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monitoring nutrition program for stunting indicators

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Hamid Hussien

Nutrition Specialist Concern WW

Normal user

26 Jun 2014, 07:37

We have implemented a preventive program through distribution of folic acid/ vitamin A and health education about food diversity ,screening

We plan to implement nutrition program to manage and prevent chronic malnutrition (stunting cases) in west Asia within CMAM interventions.
this intervention will be through community based workers

Which kind of interventions are appropriate for addressing stunting problem and how can we link them with CMAM

what is the appropriate monitoring and evaluation tools that we can use to estimate program progress and indicators

Gudrun Stallkamp

Welthungerhilfe (WHH)

Normal user

26 Jun 2014, 13:35

Dear Hamid,

sounds like a good programme idea and probably very much needed!

Couple of thoughts:
In my opinion, the key things are to get the targeting right, your actual interventions, and how you link together different sectoral approaches (which are probably necessary if you’re serious about addressing the stunting problem in your area)

- It is difficult to address the stunting prevalence in a way you would run a targeted intervention and you will have to look into a preventive approach.
For CMAM you identify your SAM kids and then you know exactly what needs to be done as per protocol.
For stunting, if a child is stunted already it also is too late for the child to benefit from your intervention. So identifying stunted kids is not the way to go, you have to focus your intervention before they become stunted.
- So, you look at moms and kids within the 1000 days window and focus your intervention there. That’s when you have a chance to prevent stunting from happening in the first place.
- This is a fundamental difference to a CMAM programme, which is a very targeted intervention, usually meant to address a problem that about 1-2% of all under-fives have, while stunting is a problem where every second or third child is affected. Therefore linking a stunting prevention to a CMAM programme is relatively tricky in a direct way because you just won’t get the kids you want.
- In an ideal resource situation, you’d go for a blanket approach because you can’t predict very well who will be stunted after the 1000 days. Stunting is not only a problem of the poorest as can be seen in many DHS: check the stunting prevalence across the different quintiles, probably close to a quarter of kids in the wealthiest quintile are stunted – that’s a lot!

Deciding about the right mix of interventions
- The Framework in the Lancet 2013 papers is a useful overview of the different bits and pieces, you could use is as a check list thing (obviously considering your context and specific situation). It can help you to not accidently forget a key area.
- Try and sit with your team to develop a pathway of how chronic malnutrition happens in your area, and then follow up that exercise by looking at the different stages and try to develop interventions that can address these different steps along your pathway. It is useful to not only ask health/nutrition staff to join this exercise but invite colleagues from agriculture, gender, WASH and social protection (even if from another organisation). Malnutrition is multi-causal, so it has to be addressed multi-sectorally. And that only works if the sectors come together right from the beginning…
- Thirdly, you could do a bit of formative research, if you have the time/resources, to understand actual and relevant barriers to the key practice that you’d like to promote but that are not yet working so well.
- The ‘Nutrition Program Design Assistant’ could be a useful tool, too. Google it… there’s a Reference Guide and a Workbook, both available online.

What could you do and delivery channels
- So, what you can do is enable the mom and caregivers to go through a good pregnancy and then care for/ feed the child optimally, many of these are nutrition-specific interventions. Enabling them to do this also means to look into nutrition-sensitive interventions.
- Looking at engagement with community-based workers (CW) is great. You’ll likely require a good network at community level where you can reach households easily and at a larger scale. This can be CWs on the health side (often they’re already in place) but it’s also useful to look at who could deliver nutrition-sensitive interventions at community level, agriculture extension workers, animal health workers, community development/ gender workers…
- Cascading trainings into groups are a very useful way to ensure good coverage and reach. There are different approaches for such groups (mother support groups, care group approach, etc. etc.)
- Looking at ways to enshrine the intervention within Government community level outreach/ extension systems will increase the chances your activities can be sustained beyond your own agency’s engagement. Try and also check with what SUN or perhaps REACH are promoting in your country, are there ways to link with that at district or province level?
- Unfortunately there is no standard protocol to addressing stunting, as e.g. for CMAM; it is dependent on the context, the family situation and probably even the situation of that very child – so all the three levels of the UNICEF framework…
-That said, concrete intervention options that probably would make sense in your situation include:
o Promoting optimal IYCF practices (individual and group level counselling
o Ensuring household level availability of the foods required for good dietary diversity. This might be through own production or through access via markets. For the own production pathway, a good thing to look into is homestead food production (kitchen gardens and small animal husbandry). For the market pathway, you’re might need to address decision-making dynamics so that decisions for buying ‘nutritious’ foods are being made. Focus on promoting animal source foods is very important and promoting bio-fortified crop varieties. Social protection mechanisms if linked to a diverse range of foods could be very useful.
o There must be direct links between these two intervention types: promote consumption of what’s available and promote production of/ access to foods that are ‘nutritious’. Anything else is a sub-optimal use of time and resources to effectively address your problem.
o Control of micronutrient-deficiencies: you seem to already consider this… should look at women and kids…
o Women’s empowerment and decision-making – super important
o PMTCT: depending on your HIV burden, this may or may not be a real important thing to consider, and it fits right into the 1000 days window.
o WASH: safer water, adequate treatment of diarrhoea and also check out the emerging stuff related to environmental enteropathy where strong links to stunting are hypothesized.
o Establish a coordination mechanisms across the different sectors, both for your project and also for the Gov’t system if you’re able to engage with them. Facilitate understanding of nutrition across the different sectors, so that people understand why you ask them to contribute to your nutrition programme and that they understand the important role they have to play within this. (They’re more likely to then really do it and continue it….)
o There is a lot of reading out there for these intervention ideas…

In terms of M&E and indicators, it’s useful to conduct a household level survey with questions related to:
- Anthropometry (all Z-scores, but would also do MUAC, oedema because you also have your CMAM programme next door) SMART is a great way to help you with this
- the standard IYCF indicators (use the WHO 2010 IYCF indicator guide to understand what to assess)
- Production diversity (e.g. look whether households produce food from the different food groups)
- Women’s empowerment (what to grow/ sell/ buy/ cook)
- Health services and treatment seeking
- Micronutrients (moms and kids): supplementation, MN powders, deworming, iodized salt. Measuring actual MN deficiencies is great if you can afford it. UNHCR’s SENS survey has some good guidance related to anaemia.
- WASH practices that are relevant to your planned intervention, especially handwashing with soap observation
- Other practices related to your prevention/ components of your programme

Hope this helps a little.

Good luck!

Hamid Hussien

Nutrition Specialist Concern WW

Normal user

29 Jun 2014, 12:40

Thanks alot

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