Adapting infant and young child feeding interventions in the context of COVID-19 in Somalia

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By Sahra Moalim Ahmed, Bishar Osman Hussein and Emmanuel Barasa

Sahra Moalim Ahmed is an Infant and Young Child Feeding Officerat Concern Worldwide Somalia based in Mogadishu with 12 years of experience in nutrition programing, reproductive health and midwifery.

Bishar Osman Hussein is a Health and Nutrition Program Manager at Concern Worldwide Somalia with over 13 years of healthcare leadership and programme management which, for the last nine years, have been in nutrition, maternal and child health programming in Somalia.

Emmanuel Barasa is the Health and Nutrition Programme Coordinator at Concern Worldwide Somalia based in Mogadishu. Emmanuel is a public health professional with nine years of experience working in the humanitarian sector in South Sudan, Ukraine and Somalia.

The authors acknowledge the support and help of the Concern Country Programme Director, Health and Nutrition Programme Coordinator, Programme Manager, Programme Officers, in charge nurses, community health workers and infant and young child feeding (IYCF) counsellors, as well as the Concern HQ technical team, for their valuable inputs, technical expertise and guidance throughout the period of writing this article. Special thanks is also given to the Somalia Nutrition Cluster for the guidance on nutrition programme COVID-19 adaptations which were very useful as a guide while drafting this article. This programme would not have been possible without the generous support of our donors including EU Humanitarian Aid, the UK Foreign Commonwealth Development Office, Irish Aid, the Vitol Foundation, UNICEF and the World Food Programme. We also thank the global Infant Feeding in Emergencies Core Group team for giving us an opportunity to present the case study at the global conference and to publish this article.

Background

Somalia is the second most fragile country in the world, with around 69% of the population living below the poverty line. Somalia's humanitarian situation has worsened in recent years due to the devastating combination of conflict and increasingly erratic weather and climate shocks including drought. Three additional shocks – a desert locust upsurge, extensive flooding and the COVID-19 pandemic –deepened the scale and scope of the humanitarian crisis in 2020, the consequences of which will exacerbate humanitarian needs in 2021. In March 2020, the COVID-19 caseload surged to 7,518 confirmed cases and, by March 2021, stood at 3,284 active cases with 249 confirmed deaths. According to a World Health Organization (WHO) global estimate, 20% of Somalis will suffer from the pandemic's direct and indirect impacts in 2021. Access to healthcare remains very limited in Somalia due to the scarce availability of skilled health professionals and a dilapidated public health infrastructure, particularly in rural areas, resulting in some of the world's worst health outcomes.

Child malnutrition remains one of Somalia's major issues and, in most cases, internally displaced persons (IDPs) are the worst affected. Somalia's Food Security and Nutrition Analysis Unit (FSNAU) has estimated that approximately 840,000 children under the age of five will be wasted in Somalia in 2021, including 143,000 who will likely be severely wasted (FSNAU, 2021). Concern Worldwide Somalia admissions data reveals a stark increase in admissions of wasted children from January to December 2019 compared to 2020 (16,140 versus 33,807) which demonstrates a worsening nutrition situation.

Protecting and promoting safe and appropriate infant and young child feeding (IYCF) practices is essential for preventing and treating malnutrition. The Somalia Micronutrient Survey 2019 by the Federal Ministry of Health (FMoH) and UNICEF Somalia revealed very poor IYCF practices in Somalia with only 5.3% of children less than six months of age exclusively breastfed and only one-quarter of newborns experiencing early initiation of breastfeeding. Inadequate knowledge and attitudes in the community around exclusive breastfeeding and the introduction of pre-lacteal feeds remains a major challenge in achieving optimal IYCF practices in IDP camps in the country (SAF-UK Internatioal, 2016). Complementary feeding practices are also often sub-optimal with children introduced to semi-solids, solids and animal milk either too early or too late. Mothers in Somalia also have limited access to information and health facilities are often the only place to access support for optimal IYCF practices (SAF-UK International, 2016).

Concern Somalia IYCF programming

The health and nutrition component of the Concern Somalia programme encompasses health and nutrition service delivery through fixed and mobile services as well as demand creation through community mobilisation and the promotion of positive behaviour changes in health, nutrition and hygiene practices. Currently, Concern supports 20 health and nutrition facilities including one national referral stabilisation centre (14 fixed and six mobile facilities) where IYCF counselling is integrated within the health and nutrition component. Five of these facilities are directly implemented by Concern Worldwide, five through the government health system with strengthening support provided and 10 facilities are implemented by Concern Worldwide partners.

The primary objective of the IYCF activities is to improve the knowledge and skills of health service providers and community health workers (CHWs) so that they will, in turn, be able to provide timely, relevant and quality IYCF counselling support to mothers, caregivers and other key community influencers. The target group for the counselling sessions are mothers/caregivers of children 6-24 months of age and pregnant and lactating women who attend the health facility for community-based management of acute malnutrition services, vaccination, antenatal care, postnatal care  or any other health services. The counselling sessions are conducted by a trained CHW who administers a general screening question to identify issues/challenges related to appropriate infant feeding practices to help to focus counselling on the topic/s presenting a challenge. Subsequent sessions mainly follow up on the advice given to support  the resolution of the problem after which the CHW moves on to any other challenges that present. Group counselling sessions are also organised at facility-level on every morning of the outpatient therapeutic programme day. Prior to the COVID-19 pandemic, group counselling involved two female community workers to facilitate a group session with five to 20 caregivers. Female faciltiators are used based on the findings of a previous assessment that found that pregnant and lactating women and caregivers were more likely to build a positive and responsive relationship with the facilitator and feel more comfortable discussing their issues (including barriers) with other women (FSNAU, 2016).

Programmatic adaptations in the context of COVID-19

The Concern team faced several challenges at the onset of the COVID-19 crisis to enable these essential IYCF counselling activities to continue. Initially, caregivers did not visit the health facilities as frequently as normal due to the fear of COVID-19 infection and were not comfortable attending the counselling sessions when they did visit. There were also widespread rumours related to breastfeeding and COVID-19 risk that needed to be addressed urgently. Therefore, following the guidance from FMoH and the Somalia Nutrition Cluster, Concern made the following adaptations to the service delivery modality to ensure the continuity and provision of quality IYCF (E) interventions in this new context. The adjustments aimed to allow the counsellors to provide IYCF counselling sessions to targeted beneficiaries to address routine challenges, as well as those that presented as a result of the pandemic, in a way that posed the minimum risk of virus transmission.  

Translation and dissemination of WHO/UNICEF key IYCF COVID-19 messages

All the key IYCF messages/recommendations in the context of COVID-19 were translated into the local language and widely disseminated and shared with the health facilities supported by Concern and its partner organisations.¹

Training of health workers on IYCF in the COVID-19 context

At the initial outbreak of the COVID-19 pandemic March 2020, routine interaction with programme staff and beneficiaries revealed a lot of misconceptions, fear and stigma associated with the disease and its mode of transmission. In order to address these uncertainties and misinformation, a series of trainings were provided to all health facility staff and CHWs on the introduction of COVID-19, infection prevention control (IPC) measures and risk communication and community engagement messages around COVID-19, specifically COVID-19 and IYCF practices. The aim of the training was to ensure that all staff and CHWs were equipped with the appropriate knowledge and skills to reduce the risk of transmission within health facilities, deal with the fear and social stigma prevalent in the community and support optimal ICYF practices in this new context. In total, 181 health staff and CHWs received training across different programme locations. Job aids were also provided to each health facility (such as laminated information, education and  communication materials for use during counselling) and additional on-the-job mentoring and support was provided. 

Infection prevention control measures implemented during individual counselling

Protocols were put in place to ensure that the IYCF counsellor and caregiver maintained a minimum distance of one metre between them at all times. Counselling took place within a well ventilated room, caregivers and counsellors washed their hands before entering counselling rooms, counsellors and beneficiaries wore face masks throughout counselling and greetings involving physical contact were avoided. These protocols were made clear to all caregivers on arrival.

Reduced number of participants at group counselling sessions

Protocols were also put in place to reduce the number of participants attending support group meetings and group promotion sessions to three to five per session (compared to the up to 20 participants per session pre-COVID-19). Numbers were determined based on the availability of space at each facility to ensure that all beneficiaries were able to maintain a one metre distance from each other. In order to ensure that, at a minimum, the same number of beneficiaries could be reached, the number of group counselling sessions was increased from approximately 100 sessions/month/facility pre-COVID-19 (four sessions per day) to 180/per month/facility (around seven sessions per day). Health facility records show that pre-COVID-19 (2019) the total number of  sessions held was 6,436 while 15,642 sessions were held post COVID-19 (2020). Figure 1 shows the number of participants attending group counselling sessions per month during 2019 and 2020. The figures show an initial drop in participants after the pandemic hit around April 2020, as caregivers lost confidence in attending the health facilities but an overall increase in attendance across the year with some variation by month initially as training and infrastructural changes were carried out in each facility. Overall, the number of participants at group sessions increased from 31,752 in 2019 to 41,245 in 2020. To support the increased number of counselling sessions held, new counselling staff were recruited so that each facility had three trained IYCF counsellors compared to two pre-COVID-19.

Figure 1: Number of participants reached with counselling sessions per month January 2019 to February 2021

Increased number of handwashing stations at health facilities

Pre-COVID-19, Concern-supported facilities only had one hand washing station. To facilitate increased hand washing, infrastructural support was provided to all facilities to increase the number of hand washing stations to three. This served to reduce overcrowding around hand washing points and ensure that hygiene protocols could be followed. Caregivers themselves played an important role in many health facilities in ensuring that other caregivers made use of the hand washing points on entry to the facilities.

Addressing the stigma and rumours associated with COVID-19

Community feedback at the onset of the pandemic indicated that many people did not believe that COVID-19 was real as they did not know anyone who had had the virus or did not see stories in the media about people who had been affected. Stories that did appear in the media tended to feature politicians or famous people who had caught the virus, adding to the belief that only rich, influential people who travel were affected by the disease. This misconception directly impacted beneficiaries' willingness to comply with COVID-19 specific IPC measures and IYCF guidance recommendations, such as wearing face masks while breastfeeding. To combat this, training and support was given to IYCF counsellors to include the sharing of stories of local people who had recovered from COVID-19 in group counselling sessions to show that the disease was real and could affect anyone.

Discussion

The quick adaptation of the IYCF programme in Somalia enabled the continuation of essential services in the COVID-19 context and enabled support for caregivers to mitigate the potential negative effects of COVID-19 myths and misconecptions around infant feeding practices. Data shows that, as a result of the adaptations made, particularly the addition of extra staff capacity and the increased frequency of group sessions, more caregivers were reached with IYCF messaging than in the previous pre-COVID-19 year. This has been a positive outcome of the adpations made. As adaptations were put in place and after initial variations due to infrastructural changes and training, the number of participants at group sessions increased showing that the adaptations were successful which allowed the programme to reach a high number of caregivers. It is too early at this stage to measure the impact of the programme on IYCF practices in the community. However, data shows that cases of acute watery diarrhoea dropped in 2020 compared to 2019 (622 cases recorded April to June 2019 compared to 436 cases April to June 2020) which is likely associated with the adoption of IPC measures in the community and at health facilities.

The adaptations made to the Concern-supported IYCF programme in Somalia were an immense challenge for programme management and staff. Much advocacy was required to bring all staff on board right down to facility-level and to provide the support needed to ensure that necessary adaptations were made and remained in place, even up until now. The necessary changes were not accepted instantly by staff and beneficiaries who were, for example, hesitant as to the need for reduced numbers of participants at the sessions, the increased numbers of sessions and the use of IPC measures. It has taken much effort to continually engage staff and beneficiaries to ensure that the need for these changes is understood and that health staff are equipped with the knowledge and skills needed to implement them. A key lesson learnt, therefore, is that even in the COVID-19 context, behaviour change takes time and requires much effort and constant engagement to be successful.

There were many additional costs associated with the programme adaptations made, for example for the procurement of personal protective equipment, the recruitment of and payment for extra staff members, extra training and mentoring of health staff, translation and printing costs of the adapted IYCF materials and the infrastructural costs associated with providing additional handwashing facilities and triage and counselling spaces. In order to support the extra costs, budgets were realigned, a key enabling factor that was only possible thanks to the flexibility of Concern’s donors.

Support from the government was also an important enabling factor. At national-level, the Somalia FMoH has played a leading role in the coordination of national-level Nutrition Cluster communications and engagement with other key government players. In addition, the FMoH has revitalised the national IYCF technical working group, of which Concern Somalia is a key member, to enable communication, alignment with national and global level recommendations and the sharing of programme adaptations and experiences in the COVID-19 context. This has been an important vehicle for the learnings from the experiences described in this article to be shared with other partners engaged in ICYF programming in Somalia and to support similar programme adaptations across the country. Efforts have also been made to align and coordinate COVID-19 mitigation measures across the different sectors, via the nutrition, health, food security, Water, sanitation and hygiene and protection clusters, to enable a harmonised response. This level of coordination has enabled the sharing of IYCF messages in the COVID-19 context to all beneficiaries for greater impact. The Government of Somalia must continue to support these efforts to enable optimal IYCF programming across all sectors moving forward.  

Conclusion

Individual and community-level IYCF counselling is critical to support optimal IYCF practices, including the provision of timely support to the carers of newborns to facilitate the early initation of breastfeeding and exclusive breastfeeding and support to improve the dietary diversity and ongoing breastfeeding of infants aged 6-23 months. The COVID-19 pandemic has uniquely challenged the ability of IYCF counsellors to reach the intended beneficiaries at a time when optimal IYCF practices are challenged by myths and misconceptions around the disease. To address this, rapid adaptations were required to the Concern-supported IYCF programme in Somalia to ensure that caregivers could still be reached with adapted, targeted IYCF-related messages and tailored support in a way that ensured the mimium risk of transmission of the virus. This required additional funds, made possible through the flexibility of donors, to support an unprecedented effort to train and recruit additional staff, make infrastructural changes at health facilities and provide the support needed to beneficiaries. While not without challenges, the increased number of beneficiaries reached during 2020 compared to the previous year is an early indicator of the positive impact of the adaptations made. Learning is still taking place and ongoing efforts to capture the impact of the programme on IYCF practices in the COVID-19 context will provide important lessons in the future.

For more information, please contact Bishar Osman Hussein at bishar.hussein@concern.net 

FSNAU (2016) Somali infant and young child feeding assessment report

SAF-UK (2016) Kismau IDP infant and young child feeding knowledge, attitude and practice survey KAP in 2016