Editorial
Editorial FEX67
Welcome to the 67th edition of Field Exchange which we are excited to announce includes a special subsection on the relationships between wasting and stunting (WaSt) featuring an insightful collection of content with its own dedicated editorial by members of the Wasting and Stunting Technical Interest Group (WaSt TIG). It is the fruit of a collaboration with the WaSt TIG, an established collective coordinated by ENN since 2014, that comprises experts in the fields of child growth, health, nutrition and epidemiology from the research, policy and programme arenas. In the subsection you will find 14 pieces (spanning country examples, views pieces, research summaries and snapshots) that add to our understanding of the often complex associations between wasting and stunting and what this means for policy and programming. In their reflections, the WaSt TIG note a relative lack of WaSt programming examples at country level. This perhaps reflects that while there has been immense progress in generating evidence for and heightening awareness of the need to address wasting and stunting together, concerted effort is now needed to figure out how to enable this and how to do this in practice. We encourage you to share experiences and developments with us in this space, however small or inconsequential you may think they are (they are not).
Moving onto the rest of issue, this edition features a rich set of contributions with some key themes featuring throughout this diverse collection. One such theme is the importance of data and information systems. Health management information systems are a critical source of routine nutrition data that can provide sub-national data more frequently than national household surveys. However, their use is not without challenges, as highlighted by authors who share their experiences of using routine data to develop the Nigeria Nutrition scorecard and provide recommendations for the improvement in the quality of routine data. Kureishy et al also describe the use of data in the development of a nutrition hotspot analysis tool. Again, although challenges persist, the development and use of this scoring tool is improving nutrition surveillance and the prioritisation of interventions in six Sahelian countries.
Also on the theme of data and assessment, we feature three articles on Link NCAs (Nutrition Causal Analysis) from different contexts. An article from Somalia on a study of risk factors for wasting and stunting found that risk factors are context-specific, with some that overlap between the two forms of undernutrition but not consistently so. They conclude that incorporating community perspectives to further understand the underlying context and to develop more appropriate programme priorities is critical. This is echoed in an article that analysed all Link NCA that analysed all Link NCA studies carried out in Africa to identify the extent wasting could be explained by the underlying causes of malnutrition and/or contextual factors. This synthesis revealed that wasting prevalence was not associated with many commonly used indicators of governance, crises and food security. The authors suggested placing more attention on improving methodologies to gain an understanding of the context-specific risk factors rather than trying to aggregate the data at a higher level in order to predict risk factors. These two articles therefore document the importance of listening to community voices to better understand and account for context in programming approaches.
However, an article by Fabregat et al, based on the analysis of more than 40 Link NCAs studies to date, found that while the Link NCA methodology adopts a participatory approach, more than half of the studies did not incorporate community recommendations and/or did not highlight these within the main report narrative (e.g., they were recorded in annexes). Furthermore, community perspectives often differed to the recommendations made by the analysts. This illustrates a paradox between what is a participatory approach alongside, as yet, a limited incorporation of these community perspectives within emerging programming actions. These findings highlight the need to unpack what ‘participation’ really means in practice, not only for Link NCAs but more broadly; participation needs to adopt a true commitment to listen to people, reflect thoroughly on what is being said including what might be uncomfortable or challenging to hear. It is to these communities that we are ultimately accountable and we have so much to learn from them on how programmes can best be adapted to local needs and opportunities.
We feature several articles from India in this issue sharing important initiatives towards more effective management of wasting including at community level. The first shares headlines from a national consultation on acute malnutrition which demonstrates the high priority given to management at government level, examples of strong leadership, progress being made in generating evidence and the encouraging improvement in case prevention and management across states. A second article summarises the findings of an analysis of the burden of wasting and its associated risk factors among children under five in India. This analysis found an overall high prevalence of wasting, with the highest burden of wasting and severe wasting occurring in the first six months of life compared to older age groups. In line with other studies, the factors associated with wasting included lower maternal education, maternal underweight, Caesarean section, low birthweight and being a male child. Both reports highlight the need to intensify efforts around strengthening the prevention and management of growth faltering in infants under six months of age, alongside active growth monitoring activities for the early identification and timely management of children with wasting, all supported with stronger coordination, capacity building, regular monitoring and by adopting a multi-sector approach. The importance of pregnancy and pre-pregnancy interventions to reduce the high burden of wasting was also strongly emphasised.
A research snapshot outlines the protocol for a study looking at the effectiveness of locally produced, nutrient-dense food supplements with different energy densities and nutrient compositions in different Indian states rolling out community-based management of wasting services. It is hoped that this study will contribute to the evidence on effective strategies to manage children with uncomplicated severe wasting in India.
Also from India, we draw readers’ attention to a case study of three COVID-19 positive children presenting with generalised oedema but without other signs of malnutrition whose oedema appeared to resolve with therapeutic feeding (F75). A postscript to this article highlights that as the understanding of preventive and therapeutic interventions to manage kwashiorkor evolves, it is helpful to observe that mechanisms in kwashiorkor have much in common with the phenomena of oedema associated with other conditions. It would be interesting to hear from readers if similar cases have been seen across other programmes.
Content featured from the Global Nutrition Cluster (GNC) highlights new online resources including the GNC mentoring programme, GNC Learn, and various online tools and guidance to support emergency preparedness. The experiences of the first GNC Technical Alliance support to a local NGO in Somalia (ARDI) highlights a situation true of many local NGOs that not only have technical needs but also seek support on programme management, financial management and resource mobilisation. The Alliance is looking at forging links with other entities who have the expertise to provide such support.
Whilst a strong focus of Field Exchange content is (quite rightly) on community-level prevention and treatment of wasting, in this edition we feature a field article from Zimbabwe by Austin et al that highlights the effectiveness of establishing a specialist multidisciplinary unit for the inpatient treatment of complicated wasting, dramatically bringing mortality rates down from nearly 46% to 14% in these vulnerable children. The article describes the journey of the Sally Mugabe Children’s Hospital, Zimbabwe in its quest to improve the quality of care for wasted children by becoming a National Centre of Excellence for wasting management, providing valuable lessons for others embarking on the same goal.
Another article from the field by Rahimov et al describes an often discussed but less often implemented approach of nutrition service rationalisation to tackle an important issue of duplication, double counting and gaps in service provision by multiple partners in Cox’s Bazar, Bangladesh. The article highlights how bringing integrated nutrition services together under one roof for a ‘one stop shop’ improved programme coverage and service quality for Rohingya refugees after one year. Such an exercise was, of course, not entirely straightforward but resulted in extremely important benefits including a more streamlined approach that supported the continuation of services during the COVID-19 pandemic. A more comprehensive evaluation, including qualitative aspects is planned, the results of which will be featured in a future issue.
Finally, two recent reports from UNICEF/WHO highlight the impact of the harmful marketing practices of the food industry on the health and nutrition of infants, children and women. A views piece by Desplats draws on two recent reports that highlight the scale and tactics of the food industry in the promotion of breastmilk substitutes and foods that contribute to unhealthy diets and the need to strengthen efforts to protect infants, children and their mothers from harmful marketing practices. One shocking statistic revealed is that the formula milk industry spends more in one year on marketing than the entire two-year operations budget of the World Health Organization. In the face of the industry’s ever more pervasive and persuasive tactics, we, as public health professionals, all need to act in more strategic ways to ensure women are supported to choose how to feed their infants and children based on informed choice and free from commercial influence.
There you have it – happy reading and please do continue to share your reactions and experiences with us. And just to whet your appetite for what’s coming, we are planning a special Field Exchange series (online, print and podcasts) on complementary feeding in emergencies this year in collaboration with UNICEF. We’ll be issuing a call for content soon – watch this space.