UNHCR Operational Guidance for use of special nutritional products

Mothers and caregivers taking part in an MNP demonstration session during acceptability tests in a refugee camp in Algeria

This article summarises UNHCR's 'Operational Guidance on the Use of Special Nutritional Products to Reduce Micronutrient Deficiencies and Malnutrition in Refugee Populations'. It is one of the outputs of the Anaemia Control, Prevention and Reduction Project, a collaborative work between the UNHCR and ENN.

Micronutrient malnutrition and undernutrition are now widely recognised as priority areas during emergency responses and protracted refugee operations. During 2009, UNHCR commenced implementation of a strategy that aims to achieve a reduction in anaemia and other micronutrient deficiencies/undernutrition, thereby enhancing growth, development and health in refugee populations across their global operations. The approach involves the use, amongst other interventions, of food supplementation products (FSP) including micronutrient powders (MNP) and lipid-based nutrient supplements (LNS).

Project activities were initiated in seven countries during 2009, together with the World Food Programme (WFP) and other partners, and will continue to expand to additional countries during 2011 and beyond. During the initial expansion phase of the project, UNHCR identified the urgent need to improve the assessment of micronutrient, acute, and chronic malnutrition, as well as the design of programmes for their control and reduction in both emergency and protracted situations. However, as many of the FSP products and approaches being adopted are still relatively new there was also a need for continued technical support for assessments, setting up and maintaining intervention programmes, monitoring and evaluation systems, and mainstreaming best practice.

The Operational Guidance (OG) has been developed by an ENN Team in coordination with UNHCR to meet this need and to help country staff deal with the challenges involved in designing programmes using new FSPs.

Development of the Operational Guidance

The OG builds on existing frameworks (e.g. WFP/Sight and Life 10 minutes to learn about nutrition programming, 2008) as well as standard selective feeding guidelines (UNHCR/WFP Selective Feeding Guidelines, 2009). Whilst these existing frameworks and guidelines provide useful guidance that is widely applicable, the OG deals with a new set of FSPs, including MNP and LNS products that are currently being used, or considered for use in UNHCR operations.

It is aimed at UNHCR health and nutrition field staff and implementing partners and its scope extends to UNHCR operations during 2011-2013. The focus of the OG is on children aged 6-59 months but can easily be adapted to other age groups, including women and adolescent girls. The interventions it describes are not intended for use alone, but to complement additional programmes for this age group as well as the general population.

The OG contains six stages, covering the key components of planning, implementing, monitoring and evaluating programmes, using the specific special nutritional products, to reduce micronutrient deficiencies and malnutrition in refugee populations. These stages should ideally be conducted in chronological order, although some stages are inter-related and complement one another (see Figure 1).

Stage one

Stage one is intended to aid readers in defining the nutritional needs present in the population of interest, namely children 6 - 59 months. Three main indicators are suggested for use in the assessment of nutritional problems and what FSPs may be considered as possible options. These are the prevalence of global acute malnutrition (weight-for-height <-2 Z-scores and/or oedema), anaemia (haemoglobin concentration <11.0 g/dl) and stunting (height-for-age <-2 Zscores). In order to classify the severity of the nutrition situation, the guidance advises that prevalence estimates should be gathered for the suggested indicators from the latest crosssectional surveys conducted in the camp(s), whilst also considering any contextual information that may have influenced the survey results. Where there is no recent survey data available or indicators are missing, priority should be to carry out a baseline nutrition survey, although other options are suggested in case this is not possible. A simplified classification table has been provided (based on WHO criteria) which categorises indicators as low, medium, and high. High levels of one or more of these indicators suggest that an FSP intervention may be appropriate, depending on the outcomes of subsequent stages. Coordination and involvement of all relevant actors (e.g. donors, government, non-government organisations (NGOs), WFP, and other partners) should also begin at this stage.

Stage two

The purpose of stage two is to aid in the selection of a potential FSP intervention for any serious nutritional problems identified and defined in stage one. In addition to fortified blended foods (FBFs), the FSPs considered in this guidance include only MNPs and specific LNS products designed for the prevention of malnutrition. A decision tool containing eight scenarios has been developed to guide the identification of potential FSP interventions for children aged 6- 59 months, depending on the context. Each scenario depicts a potential camp context presenting with high prevalence estimates of one or more of each of the nutritional problems previously identified i.e. global acute malnutrition, anaemia, or stunting. Recommendations are given to select the scenario which best reflects the camp(s) situation, and then to consider the possible intervention options that are listed.

Stage three

Mothers and caregivers taking part in an MNP demonstration session during acceptability tests in a refugee camp in Algeria

The objective of stage three is to identify any risks and precautions that need to be considered before commencing a particular FSP intervention. These risks may include, but are not limited to: adverse effects on other programmes, excessive micronutrient consumption, adverse affects on feeding practices and health including potential for breastmilk displacement, delays in importing and obtaining permission for product use, deterioration of stock, and environmental impact. Suggested solutions are provided for dealing with each of these potential risks that the assessment may highlight.

Stage four

Stage four is designed to test the acceptability of the selected FSP to the potential beneficiaries, and their adherence to the recommended dosage. A standard protocol tool is provided for use. The acceptability test includes distribution of the FSP to a group of participants for a minimum of three weeks. Among others, data on local eating habits, cultural beliefs, health knowledge, and acceptability and use of the product is collected through qualitative and quantitative methods, at baseline, midline and end-line, through focus group discussions (FGDs), key informant (KI) interviews, household interviews and direct observation. Crosschecking and interpretation of data collected from these activities will help to inform the decision about whether the product is acceptable to the community and therefore whether to proceed with the selected intervention. It can also guide the design of appropriate, context specific educational campaigns, distribution mechanisms and packaging, and other important programming elements.

Stage five

Stage five is intended to deal with the key considerations for designing and implementing an effective FSP intervention and how this might best be done, considering the risk assessment and acceptability test results. Coordination of all actors needs to be ensured by this stage. Further considerations include: logistical components such as product order, storage and stock management, the frequency and duration of product use depending on target group needs and context, training of health workers and staff so that they are familiar with use of the FSP, design of a context specific communication and education campaign, potential distribution channels/ distribution. Relevant tools are provided to aid with both standardisation of training and effective community mobilisation.

Stage six

Finally, as with any programme, strong monitoring and evaluation (M&E) should accompany any FSP intervention, particularly due to the new nature of the products being used, and this is documented in stage six. Minimum reporting requirements are provided which need to be adapted depending on individual programming requirements and the products used.

Next Steps

A launch workshop is being held in July 2011 in which training on the use of the OG will be provided to UNHCR and WFP health and nutrition staff, and in which current experiences of using these products and approaches will be shared. Lessons learnt from the use of this OG will be used in future revisions. Future updates to the OG will be uploaded as and when necessary to ensure the current version reflects the latest developments in product availability and use in this rapidly changing area of nutrition.

For more information, contact Caroline Wilkinson or Allison Oman, email: HQPNH@unhcr.org

Once finalised (August 2011), the Operational Guidance will be available at: http://www.unhcr.org/pages/49c3646cec.html