Experiences of the Nutrition in Emergencies Regional Training Initiative

By Abigail Perry, Jessica Meeker, and Andrew Seal, UCL Centre for International Health and Development (UCL-CIHD)

Abigail Perry is a nutritionist with extensive experience in development and emergency work. She worked as a Research Associate at UCL and was the coordinator and lead trainer for the Nutrition in Emergencies Regional Training Initiative (NIERTI) project between 2009 and 2011

Andrew Seal is a Lecturer in International Nutrition at UCL where he conducts research and training on various aspects of nutrition in emergencies. He was the project manager for the work described here and is continuing the work with NIERTI partners to take forward this initiative

Jessica Meeker is a graduate of the LSHTM Public Health Nutrition course, coming from a previous career in IT consultancy management. Whilst working as a Research Assistant at UCL, she conducted much of the research on Nutrition in Emergencies competencies

The NIERTI project started in the Autumn of 2009 and has just concluded. The project was funded by an OFDA award to the Emergency Nutrition Network (Agreement No. DFD-G-00-09-00289-00) and implemented by UCL-CIHD.

The upward trend in the frequency and magnitude of humanitarian disasters is set to continue and ongoing economic instability, escalating food and fuel prices, climate change and urbanisation are predicted to amplify humanitarian needs¹ . This projection of increased vulnerability has implications for development; losses associated with humanitarian disasters are thwarting progress towards meeting development goals². Central to efforts to protect communities and reduce vulnerability is the development of capacity to prepare for and respond to crises effectively³. The 2005 Humanitarian Response Review noted that the lack of capacity in the humanitarian sector hampers the quality and appropriateness of emergency response. The review provoked more detailed examination of humanitarian capacity, including a 2007 report focusing on ‘nutrition in emergencies’ (NIE)⁴. This review, completed on behalf of the IASC Global Nutrition Cluster (GNC), identified two key NIE capacity gaps: (i) inadequate ‘resident’ capacity and (ii) lack of nutritionists able to handle the demands of emergencies.

A number of projects have since emerged that have attempted to address this gap. In 2008, a standard set of technical documents, known as the Harmonised Training Package (HTP) were developed⁵. More recently, the GNC has initiated a capacity development project for cluster coordinators. In addition, two projects have been developed with support from the Office for Disaster Assistance (OFDA) to the ENN⁶; one focusing on in-service and pre-service training in NIE (implemented by NutritionWorks) and the other on the development of professional short courses. In this report we discuss the key findings from the second of these projects, the Nutrition in Emergencies Regional Training Initiative (NIERTI).

NIERTI objectives

The overall goal of the NIERTI was to increase the availability of regular, high quality training in emergency nutrition. Two principles underpinned the development of the training model. First, we viewed capacity development in the broadest sense and thus as a process that requires investment in three levels of capacity: (i) the individual, (ii) the organisation and (iii) the enabling environment⁷. Keeping this in mind, we elected to focus on strengthening the capacity of relatively senior national and international individual practitioners. This group represents the ‘tip’ of the human resource capacity pyramid. Although investment is needed in NIE capacity at every level, building this cadre will improve organisational capacity and create an enabling environment for effective capacity development among the other cadres. Second, the training would be implemented in partnership with academic institutions. Our aim was to develop a model that has financial and market sustainability and that can be owned and maintained by partner institutions, rather than being dependent on (unpredictable) external funding. The three partner institutions were the American University of Beirut in Lebanon, the University of Makerere in Uganda and the Asian Disaster Preparedness Centre in Thailand. All three institutions were already running nutrition courses as well as the Public Health in Complex Emergencies short course⁸. The NIERTI sought to work in partnership and strengthen and develop their training capacity in NIE.

Development of the training model

Cost

Financial sustainability was identified from the outset as a key factor in the success of this initiative. As such, we worked closely with our partners to develop realistic budgets that ensured all the costs associated with running the courses would be covered by course fees alone. The fee level for each course was based on estimated cost and anticipated participant numbers. The budgets were reviewed and revised following each course to ensure that on one hand, course fees are kept at a minimum and access is maximised, and on the other, that the courses are financially sustainable.

Content

Three courses of varying duration (6, 10 and 12 days) were developed and pilot tested. This process enabled us to determine the optimal duration and balance of topics. A set of learning objectives was developed for each course module. This helped to shape the content and to select appropriate course exercises. The technical content was based on the HTP, supplemented where necessary with exercises developed specifically for the initiative. Each module consisted of a technical reference document (compiled in a course manual for participants), generic PowerPoint presentations and practical exercises.

Previous reviews of NIE capacity development and interviews with NIE practitioners highlighted the importance of including activities that enable participants to apply knowledge. As a result, a 1-day emergency simulation exercise was developed in consultation with a range of NIE experts. The simulation was reviewed and revised following each course. Field-based exercises relating to the management of acute malnutrition and nutrition surveys were adapted from the HTP and tested during the course in Uganda.

Evaluation

Modules were delivered by experienced facilitators and feedback was obtained using a variety of evaluation approaches. All materials were piloted at least twice and reviewed and revised from one course to the next based on comments from course participants, our partners and course facilitators. Module-specific and end-of-course evaluation forms were administered to participants. Feedback from each partner organisation and the course facilitators was obtained verbally and via email. Follow-up of course participants was done approximately 3 months after each course ended.

Assessment

A multiple-choice questionnaire was developed and tested to assess the progress of participants. Each of the 40 questions was designed to correspond to one of the three levels of learning, based on a modified version of Bloom’s taxonomy (knowledge, combined comprehension and application, and problem solving)⁹. The MCQ was pilot tested before being administered to course participants. The test was given at the start and end of the course and scores were reviewed and analysed by participant and topic.

Results

Course uptake

Overall, 131 applications were received for the three courses run during the pilot phase. The first course (held in Lebanon) was restricted to practitioners from the Middle East and only 19 applications were submitted. Fifty-six applications were received for each of the two other courses (held in Uganda and Thailand).

A total of 67 people attended the courses. The majority of participants worked either for an international non-governmetnal organisation (INGO) (28%) or a UN agency (34%). The rest worked for government ministries (9%), academic institutions (8%), local NGOs (6%), donor organszations (6%) or were self-employed (9%). Sixty-six per cent of participants worked in nutrition, 15% in health, 9% in general emergency programme management and 8% in food security. One participant worked in logistics.

One third (33%) of participants were working in Western Asia (including Middle Eastern countries), 18% in Northern Africa (predominately Sudan), 13% in Eastern Africa, 12% in Southern Asia, and 6% each in Western Africa, South-east Asia and Australia. The rest had a regional/global remit. Overall, 73% of participants were national staff (i.e. working in the country where they are from).

An overview of each of the courses run during the pilot phase of the NIERTI is given in Table 1.

Table 1: Overview of the NIERTI courses run to date
Location	Lebanon	Uganda	Thailand
Partner	American University of Beirut	University of Makerere	Asian Disaster Preparedness Centre
Duration	6 days	12 days	10 days
Number of participants	17 (+2 students)	20	28
Modules covered	Introduction to NIE	Introduction to NIE	Introduction to NIE
	Causes of malnutrition	Causes of malnutrition	Causes of malnutrition
	Humanitarian system	Humanitarian system	Humanitarian system
	Humanitarian standards and M&E	Humanitarian standards and M&E	Humanitarian standards and M&E
	Rapid assessments	Rapid assessments	Rapid assessments
	Nutrition surveys	Nutrition surveys	Nutrition surveys
	-	Surveillance and early warning	Surveillance and early warning
	-	Food security and livelihoods	Food security and livelihoods
	Food assistance	Food assistance	Food assistance
	Micronutrient interventions	Micronutrient interventions	Micronutrient interventions
	-	Advocacy	Advocacy
	Management of severe acute malnutrition	Management of severe acute malnutrition	Management of severe acute malnutrition
	Management of moderate acute malnutrition	Management of moderate acute malnutrition	Management of moderate acute malnutrition
	Infant feeding in emergencies	Infant feeding in emergencies	Infant feeding in emergencies
	Emergency preparedness	Emergency preparedness	Emergency preparedness
	Emergency simulation	Emergency simulation	Emergency simulation
	Professional development	Professional development	Professional development
	-	Pre-/post-test MCQ	Pre-/post-test MCQ
	-	Field training (nutrition surveys)	-
	-	Field training (management of SAM)	-
	-	Field training (management of MAM)	-

 

Cost

The first of the three courses (held in Lebanon) was subsidised since it was the first ‘pilot’ course. The fee was US$500 for 6 days (excluding accommodation) and the cost of course facilitators was covered by the project funding. This course has not been included in the following analyses because it is not representative of the actual costs of running NIE training. The next two courses had a fee of US$ 2,500 including meals and accommodation. The course in Uganda was 12 days and the Thailand course lasted 10 days. This equates to US$208 per person per day for Uganda and US$250 per person per day for Thailand. As a comparison, the 5-day course in NIE run by the University of Westminster (London, UK) costs the equivalent of US$ 1,100 (based on current exchange rates), excluding accommodation and meals other than lunch. This equates to US$ 220 per day or US$ 2,640 for 12 days.

Of the 48 people who attended the full-price courses in Uganda and Thailand, 83.3% were funded by their employer, 10.4% were sponsored by another organisation and 6.3% were self funded. Feedback from participants indicated that the course was viewed as good value for money. Of the 222 enquires that had been received about the initiative by the end of August 2011, 23 were requests for funding support. None of these individuals subsequently attended a course. Sixteen people who were offered a place on a course reported that they were unable to attend because of a lack of funding.

The most expensive components of the courses were the facilitators followed by accommodation/meals for participants. Expenditure on facilitators was US$ 1,227 per participant in Uganda and US$ 661 per participant in Thailand. In both cases this does not include a fee for the lead facilitator or for an additional facilitator who taught several modules, both of whom work for UCL CIHD. The cost per participant in Thailand was lower because we had more participants and were able to secure facilitators who were based locally and who were not in a position to accept a fee (which cannot always be guaranteed). Even so, the course in Thailand only just covered all costs using fees and in Uganda we incurred a loss that was buffered using project funding. The cost of accommodation, meals and the training venue was $72 per participant per day in Uganda and $110 per participant per day in Thailand.

Evaluation

The response to each course was positive. Overall, 56% of participants strongly agreed and 42% agreed that the course they attended met the goal to prepare them to respond to the nutritional needs of people affected by emergencies. The improvement in performance and ability of participants is difficult to quantify; however there were some signs that the courses had a positive impact. The average score for the MCQ increased from 52.0% at the start of the course in Uganda to 63.5% at the end. In Thailand the average score increased from 52.5% to 65.5%. Only 29 of the 67 participants responded to the follow-up email. Among these 29, there were numerous examples of positive actions resulting from attendance on the courses. The majority of responders had provided training to their own staff or to others. A group from Lebanon had developed a country-specific emergency preparedness plan for nutrition. Others had been identifying ways to strengthen the management of moderate acute malnutrition as part of CMAM.

Based on feedback from the course evaluations, an 11-day ‘standard’ NIE course has now been developed and this will be the model that will be implemented by each of the training partners. This course includes the emergency simulation exercise but the field-based training is designed as an optional add-on to the standard course, depending on the opportunities available and the logistic feasibility at each training site.

Discussion

On one level, the overall goal of the NIERTI to increase the availability of high quality training in NIE has been met. There are also indications that the training model will be sustained by our partner organisations. The courses have gained a positive reputation among the NIE community and, at the time of writing, all three institutions have taken steps to implement their next course. Each institution has started to investigate ways to strengthen their own capacity and to institutionalise the training. This includes engaging regional practitioners to develop a network of known NIE facilitators and incorporating the course (or elements of the course) into post-graduate training. There also appears to be a reasonably steady market for the courses. Despite increased focus on the development of NIE capacity, we are only aware of one other specific course in NIE that is run on a regular basis. Other training initiatives that have emerged over the past few years are still predominately ad-hoc or one-off events hosted by international agencies. In light of the extent of the capacity gap in nutrition and the high turnover of staff within the humanitarian sector, investment in occasional training, while being very useful, will not be sufficient.

The process of setting up the NIERTI has highlighted a number of issues that will need to be considered if we are to make further progress in addressing the lack of capacity in the sector. These have been grouped into three major themes: the cost of capacity development, providing practical training in NIE and standardisation of training.

The cost of capacity development

The NIERTI course fee is undoubtedly prohibitively high for some individuals and agencies. However, the fees provide an indication, and perhaps an under-estimation of the real cost of running a course of this nature in the current climate. The cost of accommodation/meals seems quite high but in fact it is extremely difficult to find alternatives at a lower cost in Uganda, other than in hostel-type settings. The facilities in Thailand were excellent value for money and it is difficult to achieve similar at a lower cost.

The other main contributor to the cost of the courses is also challenging to solve. The main reason why NIE training is expensive is because of the reliance on relatively few NIE practitioners who need to be flown in to teach on courses. We were not able to run the NIE courses using only staff from the partner organizations. None of the available facilitators had experience of working in emergency contexts and all felt that practical experience was an essential prerequisite. As such, external facilitators had to be employed. Significant effort went in to identifying experienced facilitators based in each region. However, the NIE community is still relatively small, the work commitments of potential facilitators are unpredictable, experienced staff are in high demand and expect to be paid a fee that is commensurate with their experience, and relatively few NIE practitioners have sufficient teaching experience. The latter point is particularly important; although course participants appreciated the extensive experience of the facilitators while the ability to transmit information and to manage teaching sessions effectively was also valued highly.

The most obvious solution to this is to build the capacity of national practitioners and academic staff. This approach would reduce costs and could promote sustainability. Development of the capacity of academic staff will require exposure to emergency nutrition programmes. A recent piece of research looking at pre-service training in NIE found that academic staff can be isolated from the work of NGOs and UN agencies¹⁰. This gap needs to be bridged in order to enable academics to gain hands-on experience. Training in the sector is still more commonly undertaken by agencies rather than higher education institutions. Although this approach can improve capacity within the humanitarian sector, it has the potential to further weaken the academic system that could provide a sustainable approach to strengthening capacity in the longer term (8).

The other constraint to strengthening national academic capacity is the continuing issue of low salaries, high staff attrition and conflicting demands among academic staff in developing countries11. In order to establish academic institutions as providers of high quality nutrition training, this problem will need to be addressed. This might also help to attract experienced NIE practitioners in to the academic sector.

Providing practical training in NIE

Two key themes emerged from the evaluations and course participant follow-up. First, participants emphasised the importance of the problem-solving course exercises, field-based training and the emergency simulation for enabling them to put into practice the theory covered. Second, participants felt that postcourse internships, work placements and mentoring would have enabled them to consolidate their learning further. The role of practical training in NIE was emphasized in the 2007 capacity review by Gostelow. The field-based training included in the course held in Uganda was well received but this is a difficult activity to maintain. Running field training in an emergency programme can be disruptive and the nature of emergency response does mean that from one year to the next it is difficult to guarantee that relevant programmes exist or are accessible in the country/region where training is being held. Field training also lengthens the duration of courses, which increases both the time and financial commitment for participants.

One solution to this is to include classroombased teaching as part of an integrated work-based training programme that includes field exposure. In 2010, the Consortium of British Humanitarian Agencies (CBHA) launched a competency-based training programme for humanitarian staff, which includes field placements. More recently, Save the Children UK and Concern Worldwide initiated 1 and 2-year emergency nutrition internships, which include placements at head quarters as well as at field sites. Another option would be to develop partnerships between academic institutions that can provide theory training and humanitarian agencies operating in relevant countries. Practitioners could attend training and then opt for a shorter and more affordable work placement in their country of origin. This arrangement would also help to bridge the gap between the academic and operational agencies in these countries. For practitioners already working within the humanitarian system, a relevant work placement could be one of the pre-requisites for attending the theory training.

Standardisation of training and the need for professional competencies

A recurrent issue that emerged during the development of the NIERTI was the lack of common understanding of the competencies required by NIE staff. Although experienced practitioners have a reasonable sense of what NIE personnel need to know and be able to do, there is a great deal of subjectivity in this. As a result, the NIE courses that exist (including those provided by the NIERTI) feature different combinations of topics, are of varying duration and involve either no assessment or assessments that tend to measure knowledge gained rather than the ability of participants to function effectively. This makes it extremely difficult to ascertain whether participants of NIE courses have the necessary competencies, and whether the courses themselves are providing effective training.

One way to address this would be to adopt a more systematic, competency-based approach. Other sectors in the humanitarian community have recently moved towards competencybased training, assessment and recruitment. A set of core humanitarian competencies is now being used by the CBHA and the child protection and logistics sectors use standard competency frameworks to measure the ability and performance of staff.

Preliminary work on developing a competency framework for the NIE sector

As an addition to the NIERTI, we have taken initial steps to developing a competency framework for the sector using the Child Protection in Emergencies (CPIE) framework as a guide. The CPIE competency framework is now used as the basis for recruitment, training and staff development by a number of humanitarian agencies. The benefits of this are perceived to be very positive; one staff member commented that it had improved recruitment processes and training and has increased staff motivation and career progression (K. Bisaro, personal communication).

Research into the identification of competencies for NIE was designed to be as comprehensive as possible, and was conducted by reviewing existing competency frameworks, NIE-related job descriptions, academic and training course content, and by conducting interviews with key stakeholders and NIERTI course participants.

The competencies regarded as essential for an international emergency nutritionist have been extracted and compiled into a basic framework, which we will be publishing shortly. To increase the usability of the framework, specific behavioural indicators have been developed for each competency at three progressive levels. These facilitate its use for creating job profiles, conducting assessment during recruitment and training and for staff to identify areas for professional development.

We now have the foundations for a competency framework for NIE. However, there are still a number of actions required before this could serve as a functional tool.

1. More detailed mapping of career paths and job profiling is required to clarify which competencies are required at each level
2. The framework needs to be reviewed by the sector to identify gaps and to agree each of the indicators.
3. Finally, the framework will need to be approved and adopted by GNC member agencies.

What next for the NIERTI?

The NIERTI will continue to support partner organisations to run NIE training courses based on the materials developed and tested during the pilot phase. We would also like to incorporate competency-based training and assessment as part of broader efforts to professionalise the humanitarian sector. Having a standard framework for measuring the competencies attained by NIE practitioners would help to improve quality and performance in the sector. In the meantime, we are keen to maintain the quality of training provided under the NIERTI umbrella, which will in turn ensure continued demand and financial sustainability. This will provide the opportunity for our partner organisations to continue to strengthen their own capacity to provide NIE training. Any deterioration in the reputation of NIERTI courses would have a negative impact on existing course providers and would jeopardise the future of the initiative. To try and ensure that quality is maintained, we will continue to control the use of NIERTI training materials. Any organisation that wishes to run a course based on these materials will be free to do so, as long as they can guarantee they will be delivered to a high standard.

For further information, and to request access to the materials, please email: nierti@nietraining.net.

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¹UN General Assembly Economic and Social Council (2011) Strengthening the coordinaton of emergency humanitarian assistance of the United Nations. Report of the Secretary General, Geneva, July.

²UNDP (2004). Reducing disaster risk: a challenge for development. UNDP, New York.

³Capacity for Disaster Risk Reduction Initiative (2011) Basics of capacity development for disaster risk reduction.

⁴Gostelow L (2007). Capacity development for nutrition in emergencies: beginning to synthesise experiences and insights. NutritionWorks / IASC Global Nutrition Cluster.

⁵NutritionWorks, ENN, GNC (2011). Harmonised Training Package revised modules, v2. http://www.ennonline.net/htpversion2

⁶See ENNs 5 year strategy that reflects capacity development on NiE as one of ENNs priority activities, http://www.ennonline.net/pool/files/reports/enn-5-year-strategy-2010-to-2015-final.pdf

⁷See footnotes 3 and 4

⁸http://www.phcetraining.org/

⁹Anderson LW et al. (eds.) (2001). A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives. New York: Longman.

¹⁰NutritionWorks (2011). In-service and pre-service training in NIE. http://www.ennonline.net/meetings/servicetraining