Research snapshots

Factors influencing pastoral and agropastoral household vulnerability to food insecurity in Kenya

Kenya has a population of more than 38 million, 10% of whom are classified as food-insecure. The Kenyan drylands are populated largely by livestock-dependent pastoral tribes who are particularly vulnerable to food shortages. Prevalent high food and non-food prices, crop failure, livestock diseases and conflict have compounded the already precarious food insecurity in the arid and semi-arid lands (ASALs). Factors contributing to food insecurity and related survival mechanisms are specific to different people and regions, but there is lack of clarity in Kenya on possible causes and solutions to the problem. Further research, particularly at the household level, is needed to inform policy and action in adapting to the impacts of climate change.

This study establishes the determinants of household vulnerability to food insecurity in pastoral households of Kajiado County and agropastoral households of Makueni County in Kenya. Interviews were conducted with a randomly selected sample of 198 households. Income per adult equivalent was used to estimate household vulnerability to food insecurity, which was calculated as the proportion of households who fall below the poverty line of Ksh 1,239 (£9.99) per adult equivalent per month. Descriptive analysis showed that 59% of pastoral households of Kajiado County were vulnerable to food insecurity, compared to 27% of agropastoral households in Makueni County. Additionally, a two-stage least squares approach (regression analysis) established that vulnerability of households to food insecurity is determined by land size, household size, rainfall and herd size for Makueni County, and by access to climate information, herd size, off-farm employment and gender of household head for Kajiado County.

The findings imply that Makueni County needs access to and control over land resources, destocking through improved livestock breeds, and creation of a microclimate to enhance rainfall levels. The authors recommend that policies in Kajiado County promote access to climate information, diversification of livelihoods and female access to production resources.

Amwata DA, Nyariki DM and Musimba NRK (2016). Factors Influencing Pastoral and Agropastoral Household Vulnerability to Food Insecurity in the Drylands of Kenya: A Case Study of Kajiado and Makueni Counties. J. Int. Dev., 28: 771-787. doi: 10.1002/jid.3123. onlinelibrary.wiley.com/wol1/doi/10.1002/jid.3123/full

Determinants and trends of socioeconomic inequality in child malnutrition in Mozambique

Mozambique has experienced a slow decrease in absolute levels of child malnutrition over the last 15 years. However, levels remain very high, with chronic malnutrition (stunting) prevalence of more than 40% in children under five years of age, one of the highest in the world. Previous studies on child malnutrition in Mozambique have mainly focused on absolute levels of malnutrition and relative trends. This study examines the extent of socioeconomic inequality in child malnutrition, focusing on height-for-age Z-scores, using data from the Household Budget Survey 1996-1997 and 2008-2009, and from the Development and Health Statistics 2003 and 2011. Pro-rich inequalities in the distribution of malnutrition are found for all years, and further analysis reveals that most of the inequality in malnutrition is due to inequality in food consumption. The authors claim that, while absolute levels of chronic child malnutrition tended to decrease over time, socioeconomic inequality in malnutrition did not; and actually seems to have increased slightly over the same time period.

Salvucci V. Determinants and Trends of Socioeconomic Inequality in Child Malnutrition: The Case of Mozambique, 1996-2011. 2016. J. Int. Dev., 28: 857-875. doi: 10.1002/jid.3135.

Global and regional health effects of future food production under climate change: A modelling study

One of the most important consequences of climate change could be its effect on agriculture. Although much research has focused on questions of food security, less has been devoted to assessing the wider health impacts of future changes in agricultural production. This modelling study estimates excess mortality attributable to agriculturally mediated changes in dietary and weight-related risk factors by cause of death for 155 world regions in the year 2050. The researchers linked a detailed agricultural modelling framework (the International Model for Policy Analysis of Agricultural Commodities and Trade (IMPACT)) to a comparative risk assessment of changes in fruit and vegetable and red meat consumption and bodyweight for deaths from coronary heart disease, stroke, cancer and an aggregate of other causes.

The model projects that by 2050 climate change will lead to per-person reductions of 3·2% (SD 0·4%) in global food availability; 4·0% (0·7%) in fruit and vegetable consumption; and 0·7% (0·1%) in red meat consumption. These changes will be associated with 529,000 climate-related deaths worldwide (95% CI 314?000-736?000). Twice as many climate-related deaths were associated with reductions in fruit and vegetable consumption than with climate-related increases in the prevalence of underweight, and most were projected to occur in south and east Asia. Adoption of climate-stabilisation pathways would reduce the number of climate-related deaths by 29% to 71%, depending on their stringency. Strengthening public health programmes aimed at preventing and treating diet and weight-related risk factors could be a suitable climate change adaptation strategy.

Springmann M, Mason-D’Croz D, Robinson S, Garnett T, Charles H, Godfray J, Gollin D, Rayner M, Ballon P and Scarborough P. Global and Regional Health Effects of Future Food Production under Climate Change: A Modelling Study. 2016. The Lancet 387 (10031) (October 14): 1937-1946. doi:10.1016/S0140-6736(15)01156-3.

Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis

Underweight and severe and morbid obesity are associated with highly elevated risks of adverse health outcomes. This study estimated trends in mean body mass index (BMI) by using 1,698 population-based data sources, with more than 19·2 million adult participants (9·9 million men and 9·3 million women) whose height and weight had been measured, in 186 of 200 countries for which estimates were made; these 186 countries covered 99% of the world's population. 

Global age-standardised mean BMI increased from 21·7 in 1975 to 24.2 in 2014 in men, and from 22·1 in 1975 to 24.4 in 2014 in women. Regional mean BMIs in 2014 for men ranged from 21·4 in central Africa and south Asia to 29·2 in Polynesia and Micronesia; for women the range was from 21·8 in south Asia to 32·2 in Polynesia and Micronesia. Over these four decades, age-standardised global prevalence of underweight decreased from 13·8% to 8·8% in men and from 14·6% to 9·7% in women. South Asia had the highest prevalence of underweight in 2014, 23·4% in men and 24·0% in women. Age-standardised prevalence of obesity increased from 3·2% in 1975 to 10·8% in 2014 in men, and from 6·4% to 14·9% in women. Globally, 2·3% of men and 5·0% of women were severely obese (BMI ≥35); the prevalence of morbid obesity (BMI ≥40) was 0·64% in men and 1·6% in women.

If post-2000 trends continue, the probability of meeting the 2025 global obesity target – to halt the rise in obesity at its 2010 levels – is virtually zero. Rather, if these trends continue, by 2025 global obesity prevalence will reach 18% in men and surpass 21% in women; severe obesity will surpass 6% in men and 9% in women. Nonetheless, underweight remains prevalent in the world’s poorest regions, especially in south Asia.

Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1,698 population-based measurement studies with 19·2 million participants. 2016. The Lancet 387 (10026) (October 15): 1377-1396

Thailand eliminates mother-to-child transmission of HIV and syphilis

On June 7 2016, WHO certified that Thailand had eliminated mother-to-child transmission of HIV and syphilis. This is not only a public health success story for Thailand, but also an affirmation of how internationally agreed goals –such as the UN’s 2001 Declaration of Commitment on HIV/AIDS and the Sustainable Development Goals – can help health ministries to mobilise political will and public funds, and commit to implementation.

Thailand’s commitment to address mother-to-child transmission of HIV started in the 1980s, with family education encouraging couples to be tested for HIV before having children. After research found that use of short-course zidovudine could cut the risks of mother-to-child transmission by half, Thailand began a countrywide programme that provided zidovudine as a routine part of antenatal care, tripled the budget for prevention of mother-to-child transmission (PMTCT) services, and lowered costs by manufacturing generic versions of zidovudine locally. Universal healthcare began in 2001 and was made free in 2007; this was extended to include migrant workers, in whom much higher rates of HIV have been recorded. In 2015, 99·6% of infants born to HIV-positive mothers in Thailand received antiretroviral prophylaxis.

Sidibé, Michel, and Poonam Khetrapal Singh. 2016. Thailand Eliminates Mother-to-Child Transmission of HIV and Syphilis. The Lancet 387 (10037) (October 15): 2488–2489. doi:10.1016/S0140-6736(16)30787-5.
www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)30787-5.pdf

Who should finance the World Health Organization’s work on emergencies?

In May 2015, the 68th World Health Assembly approved the decision to reform the work of the World Health Organization (WHO) on emergencies by creating a single programme for outbreaks and health emergencies. This is accompanied by a Contingency Fund for Emergencies (CFE) to rapidly scale up WHO’s initial response to outbreaks and emergencies with health consequences (using the objective criteria set out in WHO’s Emergency Response Framework), that merges two existing WHO funds¹.Latest estimates are that core funding needs for the programme and the initial capital of the CFE will range from US$100 to US$300 million (£81.77 to £245.32 million) per year respectively, but it is currently unclear how such resources will be raised. Previous attempts to set up similar contingency funds at WHO were hindered by insufficient funding.           

This comment explores WHO funding options for the CFE. These include: voluntary contributions from member states (although less realistic due to global economic downturn); private sector foundations who have been responsive to fund appeals (although this would involve re-examining WHO rules on managing conflicts of interest relating to guidance norm setting (the authors suggest these might be less essential for its emergency programmes and cite WFP (UN World Food Programme), who engage with a wide range of private corporations, including Coca-Cola, Unilever, and Danone)); collecting flexible voluntary contributions because of the unpredictable nature of emergencies (a challenge for WHO, since 93% of such contributions are earmarked for specific activities); and bilateral agreements with governments to redirect resources from taxation systems (e.g. carbon emissions, air fuel and transportation and tobacco have all been proposed as potential new funding sources for global health). WHO should also seek to understand the institutional constraints, particularly with regard to budgeting, that precipitated the slow response to the 2014 Ebola outbreak. Major changes at an organisation-wide level will be required for WHO to truly lead the process of response to health emergencies on a global scale.

Y-Ling Chi, Krishnakumar J, Maurer J, Loncar D, Flahault A. 2016. Who should finance WHO’s work on emergencies? The Lancet 387 (June 25): 2584-2585. www.thelancet.com/pb/assets/raw/Lancet/pdfs/S0140673616305864.pdf

Decline in the prevalence of anaemia among children through wheat flour fortification in Jordan

Children of pre-school age are the most vulnerable to the detrimental long-term effects of anaemia, including impairment of cognitive and physical development and increased morbidity and mortality. In developing countries, 30-80% of pre-school children are anaemic at one year of age. WHO classifies anaemia prevalence of ≥40% as a severe public health problem and prevalence of 20-39·9% as a moderate public health problem.

Deficiencies of vitamin A, iron, zinc and iodine have been identified as public health problems in Jordan. The Government has implemented nationwide food-fortification programmes of salt and wheat flour. This study used retrospective analysis of the data from two repeated, national, cross-sectional surveys conducted in 2007 and 2009 of pre-school children aged 16-20 months and 34-36 months respectively after implementation of wheat flour fortification with multiple micronutrients in Jordan. A total of 3,789 and 3,447 children aged 6-59 months were tested in 2007 and 2009 respectively. The prevalence of anaemia in pre-school children declined from 40·4% in 2007 to 33·9% in 2009. The decline in prevalence was more pronounced among children aged >24 months (−13·7 points); children living in urban areas (−8·0 points); children from rich households (−9·0 points); children who had never been breast-fed (−17·0 points); and well-nourished children (−6·8 points). In both surveys, presence of childhood anaemia was strongly associated with child age ≤24 months, living in poor households, breastfeeding for ≥6 months, malnourishment, poor maternal education and maternal anaemia.

Al Rifai R, Nakamura K and Seino K. 2016. Decline in the prevalence of anaemia among children of pre-school age after implementation of wheat flour fortification with multiple micronutrients in Jordan. Public Health Nutrition, 19(8), pp. 1486-1497.

Making progress towards food security in rural Rwanda

Determining interventions to address food insecurity and poverty, as well as setting targets to be achieved in a specific time period, have been a persistent challenge for development practitioners and decision-makers. Food and agricultural assistance programmes have been widely implemented in sub-Saharan Africa to tackle food insecurity, but there is little evidence demonstrating the impact of those programmes.

This study assessed the changes in food access and consumption at the household level of an integrated food security intervention in three rural districts of Rwanda. Household Food Insecurity Access Scale (HFIAS) scores and household Food Consumption Scores (FCS) were compared at baseline and after one year of programme implementation. All 600 households enrolled in the Food Security and Livelihoods Programme (FSLP) were included in the study. There were significant improvements (P < 0·001) in HFIAS and FCS. Severe food insecurity decreased from 78% to 49%, while acceptable food consumption improved from 48% to 64%. The change in HFIAS was significantly higher (P=0·019) for the poorest households. However, future assessments are needed to evaluate the maintenance of HFIAS and FCS improvements and the programme’s sustainability.

Nsabuwera V, Hedt-Gauthier B, Khogali M, Edginton M, Hinderaker SG, Nisingizwe MP, Tihabyona JdD, Sikubwabo B, Sembagare S, Habinshuti A and Drobac P. Making progress towards food security: evidence from an intervention in three rural districts of Rwanda. 2015:1-9 Public Health Nutr.

Effect of lipid-based nutrient supplements on morbidity in rural Malawian children

The WHO recommends the use of iron supplements or home fortificants (such as multiple micronutrient powders and lipid-based nutrient supplements (LNS)) to improve iron status and reduce anaemia prevalence among infants and children aged 6-23 months in low-income countries. However, safety of home fortificants in children is uncertain in areas where infections are common. One large trial using iron and folic acid supplements in Zanzibar reported increased risk of malaria and deaths.

A randomised controlled trial in rural Malawi tested the hypothesis that provision of LNS containing iron does not increase infectious morbidity in children. Infants aged six months (n=1,932) were randomised to receive 10, 20 or 40g LNS/d or no supplement until age 18 months. All LNS contained a total of 6mg iron in the daily dose provided. Morbidity outcomes (serious adverse events, non-scheduled visits and guardian-reported morbidity episodes) were compared between control and intervention groups. Findings were that provision of 10 and 20 g LNS/d containing 6mg iron/d did not increase morbidity in the children. Provision of 40g LNS/d did not affect guardian-reported illness episodes, but may have increased malaria-related, non-scheduled visits.

Bendabenda J, Alho L, Ashorn U, Cheung YB, Dewey KG, Vosti SA, Phuka J, Maleta K and Ashorn P. 2016. The effect of providing lipid-based nutrient supplements on morbidity in rural Malawian infants and young children: a randomized controlled trial. Public Health Nutrition, 19(10), pp. 1893-1903. doi: 10.1017/S1368980016000331.

Meta-analysis of associations between stunting and child development

Despite documented associations between stunting and cognitive development, few population-level studies have measured both indicators in individual children or assessed stunting’s associations with other developmental domains. Because stunting is more easily measured, it is often used as a proxy for developmental delay. Yet, although stunting and developmental delay are associated and share many risk factors (illness, poverty, low birth weight, maternal depression, lack of breastfeeding), other risk factors for developmental delay – such as exposure to violence or toxic metals, lack of caregiver responsiveness and inadequate stimulation ­– will not necessarily result in stunting.

This meta-analysis, using publicly available data from 15 Multiple Indicator Cluster Surveys (MICS-4) in low- and middle-income countries, assessed the association between stunting and development, controlling for maternal education, family wealth, books in the home, developmentally supportive parenting and sex of the child, stratified by country prevalence of breastfeeding (BF) (‘low BF’<90 %, ‘high BF’ ≥90 %). Ten-item Early Childhood Development Index (ECDI) scores assessed physical, learning, literacy/numeracy and socio-emotional developmental domains. Children (aged 36-59 months) on track in three or four domains were considered ‘on-track’ overall. The authors found that stunting is associated with many but not all developmental domains across a diversity of countries and cultures.  However, associations varied by national breastfeeding prevalence and developmental domain. Mean prevalence of breastfeeding at six months was 89.1% and mean percentage of children aged 36-59 months with on-track development was 65.5%, ranging from 42.6% in Sierra Leone to 85.9% in Belize. Severe stunting (height-for-age Z-score <-3) was negatively associated with on-track development. Any stunting, including severe stunting, was negatively associated with physical development and literacy/numeracy development in high BF countries but not low BF countries. Any stunting (Z-score <-2) was negatively associated with on-track development in countries with high BF prevalence.

Miller AC, Murray MB, Thomson DR and Arbour MC, 2016. How consistent are associations between stunting and child development? Evidence from a meta-analysis of associations between stunting and multidimensional child development in fifteen low- and middle-income countries. Public Health Nutrition, 19(8), pp.1339-1347. 10.1017/S136898001500227X.

The migrant camp that doctors built

All around the edges of Europe, as the numbers of refugees and economic migrants have surged in recent years, charities and individual volunteers rather than governments have provided much of the humanitarian assistance on the ground. Although many European countries have officially committed to providing medical services to undocumented migrants,

The medical charity Médecins Sans Frontières (MSF) has built its first refugee camp, at Grand-Synthe near Dunkirk, to provide basic humanitarian assistance to people in need, regardless of their status. Normally the charity provides medical aid at refugee camps in developing countries that are built and run by United Nations agencies. Doctors at the camp, known as La Linière, have been treating migrants for health issues such as respiratory problems and dermatological problems (including eczema and scabies). There are also chronic diseases and mental health problems. After months of lobbying by non-governmental organisations (NGOs), the state hospital at Grand-Synthe has opened a clinic specially for migrants. The new camp goes against French Government policy, which is to encourage migrants to give up their dream of getting to Britain and instead claim asylum in France and move to government-provided accommodation for migrants elsewhere in the country.  

Sophie Arie The migrant camp that doctors built. BMJ 2016;352:i1696 dx.doi.org/10.1136/bmj.i1696

ODK. World Vision Kenya introduced the concept of ODK for nutrition surveys conducted in Kenya; this article shares their experiences around this.