feeding and nutritional rehabilitation,not on tackling the underlying causesof the MN. As such, beneficiaries cycle through the program, but are returned the same environment that caused the MN in the first instance. BSFP: Traditionally used to prevent MAM in high risk groups, through the provision ofa supplementary ration for an entire sub-sect of the population (irrespective of nutritional status) i.e. all children 6-59mths. This willhave a potential impact on the prevalence of SAM & associated mortalityas per TSFP, andmightalso play apartialrole in reducing MAM prevalence within the specific sub-group selected in the short-term,if food insecurity is an identified cause of MN. But as above,it rarely tackles any of the synergistic underlying causes of MN in any meaningful way. Added to which, there are very significant issues around plausibility and sustainability ofsupplementary feeding programsin contexts of chronic or cyclical emergencies:
- How do NIPPs attempt to achieve these outcomes? By using a grass-roots based approach, tackling a multi-sectoral package of underlying behavioural causes of acute & chronic MN, through changing community norms, targeting infants, children, PLW &/or CI. This package includes: Improving whole familiesunderstanding ofwhy malnutrition occursin high risk individualsand what can be done to prevent it Improving household (HH)hygiene-sanitationpractices Improving HHhealth seekingpractices Improving household (HH)diet diversityand Eliciting sustainable improvements inHHcare & feeding practices. Therefore: Improving thenutritional statusof those with identified mild or moderate malnutrition (MN) Reducing the risk of further undernutritionin high risk, targeted individuals Despite having a nutrition focus, you will see that NIPPs have been designed to besensitiveto pre-identified health, hygiene-sanitation and nutrition security causes of MN, in addition to addressing problematic care and feeding practices. Whereby the overallObjective: Is to achieve positive and sustained Behaviour Change NIPPs have taken about 4 years in their development and have evolved from a mish-mash of different sectoral activities that were all run concurrently, but were being implemented poorly together. In the reality of the field, it is difficult for implementing sectoral staff to get out of the mind-set that they are a LLH officer, a WASH officer or a health or nutrition officer – rather that they are an aid worker, helping to contribute to a common goal. Thus we decided to design a project, packaging multi-sectoral activities under one roof to eliminate this issue.
- The diagram illustrates: The female/male & community circles The 3 main components that are repeated during each session Behaviour Change Communication & Counselling Micro-gardening Cooking demonstrations In addition to the green box on the left, which are the ‘non-negotiables’ of the project. If there is no hand-washing facility, or HH latrine, then participants will be taught how to make them. If HH’s are not using FESs – they are also taught how to make them and encouraged to use them at home. All groups will have demonstrations on food process, preservation and storage techniques to improve access to improved diet diversitythroughout the year.
- Structure of the project: This highlights the modalities of NIPPs “Macro-circles”are comprised of a♀circle, a♂circle & a community circle The design tries to giveequal attention to: Females(primary care givers & ‘grannies’)and Males(often one of the primary influencing groups) As well as including thecommunityat large, to improve transparency, awareness and buy-in and reduce negative messaging. To give you an idea of how the circles actually run, with rough estimates of participant numbers, along what time-frames and who leads the sessions: Female NIPP Circles: Between ~10-15 female primary carer(s) Circles run for ~12 weeks, for ~2-3 hrs/day, a min’ of 3 x a wk Hosted by a female PD volunteer at a time that is most suitable to all Male NIPP Circles: Held with fathers, brothers and/or other influential male family members from the same HHs as the female participants, between ~10-15 Similar timeframe to the women’s sessions is followed, but sessions are usually shorter, as men don’t have to undertake all the practical exercises. Hosted by a male PD volunteer at a time that is most suitable to all Community Member NIPP Circles: Include traditional healers, TBAs, key community representatives, influential religious figures, respected elderly etc. – no limit on numbers Sessions are run at the outset of the project to introduce key topics included in circles and discuss key practices that are reinforced for both men & women and therefore improve transparency, understanding & acceptance of promoted positive practices – hosted by a PD volunteer or community health volunteer/worker Sessions comprise of anywhere from ~3-7 days for ~2hrs/day As it is well understood thatknowledge does not necessarily translate into action, NIPP sessions useparticipatory practicalmethods,positive reinforcementby the lead volunteer andrepetition, to habituate participants to the use of positive practices. The circles aim to facilitate knowledge and skills sharing ofboth men and women,using locally available resources with all contributions made by the group members themselves,focussing on 3 main components which are repeated during each session: Behaviour Change Communication & Counselling- forimproved awareness and practice, including appropriate care and feeding practices, plus themes from other sectors (health/WASH/HIV/LLH i.e. lessons on construction and use of energy saving stoves, locally fabricated latrines, hand-washing points such as tippy taps, active health seeking of PLW for ANC/PNC & micronutrient supplementation, promotion of VCT or adherence to ARVs etc. Micro-gardeningforimproved food/nutrition security Cooking demonstrationsforimproved child feeding & care practices.
- In summary, there is a staged admission criteria whereby the ‘most vulnerable’ are prioritised for admission first. These include OTP discharges and children with identified MAM, then PLW with identified MAM, then families with CI, then ‘other’ high risk families. If all spaces are filled in a local circle cycle, then either another circle can be started up (if there are resources to do so), or the remaining participants will be included in the second cycle of their local circle.
- How do we maximise outcomes? We conduct formative research, including review ofS&Afindings,situational analyses, Designing for Behaviour Change (DBC) frameworks (includingBarrier Analyses), prior to implementationin target communitiesand specific activities are designed for the NIPP sessions based on findings. Note: different messages & activities can be promoted in different settings, dependent on causes identified. How do we monitor whether it’s working? Prior to project commencement (as a baseline), then annually, anLQAS is conducted to assess chronic and acute MNin children 6-23m in target areas, as an indication of the ‘impact’. Then, on alongitudinal basis, in an effort to determine ‘outcomes’ and the sustainabilityof these outcomes over time, we collect data: at admission & upon graduation (~12wks after admission) for all participants and then 2mths, 6mths and 12mths post-graduation for a representative sample. The key indicators for longitudinal data collection include: anthropometry of children <5 and PLW, care practices, feeding practices of both PLW & children, LLH practices, hygiene-sanitation practices and HIV knowledge.(if people want more info’ on the specific indicators – just look at the NIPP DB that details all headings under the ‘Outcome indic Summ-AUTO’ tab.
- The next 6 slides show photos illustrating the types of activities incorporated.
- To give an overview of where we are presenting implementing this community based approach
- Why does it work? Because we looked at what was working and what wasn’t in an array of different community based projects, we eliminated the practices that were thought to be ineffective and focused on areas that were deemed to be key to elicitingpositive and sustained BC.
- In terms ofresults– the M&E section has taken quite some time to develop and went live in 2013. We now have admission data from over 130 circle cycles, graduation data from 59 circle cycles, 2 month follow up data from 33 circle cycles, 6 month follow up data from 2 circle cycles. Unfortunately SS have been terribly affected by recent security issues which has led to the suspension of a number of circles and/or inability to collect data for those that have continued to function. However, in Sudan and SS, along with various very encouraging results from care practices, feeding practices, micro-gardening and hygiene-sanitation practices, from an anthropometric point of view, the average% of children 6-59m admitted with a MUAC between 12.5cm & 11.5cm reaching graduation with a MUAC >12.5cm, infants with a MUAC <11cm with an appetite reaching graduation with a MUAC >11cm & PLW admitted with MUAC <23cm reaching graduation with MUAC >23cmwas 79.7% (#419 cases).
- People often ask about the scalability of activities. This slide gives an example of the numbers that will be targeted in Zim’ over a 3 year period – whereby approximately 22,000 direct beneficiaries from participating HH’s (normally including the mother, father and children) will have benefited from participating in a NIPP circle. So it is relatively scalable, but given that we’re trying to elicit sustainable BC, it’s obviously not as simple or easy as merely handing out a cure.
- Thinking long-term: Eventually, ideally the MoH, a local CBO or national NGO would run the NIPP circle project. The M&E component can be downscaled in accordance with need. At present however, we want to collect data to review efficacy. Added to which, as such organisations will be unable to afford an expensive project, costs are purposefully kept to a minimum: Volunteer incentives are limited to non-expensive means e.g. volunteer recognition days, on-going feedback and support sessions. The only hand out to participants – is a starter seed pack: everything else is sourced by the participants locally. E.g. South Sudan: SMART, a local NGO, is working with GOAL to understand supervision mechanisms of this activity and to assist with anthropometric measurements/ micro-gardens
- Needed an alternative means ofcommunity based, moderate acute malnutrition (MAM) treatment and preventionto food hand-out style nutrition programs (SFPs) in non-emergency settings To Help treat mild or moderate MNin the community To Prevent future episodes of acute MNincluding low birth weight (LBW) due to intrauterine growth restriction through treatment/prevention of pregnant/lactating women (PLW); and thus To Help to reduce the prevalence and thus burden of chronic MN