Nutrition Program Design Assistant: A Tool for Program Planners Reference Guide

April 2010

FANTA 2
FOOD AND NUTRITION T E C H N I C A L A S S I S TA N C E

NutritionProgramDesignAssistant: AToolforProgramPlanners(NPDA) ReferenceGuide

April2010

REFERENCEGUIDE

COREGroup
COREGroupfosterscollaborativeactionandlearningtoimproveandexpandcommunityfocused publichealthpractices.Establishedin1997inWashingtonD.C.,COREGroupisanindependent 501(c)3organization,andhomeoftheCommunityHealthNetwork,whichbringstogetherCORE Groupmemberorganizations,scholars,advocatesanddonorstosupportthehealthofunderserved mothers,childrenandcommunitiesaroundtheworld.

FoodandNutritionTechnicalAssistanceIIProject(FANTA2)
FANTA2workstoimprovenutritionandfoodsecuritypolicies,strategiesandprogramsthrough technicalsupporttotheUnitedStatesAgencyforInternationalDevelopment(USAID)andits partners,includinghostcountrygovernments,internationalorganizationsandNGOimplementing partners.Focusareasfortechnicalassistanceincludematernalandchildhealthandnutrition,HIV andotherinfectiousdiseases,foodsecurityandlivelihoodstrengthening,andemergencyand reconstruction.FANTA2developsandadaptsapproachestosupportthedesignandquality implementationoffieldprograms,whilebuildingonfieldexperiencetoimproveandexpandthe evidencebase,methods,andglobalstandardsfornutritionandfoodsecurityprogramming.The projectisfundedbyUSAID,managedbytheBureauforGlobalHealth(GH)andimplementedby theAED.

SavetheChildren
SavetheChildrenistheleadingindependentorganizationcreatinglastingchangeforchildrenin needintheUnitedStatesandaroundtheworld.SavetheChildrenworkstoensurethewellbeing andprotectionofchildreninmorethan120countries. Thispublicationwasmadepossiblebythegeneroussupportofthe AmericanpeoplethroughthesupportoftheOfficeofHealth,Infectious Disease,andNutrition,BureauforGlobalHealth,UnitedStatesAgencyfor InternationalDevelopment(USAID)undertermsofCooperative AgreementsNo.GHSA00050000600managedbytheCOREGroup,and No.GHNA00080000100,throughtheFoodandNutritionTechnical AssistanceIIProject(FANTA2),managedbyAED.Thecontentsarethe responsibilityofCOREGroupandAEDanddonotnecessarilyreflecttheviewsofUSAIDorthe UnitedStatesGovernment.Itmaybereproducedifcreditisproperlygiven.

RecommendedCitation
COREGroup.NutritionWorkingGroup.NutritionProgramDesignAssistant:AToolforProgram Planners,Washington,DC:2010.

Abstract
TheNutritionProgramDesignAssistant:AToolforProgramPlannershelpsprogramplanning teamsselectappropriatecommunitybasednutritionapproachesforspecifictargetareas.Thetool hastwocomponents:1)areferenceguidethatprovidesguidanceonanalyzingthenutrition situation,identifyingprogramapproachesandselectingacombinationofapproachesthatbest suitsthesituation,resourcesandobjectivesand;2)aworkbookwheretheteamrecords information,decisionsanddecisionmakingrationale.

REFERENCEGUIDE

TableofContents

ACKNOWLEDGMENTS.............................................................................................................I ACRONYMSANDABBREVIATIONS........................................................................................III INTRODUCTION.....................................................................................................................1 Background...............................................................................................................................1 Purpose.....................................................................................................................................2 Use ............................................................................................................................................2 . NutritionApproachesIncluded.................................................................................................3 KEYCONCEPTS.......................................................................................................................4 NutritionConcepts....................................................................................................................4 EssentialNutritionActions........................................................................................................7 HOWTOUSETHENPDA......................................................................................................10 UseofIcons.............................................................................................................................10 AssumptionsMade .................................................................................................................10 . KeySteps.................................................................................................................................11 STEP1.GATHERANDSYNTHESIZEINFORMATIONONTHENUTRITIONSITUATION..............14 Step1PartI.GatheringQuantitativeInformation...............................................................14 Step1PartII.GatheringQualitativeInformation................................................................16 Step1PartIII.SynthesizingData..........................................................................................19 STEP2.DETERMINEINITIALPROGRAMGOALANDOBJECTIVES...........................................29 FormingProgramGoalsandObjectives..................................................................................29 STEP3.REVIEWHEALTHANDNUTRITIONSERVICES............................................................31 GatheringDataonHealthandNutritionServices...................................................................31 OtherResources......................................................................................................................32 STEP4.PRELIMINARYPROGRAMDESIGN:PREVENTION......................................................34 Step4SectionA.CrossCuttingApproachestoImproveNutritionalStatus........................35 Step4SectionB.InfantandYoungChildFeeding ...............................................................47 . Step4SectionC.MaternalNutrition...................................................................................54 Step4SectionD.MicronutrientStatusofChildren.............................................................57 Step4SectionE.UnderlyingDiseaseBurden......................................................................61 STEP5.PRELIMINARYPROGRAMDESIGN:RECUPERATION..................................................64 DevelopandStrengthenReferralSystems.............................................................................64 STEP6.PUTTINGITALLTOGETHER......................................................................................71 CostingOuttheNutritionProgrammingPlan.........................................................................71 ANNEX1.TERMINOLOGY.....................................................................................................74 ANNEX2.RESOURCES..........................................................................................................79

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Acknowledgments
Manypeoplecontributedtothecreationofthistooldevelopingtheconcept,writingand reorganizingthetext,providingtechnicalfeedbackontheaccuracyandflow,andtesting thetoolinprojectsites.WewanttothankthemanyCOREmembersandpartnerswho havecontributedtheirinput,guidance,andhardworktomakethistoolareality. JoanJenningsdevelopedtheconceptualframeworkforthetoolandworkediteratively withtheNutritionWorkingGrouptodrafttheinitialversions. KristenCashin(AED/FANTA2),PaigeHarrigan(SavetheChildren),andLynetteWalker (Consultant)wrotethefinalversionofthisdocumentwithsolicitedinputfromavarietyof reviewers. KathrynBolles(SavetheChildren),PaigeHarrigan(SavetheChildren),andMary Hennigan(CatholicReliefServices)shepherdedthistoolfromitsinitialconceptiontothe finalproductascochairsoftheCORENutritionWorkingGroup. Thefollowingindividualsprovidedtechnicalcommentsandreviewonvariousdrafts: FerdousiBegum(SavetheChildren),JudyCanahuati(USAID),EunyongChung(USAID), HedwigDeconinck(AED/FANTA2),LeslieElder(SavetheChildren),NadraFranklin(AED), RaeGalloway(PATH),MarciaGriffiths(ManoffGroup),MaryHennigan(CatholicRelief Services),JoanJennings(Consultant),NazoKureshy(USAID),KarenLeBan(COREGroup), CarolynMacDonald(WorldVisionInternational),MichaelManske(SavetheChildren), JudiannMcNulty(Consultant),JenniferNielsen(HelenKellerInternational),Michel Pacque(MCHIP/ICFMacro),SandraRemancus(AED/FANTA2),MarionRoche(World VisionInternational),KavitaSethuraman(AED/FANTA2),DavidShanklin(ChildFund International),MariannaStephens(WorldVisionInternational),AnneSwindale (AED/FANTA2),CarolineTanner(SavetheChildren),MonicaWoldt(AED/FANTA2),and JenniferYourkavitch(MCHIP/ICFMacro). Anumberofindividualsactivelyparticipatedinseveralmeetingstodeterminetheinitial needandobjectivesofthetoolandaddressemergingchallengesandtechnicalissues: KathrynBolles(SavetheChildren),ErinBoyd(USAID),KristenCashin(AED/FANTA2),Erin Dusch(Consultant),LeslieElder(SavetheChildren),PaigeHarrigan(SavetheChildren), MaryHennigan(CatholicReliefServices),KarenLeBan(COREGroup),Kathleen MacDonald(AED/FANTA2),JudiannMcNulty(Consultant),MichelPacque(MCHIP/ICF Macro),TomSchaetzel(BASICS/USAID),DavidShanklin(ChildFundInternational),Lynette Walker(Consultant),andJenniferYourkavitch(MCHIP/ICFMacro). MaryHennigan(CatholicReliefServices),TinaLoren(SavetheChildren),andtheSavethe ChildrenandCatholicReliefServicesfieldteamsinMalawitestedtheinitialtoolduring thedevelopmentofajointTitleIIproposal.

REFERENCEGUIDE

 MembersoftheNutritionWorkingGroupandparticipantsinthenutritionsessionatthe CORESpringmeetingin2009providedvaluableinput,reviewandcommentsonthe evolvingtool. HeatherFinegan(AED/FANTA2)designedandformattedtheNPDAandthefollowing individualssupportedtheinstructionaldesign,layoutandediting:KevinBlythe (AED/FANTA2),RachelElrom(AED/FANTA2),TulaMichaelides(AED),EricaOakley (AED/FANTA2)andJoanWhelan(AED).HoukjeRoss(COREGroup)facilitatedthe finalizationandprintingoftheNPDA. Inadditiontothosementioned,thistoolbuildsontheexperiencesandlessonslearnedof manyindividualsandorganizationsworkingwithhealthandnutritionprogramsaround theworld.Weareindebtedtothemfortheircommitmentandingenuityincreating, implementingandevaluatingnutritionprograms. Wehopethatthistoolwillenhanceyourownprogrammingeffortsandthatyouwill contributetoourgrowingunderstandingofthemosteffectiveinterventionsand approachesforimprovingmaternal,infantandchildnutrition. Sincerely, PaigeHarrigan,CoChair TheNutritionWorkingGroup COREGroup KarenLeBan,ExecutiveDirector COREGroup WorldVisionscontributiontotheprintingcostsisappreciated.

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AcronymsandAbbreviations
ARI BCC BFHI BMI CBGMP CCM CCT CHV CHW CIMCI CMAM CNV CRS CSHGP dl DHS EBF ENA FANTA2 FBA g GAM GMP Hb HFA HIV HMIS IEC IFA IMCI IPT IYCF kcal kg KPC l Acuterespiratoryinfections Behaviorchangecommunication BabyFriendlyHospitalInitiative Bodymassindex LNS m MAM MAMI Lipidbasednutrientsupplement Meter(s) Moderateacutemalnutrition ManagementofModerateAcute MalnutritioninInfantsProject MultipleIndicatorClusterSurvey Millimeter(s) MinistryofHealth Midupperarmcircumference Nongovernmentalorganization NationalNutritionPolicy NutritionProgramDesignAssistant NutritionWorkingGroup OpinionResearchCorporationMacro International,Inc Oralrehydrationsolution Oralrehydrationtherapy PositiveDeviance PositiveDevianceInquiry PreventingMalnutritioninChildrenUnder 2Approach Preventionofmothertochildtransmission ofHIV Partspermillion ParticipatoryRapidAppraisal Privatevoluntaryorganization RapidRuralAppraisal Readytousetherapeuticfood Severeacutemalnutrition Socialandbehaviorchange Socialandbehaviorchangecommunication Supplementaryfeedingprograms DHSServiceProvisionAssessment TechnicalReferenceMaterial UnitedNations UnitedNationsChildrensFund UnitedStatesAgencyforInternational Development Weightforage Weightforheight WorldHealthOrganization Micromole(s)

Communitycasemanagement Conditionalcashtransfer Communityhealthvolunteer Communityhealthworker CommunityIntegratedManagementof ChildhoodIllnesses

mm MOH MUAC NGO NNP

NPDA CommunityBasedManagementofAcute NWG Malnutrition ORCMacro Communitynutritionvolunteer CatholicReliefServices USAIDChildSurvivalandHealthGrants Program Decileter(s) DemographicandHealthSurveys Exclusivebreastfeeding EssentialNutritionActions ORS ORT PD PDI PM2A

PMTCT FoodandNutritionTechnicalAssistanceII Project ppm PRA PVO RRA RUTF SAM SBC

Foodbasedapproaches Gram(s) Globalacutemalnutrition Growthmonitoringandpromotion Hemoglobin Heightforage Humanimmunodeficiencyvirus

SBCC Healthmanagementinformationsystem SFP Information,educationand SPA communication TRM Iron/folicacid UN IntegratedManagementofChildhood UNICEF Illnesses USAID Intermittentpreventivetreatmentof malaria WFA Infantandyoungchildfeeding WFH Kilocalorie(s) WHO Kilogram(s) mol Knowledge,PracticeandCoverageSurvey Liter(s)

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REFERENCEGUIDE

Communitybasedgrowthmonitoringand promotion MICS

Introduction
WelcometotheNutritionProgramDesignAssistant:AToolforProgramPlanners(NPDA).

BACKGROUND
Childundernutritionisaseriousandpersistentproblemcontributingtooveronethirdof deathsamongchildrenunder5yearsofageandisanunderlyingcauseinonefifthof maternaldeaths.1Thechildrenwhosurvivearemorevulnerabletoinfectionandhave compromisedphysicalgrowth,impairedcognitivedevelopmentandreducedlifetime earnings.2 ToreachtheMillenniumDevelopmentGoals,maternalandchildnutritionneedsto improveatarapidpace.Expertsarecallingforurgentandevidencebasedprogramaction atgreaterscaletopreventundernutritioninchildrenbytargetingpregnancyandthefirst twoyearsoflife.Thisdevelopmentwindowofopportunityiswhennutritionhasthe greatesteffectonchildhealth,growthanddevelopment;3ifactionisnottakenduringthis period,thedamagecanbeirreversible.Moreover, thereisgeneralagreementthateffectiveinterventions Whatisthedifferencebetweenan existandareavailabletopreventandtreat interventionandanapproach? undernutrition.4Ifcoverageoftheseevidencebased interventionsincreasesandreachesagreaternumber Inthistool,interventionsreferto ofwomenandchildren,therecouldbesubstantial evidencebasedbehaviors,services reductionsinundernutritionanddeath. orcommoditiesthatpreventor treatmalnutritionorsavelives. Thereislessagreement,however,onhowto Approachesrefertowaysto implementevidencebasednutritioninterventionsand deliverinterventions. otherpromisingpracticestoaddressundernutrition. TheNPDAprovidesaframeworkforprogrammersto analyzethenutritionsituationandoffersguidancesothatdesignteamscanchoosethe mostappropriatenutritionapproachesbasedonthespecificcontextandneed.Equally important,thetoolalsohelpsprogrammersavoidanapproachthatwouldbe inappropriateorineffectiveinthespecificcontext. ThecreationoftheNPDAwasahighlycollaborativeeffortcoordinatedbytheCORE GroupsNutritionWorkingGroup.Theguidanceprovidedhereisbasedonthecollective experienceofthenongovernmentalorganization(NGO)membersoftheCORENutrition
Black,REetal.,MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequencesinLancet2008. VictoraCG,AdairL,FallC,HallalP,etal.fortheMaternalandChildUndernutritionStudyGroup.2008.Maternalandchild undernutrition:consequencesforadulthealthandhumancapital.Lancet2008.PublishedonlineJan17.DOI:1016/S0140 6736(07)616924. 3 WorldBank.2006.Repositioningnutritionascentraltodevelopment:astrategyforlargescaleaction.WashingtonDC:The InternationalBankforReconstructionandDevelopment/TheWorldBank 4 Bhutta,Z.A.,T.Ahmed,R.E.Black,S.Cousens,K.Dewey,E.Giugliani,etal.2008.WhatWorks? InterventionsforMaternalandChildUndernutritionandSurvival.Lancet371(9610):41740.
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INTRODUCTION

PURPOSE
TheNPDAisatooltohelpprogramplanningteams,includingthosedesigningUSAIDChild SurvivalandHealthGrantsProgram(CSHGP)orTitleIIfoodsecurityprogramproposals, designthenutritioncomponentoftheirprogramsandselectthemostappropriate communitybasednutritionapproachesfortheirspecificgeographictargetareas.Asimple referenceguideandworkbook,theNPDAisbestusedincollaborationwitharangeof partners,includingministrystaff,communityleadersandrepresentatives,andlocal organizations.TheNPDAfocusesonthedesignofpreventiveprogramsandisintendedfor useinareaswherethereisahighprevalenceofstuntingand/orunderweightinchildren. TheNPDAalsoprovidesguidanceonrecuperativeapproachesthatmaybeincludedin preventiveprogramsinareasthatalsohaveahighprevalenceofacutemalnutritionanda veryhighprevalenceofunderweightinchildren.

USE
TheNPDA: Assistsindevelopingprogramsand/orproposals,andcanalsobeusedinprogram reviewstoreassessthedesignofnutritionprogramsthatarenotmakingprogress Providesguidancebasedonthemostrecentconsensusbyexpertsonrecommended interventions,approaches,protocols,andindicatorsforcommunitybasednutrition programming Focusesprimarilyonpreventiveprogramsthataddressstuntingandunderweight andmayincorporaterecuperativeapproachestoaddressacutemalnutritionwhen necessary Emphasizeslocalcommunityparticipationandownershipaspartoftheprogram designprocess:Communityownershipandparticipationandcommunitybased participatorydatacollectionandassessmenttoolsarecriticaltotheprogramdesign process.Atechnicallyperfectinterventionorapproachcanbederailedifitdoesnot addressacommunitypriorityorvalue.Notonlyisitcriticaltobuildinsufficienttime andresourcesformeaningfulcommunityparticipationandcommunitymobilizationas partofprogramimplementation,itisimportanttoincorporatetheobservationsand recommendationsfromcommunitymembers,localministriesandimplementing
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INTRODUCTION

WorkingGroup,localcommunitybasedpartnershiporganizations,UnitedStatesAgency forInternationalDevelopment(USAID)technicalexpertsandUSAIDtechnicalassistance projectsaswellastheliterature.Thetoolsguidanceonapproaches,protocolsandcutoff pointsisbasedonexpertconsensusdocumentssuchasjointstatementsmadebyUnited NationsChildrensFund(UNICEF)andWorldHealthOrganization(WHO)becausenutrition recommendations,protocolsandbestpracticesevolveandcontinuallyimprove.Someof therecommendationsmightchangeovertime,buttheprinciplesofusingdatatodesign programsbasedonnutritionneeds,applyinginterventionsandapproachesthathavea strongevidencebase,andbuildingtheevidencebasebycontinuallytesting,refiningand documentingnew/improvedapproacheswillcontinuetobeapplicable.

Useofthistoolrequiresdedicatedtimeandfocusedattentionandmighttakeplaceina multipledayprogramdesignworkshop.Inordertogetthemostoutoftheworkshop, situationanalysisdatashouldbecollectedpriortotheworkshop.Theworkshopshould offersufficienttimeforallparticipantstodiscusstheproposedprogramcontextandwhat thesituationanalysisdataindicateandtoreview/prioritizepotentialprogram interventionsandapproaches.TheNPDAwillmostlikelybeusedonceduringprogram designandpossiblyagainduringprogramimplementationaspartofaprogramreview. Therearespecificcriteriaforselectionforsomeprogramapproaches;forothersthe selectioncriteriamaybemoregeneral.TheCORENutritionWorkingGroupencourages programmerstoconsiderarangeofapproachesthatintegrateintoexistinghealthand nutritionservices,linktootherrelevantservicesinothersectorswhenpossible,are communitycenteredandincludeastrongemphasisonSBCratherthanselectingsingle, standaloneapproaches.

NUTRITIONAPPROACHESINCLUDED
Theapproachesincludedinthisdocumentfocusonimprovingthenutritionalstatusof childrenunder5yearsofage(andinparticularfrompregnancytoage2),andwomenof reproductiveage.Thereisastrongfocusonpreventiveapproaches.Thecommunitybased nutritionfieldandbestpracticesarecontinuallyadvancing.Theprogramapproaches summarizedintheNPDAarethosethatarecommonlyusedincommunitybasednutrition andhealthprogramsworldwideandhaveabodyofexperienceattachedtothem.The NPDApresentseachapproachsobjective,abriefdescription,thetargetgroup(s),criteria thatmustbeinplaceforimplementation,definingcharacteristics,elementsthatshould beinplacetoenhancethequalityofprogrammingandreferencesforfurtherinformation. Researchontheimpactandeffectivenessofmanyoftheapproachesisongoing. Programmersmaywishtoconsiderresearchandevaluationactivitiesthatcancontribute tothebodyofknowledge.
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http://www.mchipngo.net/controllers/link.cfc?method=tools_trm

INTRODUCTION

partnersinthedesignphase.TheNPDAfacilitatesdiscussion,communication,and decisionmakingamongmanystakeholders.Therearemanyparticipatoryassessment anddesigntoolsthathavebeendevelopedandareusedfrequently.Someare referencedinthequalitativemethodsdiscussiononpages1619. Focusesonnutritionandhealthfromafoodutilization/consumptionlens:Agreat dealoftheNPDAfocusesondiet,dietqualityandfeedingpracticeswithanemphasis onsocialandbehaviorchange(SBC)approaches.Thereisalsoabriefdiscussionof foodbasedapproachesthataddressavailabilityandaccessissues.However,guidance ondevelopingcomprehensivefoodsecurityprogramsisbeyondthescopeofthistool. Isforuseindevelopmentcontextsandisnotappropriateforemergencyconditions Complementsotherresources:TheTechnicalReferenceMaterials(TRMs)forthe USAIDChildSurvivalandHealthGrantsProgram(CSHGP)5andtheEssentialNutrition Actions(ENA)arediscussedunderKeyConceptsinthenextsection.

KeyConcepts
Thissectionprovidesageneraloverviewofnutritionconcepts,includingalistingofthe ENA.AglossaryofnutritiontermscanbefoundattheendoftheReferenceGuide.

NUTRITIONCONCEPTS

CausesofUndernutrition
TheWorldBankidentifiesmalnutrition6astheworldsmostseriouspublichealthproblem andthesinglebiggestcontributortochildmortality.7Theframeworkonthenextpage illustratesthecausesofundernutritionandmortality.Undernutritioninchildreniscaused byinadequatedietaryintake,diseaseoracombinationofthetwo.Underlyingthese immediatecausesareelementsincludingfoodinsecurity,inadequatecareofmothersand childrenandpooravailabilityandqualityofwater,sanitationandhealthservices.Intheir effortstoreduceundernutrition,NGOsoftenworkdirectlyontheunderlyingandbasic causesofundernutritionatthecommunity,householdandindividualleveltoimprove foodsecurity,carepractices,healthandtheenvironmentandaddresssocialchallenges suchasgenderandotherinequities.

PreventiveApproaches
Apreventivenutritionapproachisonethattargetsallmembersofavulnerable population,regardlessofnutritionalstatusofindividualchildren,toprevent undernutritionanditsconsequences.Suchpopulationbasedpreventivestrategiesare recommendedforcommunitiesthathaveahighprevalenceofundernutrition.Preventive programsareespeciallyimportantwheretherearehighratesofstunting,whichisoften irreversible,andthereforeneedstobeaddressedbeforeitoccurs.Promotingand protectinggrowthforallchildrenisproventobemoreeffectiveatreducing undernutritioninthepopulationthaninterveningonlyonanindividualbasisafterachild isalreadyundernourished.8Mostpreventivenutritionprogramsfocusonchildrenduring thedevelopmentwindowofopportunityyearsofconceptionthroughage2,when childrenaregrowingmostrapidly,aremostvulnerabletogrowthfalteringandaremost responsivetonutritioninterventions.
Exceptwhenreferringtoacutemalnutrition,whichisstandardterminology,theNPDAwillusethetermundernutrition,which referstovariousconditionsofbeingdeficientornothavingenoughnutritionandincludesstunting,wasting,underweightand micronutrientdeficiencies.Thetermmalnutritionincludestheconditionsrelatedtobothdeficienciesandovernutrition,suchas overweightandobesity. 7 WorldBank.2006.Repositioningnutritionascentraltodevelopment:astrategyforlargescaleaction.WashingtonDC:The InternationalBankforReconstructionandDevelopment/TheWorldBank. 8 ThisissupportedbyresearchconductedinHaitithatcomparedapreventiveapproachtargetingallchildrenunder2yearsofage, toarecuperativeapproachthatprovidedsimilarservicesbuttargetedonlyundernourishedchildrenunder5yearsofage.RuelM, etal.2008.Agebasedpreventivetargetingoffoodassistanceandbehaviourchangeandcommunicationforreductionof childhoodundernutritioninHaiti:aclusterrandomisedtrial.Lancet.371:588595.Moreinformationonthisstudycanbefound at:http://www.fanta2.org/
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KEYCONCEPTS

Figure1.CausesofUndernutrition9 ChildNutrition Food/Nutrient Intake

ImmediateCauses

Health

UnderlyingCausesat Household/Family Level

Agriculture Poverty reduction Education HealthSystems Strengthening IGA Womens Empowerment

BasicCausesatSocietal Level

Institutions Political&Ideological

Resources,Environment, Technology,People

EconomicStructure

RecuperativeApproaches
Recuperativeapproachesarethosethatprovidetreatmenttochildrenwhoare undernourished,including:therapeuticfeedingandmedicalcareforchildrenwithsevere acutemalnutritionSAM),andsupplementaryfeedingandmedicalcareforchildrenwho
9

MarieRuel,SCNNews2008,revised.

KEYCONCEPTS

BF/CF DietDiversity SBCC VA,Iron,Zinc Hygiene

aremoderatelyundernourished.Thepurposeistobringthechildbacktoanormal nutritionalstatus.Eveninareaswithstrongpreventiveprogramming,somechildrenwill stillbecomeundernourishedandrequirespecializedtreatment.Programsthatidentify andtreatchildrenneedingrecuperationgenerallytargetchildrenthroughtheageof59 months.Recuperativeprogramsaremostappropriateinareaswithhighprevalenceof moderateacutemalnutrition(MAM)andSAMandveryhighprevalenceofunderweight.

DevelopmentWindowofOpportunity:PregnancytoAge2
Theriskofundernutrition,thoughpresentthroughoutlife,isheightenedatcertainstages ofthelifecycle,inparticularduringpregnancy,lactationandthefirst24monthsoflife. Thisperiod,frompregnancyuntilachildssecondbirthday,duringwhichchildrenaremost vulnerabletoundernutritionandtheaccompanyingirreversibledeficitsingrowthand development,alsopresentsacrucialwindowoftimeduringwhichundernutritioncanbe prevented.Becausetheyaregrowingsorapidly,childrenatthisageareveryresponsiveto nutritioninterventionsthatpromotegrowthandpreventundernutrition.Focusingon childrenunder2yearsofagepresentsagreatopportunitytointervene,promoting adequategrowthanddevelopmentwhentheyaremostabletobenefit.

GenderandOtherFactorsinUndernutrition
Inadditiontovulnerablepointsinthelifecycle,therearegeographic,socioeconomicand genderbasedconstraintstoundernutrition.Over80percentoftheworlds undernourishedchildrenliveinjust20countries,concentratedinsubSaharanAfricaand SouthAsia.Inbothregions,genderinequitiessubstantiallyinfluencepoormaternaland childfeedingpracticesandundernutrition.Theseinequitiesstemfrominadequate attentiontotheneedsandrolesofwomen,resultingininadequatecareforpregnantand lactatingwomen,lackofeducation,poorselfconfidence,loweconomicstatusanda workloadthatallowslittletimeformodifyingpracticestoimprovenutrition.Tobe effective,programsmayhavetoaddressarangeoffactorsaffectingthecaregiving environmentanddynamicsofthehousehold,suchaswomensworkload.10Whilethe evidencebaseisstrong,ourknowledgeaboutundernutritionandourexperience continuestoevolve.Whetherrevisitingthebestprogrammaticapproachestomitigatethe impactoflongidentifiedcausesofundernutritionorinvestigatingnewerthemes,suchas HumanImmunodeficiencyVirus(HIV)and/orthefood/fuel/financialpricecrisis,continued research,sharing,learningandconsensusisrequired. Thereareanumberofreferencesandconceptualframeworksthatsimplifycomplicated nutritionconcepts.ThecentralorganizingframeworkthatwillbeappliedintheNPDAis theENA,describedonthenextpage.

DrawnfromDicken,K:GriffithsM;andPiwoz,E.1997.DesigningByDialogue:AProgramPlannersGuidetoConsultative ResearchforImprovingYoungChildFeeding.Washington,DC:AcademyforEducationalDevelopment.
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KEYCONCEPTS

ESSENTIALNUTRITIONACTIONS
TheENAaresevenaffordableandevidencebasednutritioninterventionsdeliveredat healthfacilitiesandcommunitiestoimprovethenutritionalstatusofwomenand children.11TheENAprovideaholisticframeworkonwhichtobasenutritionprogramming. TheENAframeworkmaximizescoverageoftheseinterventionsbydeliveringkeymessages andservicesthroughmultiplecontactpointsinrelevantnutrition,healthandsocialsector programs,andespeciallyfocusesonsixcriticalcontactpoints:prenatalvisits,delivery care,postpartumcareformothersandinfants,immunization,sickchildvisitsandwell childvisits(includingcounselingandgrowthmonitoringandpromotion[GMP]).Theseven ENAare: 1.Promotionofoptimalbreastfeedingduringthefirstsixmonths Promoteearlyinitiationofbreastfeeding(i.e.,withinonehourofbirth);donotgive prelactealfeeds12 Promoteexclusivebreastfeeding(EBF)forthefirstsixmonthsoflife(i.e.,noother liquidsorfoods) Promotebreastfeedingondemand,dayandnight(i.e.,usually812timesperday)for anadequatetimeateachfeeding;offerthesecondbreastafterinfantreleasesthefirst Practicecorrectpositioningandattachmentofinfantatthebreast Promotegoodbreasthealthcare 2.Promotionofoptimalcomplementaryfeedingstartingat6monthswithcontinued breastfeedingto2yearsofageandbeyond13 Continuefrequent,ondemandbreastfeedingthrough24monthsofageandbeyond Introducecomplementaryfoodsat6monthsofage Prepareandstoreallcomplementaryfoodssafelyandhygienically Increasefoodquantityaschildgetsolder o 68months:200kcal/dayfromcomplementaryfoods o 911months:300kcal/dayfromcomplementaryfoods o 1223months:550kcal/dayfromcomplementaryfoods Increasefrequencyoffeedingcomplementaryfoodsaschildgetsolder o 68months:23mealsperday o 923months:34mealsperday,12snacksperday(asdesired) Increasefoodconsistencyandvarietygraduallyaschildgetsolder Feedavarietyoffoodsdailytoensureadequatenutrientintake,includinganimal products,fortifiedfoodsandvitaminArichfruitsandvegetables
TheENAencompassamenuofrecommendationsforkeyoptimalinfantandyoungchildfeedingbehaviors,maternalnutrition behaviorsandmicronutrientintakeforwomenandchildrentobepromotedatfacilityservices,andduringcommunitybased activitiesandhomebasedcare. 12 Prelactealfeedsincludeanyfoodorliquidotherthanbreastmilkgiventoachildinthefirstthreedaysoflife. 13 Internationalguidanceonoptimalfeedingofchildren623monthscanbefoundinPAHO.2003.GuidingPrinciplesfor ComplementaryFeedingoftheBreastfedChild623months: http://www.who.int/child_adolescent_health/documents/a85622/en/index.htmlandWHO.2005,GuidanceforFeedingnon breastfedchildren624months:http://whqlibdoc.who.int/publications/2005/9241593431.pdf
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KEYCONCEPTS

Practiceresponsivefeeding(i.e.,feedinfantsdirectlyandassistolderchildren, encouragechildrentoeat,donotforcefeed,minimizedistractions,showloveto childrenbytalkingandmakingeyecontact) 3.Promotionofoptimalnutritionalcareofsickandseverelymalnourishedchildren Continuefeedingandincreasefluidsduringillness o Childunder6monthsofage:increasefrequencyofEBF o Child624months:increasefluidintake,includingbreastmilk,andofferfood Increasefeedingafterillnessuntilchildregainsweightandisgrowingwell Fordiarrhea:providezincsupplementationfor1014days,accordingtoWHOprotocol Fordiarrhea:providelowosmolarityoralrehydrationsolution(ORS)tochildrenover6 months Formeasles:providevitaminAtreatment,accordingtoWHOprotocol ReferseverelymalnourishedchildrenfortreatmentaccordingtoWHOprotocol,through communitybasedmanagementofacutemalnutrition(CMAM),inpatientcare,orother appropriateprogram 4.PreventionofvitaminAdeficiencyinwomenandchildren Breastfeedchildrenexclusivelyforthefirst6months,andcontinuebreastfeedinguntil thechildis24monthsorolder TreatxerophthalmiaandmeaslescaseswithvitaminA,accordingtoWHOguidelines ProvidehighdosevitaminAsupplementationtochildren659monthsofage,everysix monthsaccordingtoWHOguidelines ProvidepostpartumhighdosevitaminAsupplementationtowomenassoonas possibleafterdelivery: o Ifbreastfeeding,withineightweeksofdelivery o Ifnotbreastfeeding,withinsixweeksofdelivery PromoteconsumptionofvitaminArichfoods,includingliver,fish,egg,redpalmoil, darkyellowororangefruits(e.g.mangoripeanddried,papayaripeanddried,apricots freshanddried,persimmon),darkgreenleafyvegetables,andorangeordarkyellow fleshedvegetables,rootsandtubers(carrots,pumpkin,squash,sweetpotatoes). PromoteconsumptionofvitaminAfortifiedfoods,whereavailable 5.Promotionofadequateintakeofironandfolicacidandpreventionandcontrolof anemiaforwomenandchildren Promoteintakeofironrichfoods,especiallyanimalproductsandfortifiedfoods Provideiron/folicacid(IFA)supplementationtoallpregnantwomen;continue supplementationforthreemonthspostpartuminareaswithanemiaprevalence greaterthan40percent ProvideIFAsupplementationforchildren14
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CurrentWHOguidelinesincludeironsupplementationforchildren,andallsupplementationshouldbeinlinewithnational guidelines.However,guidelinesforsupplementationofchildreninareaswheremalariaishighlyprevalentmaybemodified.A randomized,controlledtrialinPemba,Zanzibar,wheremalariaishighlyendemic,showedthatdailyironsupplementationofall childrenresultedinastatisticallysignificantincreaseinhospitalization.Theadverseoutcomesappeartohaveoccurredinchildren whowereironrepletepriortosupplementation.Furtherresearchneedstobedone,andironsupplementationrecommendations

KEYCONCEPTS

Dewormchildrenover12monthsofage,pregnantwomenafterthefirsttrimesterand lactatingwomenaccordingtoWHOprotocolinareaswhereparasiticwormsarea commoncauseofanemia Preventandcontrolmalaria o Intermittentpreventivetreatmentforpregnantwomen o Longlastinginsecticidalnets(LLINs)forwomenandchildren 6.PromotionofAdequateintakeofiodinebyallmembersofthehousehold Promoteconsumptionofiodizedsalt Supplementpregnantandlactatingwomenandchildren624monthsofagewith iodizedoilcapsuleswheniodizedsaltisnotavailable,accordingtoWHOrecommended doses15 7.Promotionofoptimalnutritionforwomen Consumemorefoodduringpregnancyandlactation o Pregnancy:285extrakcal/day(oneadditionalsmallmealeachday) o Lactation:500extrakcal/day(12additionalsmallmealseachday) Increaseproteinintakeduringpregnancyandlactation(e.g.,beans,lentils,legumes, animalsourcefoods,oilseeds) ProvideIFAsupplementationforallpregnantwomen,accordingtoWHOprotocol16 Treatandpreventmalaria Dewormduringpregnancy(afterfirsttrimester)inareaswhereparasiticwormsarea commoncauseofanemia ProvidepostpartumvitaminAsupplementation Promoteconsumptionofiodizedsalt Supplementpregnantandlactatingwomenwithiodizedoilcapsuleswheniodizedsaltis notavailable,accordingtoWHOrecommendeddoses17

inmalariouszonesmaychange.(Sazawaletal.2006.LancetVol367:133). www.who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf 15 http://www.who.int/nutrition/publications/micronutrients/WHOStatement__IDD_pregnancy.pdf 16 WHO/UNU/UNICEF.2001.IronDeficiencyAnaemia:Assessment,PreventionandControl.Thereisachartonpage58that indicatestherecommendedIFAdosagesfordifferenttargetgroups.http://whqlibdoc.who.int/hq/2001/WHO_NHD_01.3.pdf
17

Ibid.

KEYCONCEPTS

HowtoUsetheNPDA
Thistoolconsistsoftwoseparate,interrelateddocuments: 1. NutritionProgramDesignAssistant:AToolforProgramPlanners:ReferenceGuide 2. NutritionProgramDesignAssistant:AToolforProgramPlanners:Workbook TheReferenceGuide,whichyouarecurrentlyreading,providesanintroduction,key conceptsandterminology,andreferencematerialstoguidethesituationanalysisand decisionmakingoninterventionsandapproachesthatareappropriatebasedonneeds, resourcesandobjectives. TheWorkbookisforrecordingthekeyinformation,dataanddecisionsandthedecision makingrationale.Detailedquestionsandtextboxesforrecordingtheteamsthought processanddecisionsareincludedintheWorkbook.Uponcompletion,theWorkbook providesarecordofthethoughtprocessinvolvedincreatingthenutritionprogram design.Withrepeateduse,itisanticipatedthatateamwouldmainlyusetheWorkbook andconsulttheReferenceGuideonanasneededbasis.

USEOFICONS

Icon

Indicates

InformationisgivenaboutwheretofindthissectionintheWorkbook. Writeyourinputs. Anexampleisgiven. Gotothenextsection.

ASSUMPTIONSMADE
GroupDecisionMaking
Itisassumedthatyouwillbeworkingthroughthistoolasateam.Thistoolisdesignedto assistyourprogramteaminprogressingthroughthedecisionmakingstepstowardsafinal consensusonthemostappropriatecombinationofprogramapproachesforthetarget area.Itisorganizedasaseriesofquestionsanddiscussionpoints.Questionsaredesigned tochallengeyourteamtothinkthroughtherelevantpointsandcometoyourown conclusionsonthebestapproachesforyourgeographicarea.

10

HOWTOUSE

GeographicTargeting
Thistoolcanbeusedtodevelopprogramapproachesforanygeographiclevellocal community,district,provinceornational.Thelevelyourteamchoosesshouldbebased uponwhatismostusefulforyourplanningpurposes.TheQuantitativeDataCollection TablesatthebeginningoftheWorkbookprovidescolumnsforgeographicdisaggregation ofdataincaseyouwanttodoaninitialcomparisonofneedsinmakingyourfinaldecision onthetargetarea.Thetooldoesnotprovideanyadditionalguidanceingeographic targeting,butassumesthatyourteamalreadyhassubstantialexperienceinchoosinga geographictargetarea.

KEYSTEPS
Step1.GatherandSynthesizeInformationontheNutritionSituation Step1providesguidanceongatheringandsynthesizingdatato:1)determinewhether implementationofacommunitybasednutritionprogramiswarrantedinthesetting;2) identifypotentialcausesofundernutritionandkeyinterventionareas;and3)decide whethertheprogramwillfocusonpreventiononlyorpreventionandrecuperation.Step1 reviewsdataon:

A. Nutritionalstatus:Anthropometry B. Infantandyoungchildfeeding C. Maternalnutrition D. Micronutrientstatusofchildren E. Underlyingdiseaseburden TheWorkbookprovidesspaceforrecordingthedataoneachoftherelevantindicators, conclusionsonlevelofpublichealthsignificancebasedonthetablesintheReference Guide,answerstoadditionalquestionsforinterpretingthedata,andyourfinaldecisions onwhetherthespecificinterventionareashouldbeapriority.Lateranalysiswillhelpyou determinewhetheryouwillattempttoaddressallofthepriorityareas. Result:Determinationofprogramfocus(preventiononlyorprevention+recuperation)and indicationofpriorityinterventionareasforaddressingwoman,infantandchildnutrition Step2.DetermineInitialProgramGoalandObjectives Step2guidestheusertodraftinitialprogramgoalsandobjectivesbasedonthe conclusionsinStep1,andtonoteinformationonotherissuessuchasthefunding available,communitypriorities,donorinterestsandorganizationalstrengths.Thegoaland objectivesdraftedinStep2willberevisitedinStep6aftercollectingandreviewing additionalinformation. Result:Initialprogramgoalandobjectives
11

HOWTOUSE

Result:Mappingoftheexistingcapacityoflocalhealthandnutritionservicesatthe communityandfacilityleveltoinformsubsequentdecisionmakingonappropriate nutritionapproaches Step4.PreliminaryProgramDesign:Prevention Step4providesinformationonpotentialpreventiveapproachestodeliverthepriority interventionsselectedinStep1.Informationandguidanceonvariousprogramapproaches isprovidedintheReferenceGuide.Summarytablesofcommonapproachesareincluded forrapidcomparisonandreview.QuestionsareprovidedintheWorkbookunderthisstep toguideyourthinkingaboutassets,gapsandopportunities. Result:Listingofallpotentialpreventiveapproachesthatcouldbeconsideredbasedonan analysisoftheneedsandassetsinthetargetarea Step5.PreliminaryProgramDesign:Recuperation Step5providesinformationonpotentialrecuperativeapproachesthatcanbeaddedto thepreventiveprogram,asnecessary.TheReferenceGuidedescribeskeycomponentsof recuperativeinterventionstoaddressMAM,SAMandunderweightandsummarytablesof commonapproachesthatmeetkeycriteria.TheWorkbookprovidesquestionstoguide teamdiscussionsandselectionofrecuperativeapproaches. Result:Listingofpotentialrecuperativeapproachesthatcouldbeaddedtothepreventive program,basedonthesituationinthetargetarea
12

HOWTOUSE

Step3.ReviewHealthandNutritionServices Step3guidestheuserthroughmappingwhatcurrentlyexistsintermsof: Nationalpolicy Serviceavailability,access,anduptake Qualityofservices Availabilityofmaterialsandequipment,toincludeinformation,educationand communication(IEC)andbehaviorchangecommunication(BCC)materials TheReferenceGuideprovidesguidanceoncollectingthisinformationandtheWorkbook providesdetailedquestionsandspaceforrecordingasummaryofthenationalpolicy environmentandareviewoflocalservices.

Step6.PuttingItAllTogether Step6isthefinalstepintheNPDA.Inthisstep,theuserproceedsthroughaseriesof questionstoreassesstheinitialprogramobjectives,costoutprogrammingoptions,review keyprogrammingconsiderationsandfinalizethenutritionalprogramapproach. Result:Finaldecisiononthecombinationofnutritionprogramapproachestoproposefor thetargetarea

LETSGETSTARTED!

13

HOWTOUSE

STEP1.Gatherand SynthesizeInformation ontheNutrition Situation

Step1beginsonpage1oftheWorkbook.
InStep1youwillidentifytheareasofkeypublichealthsignificancetoensurethatthe approachesyouselectaddresstheareasofgreatestneed.Attheendofthisstep,your teamwillreachconsensusregardingtheoverallprogramfocus(preventionor prevention+recuperation)andinterventionareasindicatedaskeypublichealthconcerns. Insubsequentsteps,youwilldecidewhetheryourteamwillactuallyattempttoaddress eachinterventionareayouprioritizeinthisstep.

Thisstepprovidesguidanceongatheringandsynthesizingdatainfiveareasofpublic healthsignificance: A. Nutritionalstatus:Anthropometry B. Infantandyoungchildfeeding C. Maternalnutrition D. Micronutrientstatusofchildren E. Underlyingdiseaseburden

Theguidanceinthissectioncovers: PartI.Gatheringquantitativeinformation PartII.Gatheringqualitativeinformation PartIII.Synthesizingdata

STEP1PARTI.GATHERINGQUANTITATIVE INFORMATION
Anygoodanalysisstartswithgooddata.Doingananalysistodetermineappropriate nutritioninterventionsisnodifferent.Whatisoftenchallengingissortingthroughthe manypotentialindicatorsandtypesofinformationtodeterminewhichonesyourteam willuseduringdecisionmaking.Toomuchdatacanbeasconfusingastoolittle. Step1PartIoftheWorkbookhelpsyourprogramtodocumentnecessarydata. QuantitativeDataCollectionTablesAEidentifywhichdataareessentialtousewhen prioritizingnutritioninterventionareas(thenumberedindicators).Thetablesalsoinclude additionalindicatorsthatprogramsmayfindusefultoconsider,butthatarenot
14

GUIDESTEPONE

specificallyaddressedinthetool.TheindicatorsareprimarilytakenfromtheDemographic HealthSurveys(DHS);MultipleIndicatorClusterSurvey(MICS);andKnowledge,Practice andCoverageSurvey(KPC).18Theseindicatorsareageneralguideandrepresenta minimumset.Yourteammaygatherdatafromothersourcesthatuseslightlydifferent formsofthesesameindicators(e.g.,adifferentagerange),orthedonorforyourprogram mayhavedifferentrequirementsforindicators.Variationsoftheindicatorsareacceptable forthepurposeofusingthistoolandselectingappropriatenutritioninterventions. TheessentialindicatorsfoundintheQuantitativeDataCollectionTablesintheWorkbook aredividedintofivesections: TableA:Nutritionalstatus:Anthropometry TableB:Infantandyoungchildfeeding TableC:Maternalnutrition TableD:Micronutrientstatusofchildren TableE:Underlyingdiseaseburden

SourcesofQuantitativeData
Datacanbecollectedfromseveraldifferentsources.Keepinmindthatifdisaggregated dataareavailable,theywillprovideabetterunderstandingofwhoismostaffectedbased onfactorssuchasage,sex,socioeconomicstatusorgeographiclocation.Itisalsohelpful tolookatchangesovertimetobetterunderstandtrendsinnutritionalstatusandprogram effectiveness.Torecorddisaggregateddata,addcolumnstotheQuantitativeData CollectionTablesasnecessary.AneasytomanipulateExcelversionoftheQuantitative DataCollectionTablesareavailableonlineat:www.coregroup.organdwww.fanta2.org. DemographicandHealthSurveys Inmanycountries,aDHSisconductedeveryfiveyearsandthedataaredisaggregatedby geographicregionsandotherfactors.Althoughthisinformationshouldnotbeusedasa substituteforabaselinesurveyorfutureevaluationofprogramimpact,itcanprovide informationthatisusefulforanalyzingandinterpretingthehealthandnutritionsituation inatargetareaduringtheprogramdesignphase.DHSsurveyreportscanbefoundat www.measuredhs.com. MultipleIndicatorClusterSurvey TheMICS,developedbyUNICEF,canprovideusefulinformationatanationalandregional levelofthecountry.MICSarecurrentlydoneeveryfiveyears,butbeginningwiththenext round(MICS4),UNICEFwillprovidesupporttocountrieseverythreeyears.MICSdatacan befoundatwww.childinfo.org.
DevelopedforusebyUSAIDfundedchildsurvivalprojects,theKPCincludesmostoftheRapidCatchindicators.AlloftheRapid CatchindicatorsshouldbeincludedinthebaselinesurveyforprogramsfundedbytheUSAIDCSHGP.ForTitleIIFoodSecurity Projectsand/orproposalstootherdonors,theremaybesomevariationinrequiredindicators.Theteamshouldselectthe indicatorsmostappropriatefortheirprojectandfundingsource.
18

15

GUIDESTEPONE

Knowledge,PracticeandCoverageSurvey
GoodqualitylocalinformationwillcomefromaKPCifonehasbeenrecentlydoneinthe targetarea.Unfortunately,aKPCmaynotbeavailabletoyouintheearlyprogramdesign stagesinceitisgenerallyconductedfollowingtheawardofagrant.Excellentresourcesfor conductingaKPCwithinformationonsampling,indicators,tabulationandsurveytools canbefoundat:www.mchipngo.net/controllers/link.cfc?method=tools_kpc_modules.

MinistryofHealth(MOH)NationalHealthManagementInformationSystem(HMIS)
LocalMOHdatacanbeuseful,butinterpretationmusttakeintoaccountthatsomehealth facilitiesmaynotregularlyprovidereportsand/orthatdatacomefromonlythosechildren andwomenwhoactuallyuseavailablehealthservicesandmaynotincludemore vulnerablewomenandchildrenwithbarrierstoaccess.MOHdataprovidesinformation onhealthservicedelivery,butdoesnotprovideacompletepictureofthehealthand nutritionsituationforallwomenandchildren(bothusersandnonusers).Inaddition, MOHsystemsrarelygatherimportantdataonmaternalandchildfeedingpractices,which iscriticalfordesigninganynutritionapproach. OtherLocalSurveys TheremaybeothersurveysthathavebeenconductedinthelocaltargetareabyUNICEF (orotherUnitedNations[UN]agencies),nationalcampaigns,NGOs,researchinstitutions and/ordonoragencies.

STEP1PARTII.GATHERINGQUALITATIVE INFORMATION
Step1PartIIbeginsonpage12oftheWorkbook. Qualitativedatawillfurtheryourunderstandingoftheimplicationsofthequantitative dataandiskeytounderstandinglocalpractices,beliefsandculturalnorms.Information gatheredatthisstageforidentifyingappropriateinterventionswillhelptotailorthe programtothelocalcontextandtodevelopimplementationstrategies.However, programswilllikelyneedtogathermoredetailedqualitativedataduringprogram implementation. TheFoodConsumptionSummaryTableinStep1PartIIoftheWorkbookhelpsto summarizethequalitativefoodconsumptioninformationthattheyteamgathers.NPDA usersareencouragedtomodifythistable,usingtheMSExcelfileavailableat www.coregroup.organdwww.fanta2.org,oryoumayuseotherformats.Program plannersshouldalsokeepaseparatenotebooktodocumentadditionalqualitativedata thattheycollect(describedonthenextpage).

16

GUIDESTEPONE

QualitativeDatatoCollect
Qualitativedatawillassisttheprograminbetterunderstandingthequantitativedata.The listheresummarizesbroadcategoriesofqualitativedatathatcanhelpinnutrition programdevelopment,andmuchoftheinformationwillbeusedinStep3.Theteam shouldincludeotherpertinentqualitativedataasappropriate. Categoriesofqualitativeinformationinclude:19 Foodconsumptionpractices:Whichfoodgroupsareconsumedbyvarioustarget groups,theiravailabilityinthemarket,andtheiraccessibilitytopeopleoflow socioeconomicstatus.ThereisaFoodConsumptionSummaryTableonpage12ofthe Workbooktorecorddata. Nationalpoliciesandprotocols(ThisinformationwillbeneededinWorkbookStep3): Keyelementsofnutritionrelatedpoliciesthatthegovernmenthasestablished(e.g., nationalnutritionpolicy,communityhealthpolicy,guidelinesonmanagementofSAM, infantandyoungchildfeeding[IYCF]policy,nutritionandHIV,micronutrient supplementation) Healthservices:Availableservices,distancetoservices,explanationsofwhypeopledo ordonotusethehealthservices,staffing,communityperceptionsofthehealth services,qualityassessments Descriptionofcommunities:Socialstructureofcommunityandfamilies, infrastructure,includingexistenceofandaccesstowaterandsanitationfacilities, government(committees,councils,leadership),communitybuildings,markets, agriculturalactivities,informationoncommunitydecisionmakingprocess Culturalbeliefsandpractices:Cancoverarangeoftopics,includingchildcare, womensandmensrolesinfamilyandcommunity,healthandhealthcare, education/schooling Livelihoodsourcesandpatterns:Howpeopleprovideforthemselvesandtheir families;wherepeopleaccessfood(homeproduction,purchase,foodassistance), seasonalityofincomeandfoodaccess Vulnerablegroups:Inmanycommunities,thereareoftengroupsofpeoplewhoare morevulnerablethanothersbecauseofethnicdiscrimination,socioeconomicstatus, geographiclocation,sexorageofhouseholdhead,illness,sex,ageoreducationlevel; Itwillbeimportanttofindoutwhoarethemostvulnerableinanygivencommunity andmakesuretheprogramisabletomeettheirneeds Externalcontext:Relativepoliticalstability,conflict,and/ornaturaldisasterriskprofile

SourcesofQualitativeData
Youmayhavesomerecentandgoodqualityqualitativedatatodrawuponthathas alreadybeencollectedandsummarized,whichwillsavetimeandresources.Extensive qualitativeresearchresourcesexistandshouldbeconsulted.Theresourcesectionatthe
19

ManyofthesecategoriesweredrawnfromNutritionEssentials:AGuideforHealthManagers. http://www.basics.org/documents/pdf/NutritionEssentials_English.pdfandSchoonmakerFreudenberger,Karen. 1999.RapidRuralAppraisal(RRA)andParticipatoryRuralAppraisal(PRA):AManualforCRSFieldWorkersand Partners.Baltimore,MD:CatholicReliefServices.

17

GUIDESTEPONE

Foodconsumptiondata,suchasthatintheFoodConsumptionSummaryTableinthe Workbook,canbechallengingtofindandcollect.Informationcanbeobtainedfrom varioussources,includingregionalandnationalacademicandresearchinstitutes,private voluntaryorganizations(PVOs)/NGOsandotherlocalsurveysandreports.DHSsurveys providequalitativedataonwhatyoungchildrenwereeatingthatisextremelyusefulin programdesign;morerecentandlocalinformationisbetter.NPDAuserscanalsoreferto marketreportsandconductkeyinformantandfocusgroupsinterviewstogainqualitative informationrelatedtofoodavailabilityandthediet. FocusGroupDiscussions Focusgroupdiscussionsprovideanopportunityforastructureddiscussioninasmall grouptoobtaininformationaboutperceptionsofcommonpractices,beliefsandconcerns. Theprogramdesignteamoftenconductstheirownfocusgroupswithcommunity membersand/orobtainsinformationfromothersources.Potentialfocusgroup participantsalsoincludeotherNGOsactiveintheareaandstaffatcommunityhealth facilities.Itisimportanttohaveindividualsexperiencedinqualitativemethodsinvolvedin developing,leadingandanalyzingthefocusgroupdiscussions. KeyInformantInterviews Keyinformantinterviewsprovideanopportunitytotalkindepthwithspecificindividuals knowledgeableaboutthetargetgroup(s)andprogramarea.Yourteammaywishto conducttheirownkeyinformantinterviewsorobtaininformationfromothersources. PotentialkeyinformantsincludestaffofotherNGOsactiveinthearea,community leaders,communitymembersandstaffatcommunitylevelhealthfacilities. Observations Directobservationsallowtheobservertoassesswhetherknowledge(e.g.,theimportance ofwashinghandsbeforeeating)isactuallypracticed.Observationscanconfirmor contradictwhatpeoplesay;peopleareoftenunawareofeverythingtheyareactually doingandthereforearenotabletoverbalizepracticesthatmaybecomeevidentthrough careful,respectfulobservation. RapidRuralAppraisals(RRA)andParticipatoryRapidAppraisal(PRA) PRAandRRAtechniquescanbeusefultoolsforengagingcommunitiesindialogueto betterunderstandthelocalsituation.AmanualontheseapproachesbyCatholicRelief Services(CRS)20definesthemasfollows.
20

SchoonmakerFreudenberger,Karen.1999.RapidRuralAppraisal(RRA)andParticipatoryRuralAppraisal(PRA):AManualfor CRSFieldWorkersandPartners.Baltimore:CatholicReliefServices.

18

GUIDESTEPONE

endofthisReferenceGuidelistsseveralgoodsources.Inmanycases,however, programmerswillneedtoconductfieldbasedqualitativedatacollection.Qualitativedata maycomefromthefollowingsources,amongothers. PublishedReports

RRAreferstoadiscretestudy(orseriesofstudies)inoneormorecommunities.These RRAstudiestypicallylastfromfourtoeightdays.Duringthisperiodamultidisciplinary teamofresearcherslooksatasetofissuesthatareclearlydefinedbythestudyobjectives. Theteamworksinclosecollaborationwithcommunitymembers,involvingtheminall aspectsofthecollectionandanalysisofinformation.Informationiscollectedusinga diversesetoftoolsandtechniquesthatfacilitatetheparticipationofcommunity members.Thefocusisgenerallyongatheringinformationandensuringthatthe informationisasrichandasaccurateaspossible.AnRRAgenerallyresultsinareportthat summarizestheresearchfindings.Thisinformationcanthenbeusedinavarietyofways includingprogramdesign,improvementofanongoingprogram,revisionofnational policies,etc. PRAreferstoamoreextendedprocessthatinvolvesnotonlythecollectionof informationbutalsoitseventualusebythecommunityasitplansfurtheractivities.The emphasisinPRAisoftennotsomuchontheinformationasitisontheprocessand seekingwaystoinvolvethecommunityinplanninganddecisionmaking.IfanRRAisa discretestudy,aPRAisanextendedprocessthatcanlastformonthsoryearsas communitiesdeveloptheirownskillsneededtoaddressissues,analyzeoptions,andcarry outactivities.

STEP1PARTIII.SYNTHESIZINGDATA
InStep1PartIII,theteamwillreviewandsynthesizethequantitativeandqualitative datagathered.First,recordthepertinentquantitativeandqualitativedatafromPartsI andIIintoTablesAEinPartIIIoftheWorkbook.Onceyouhavedoneso,reviewthedata synthesisguidanceforTablesAEinPartIIIofthisReferenceGuide(below).Discussthe implicationswithyourteamanddetermineprioritiesbasedonthelevelofpublichealth significance.Itisimportanttorememberthatthesearenotstraightforwarddecisions. Discusstheinterpretationofthedataasateambeforemakingfinaldecisions.Baseyour decisionsonthedata,anddebatetheappropriateinterpretationofthatdataforthe programsite.

SectionA.SynthesizingDataonNutritionalStatus:Anthropometry
Step1PartIIISectionAbeginsonpage15oftheWorkbook.
Preventionofundernutritionshouldbeaprogrampriority.However,childrenwhoare malnourishedrequiretreatmenttopreventillness,deathandothernegative consequencesofundernutrition.Inthissection,youwilldiscusstheanthropometricdata gatheredonstunting,underweight,wastingandacutemalnutrition,anddetermine whethertheprogramwillfocusonpreventiononly(withreferraltohealthservicesfor childrenneedingtreatment)oraddrecuperativeapproachestothepreventionprogram. DatasynthesisforSectionsBEwillhelpdeterminethemostappropriateintervention areasforafocusonprevention.
19

GUIDESTEPONE

GuidanceforDataSynthesis
WHOprovidesacategorizationofthepublichealthsignificanceofanthropometric indicators. WHOCategorizationofthePublicHealthSignificanceofUndernutritionIndicators
Indicator Low A1.%Stunted(HFA<2Zscores) A2.%Underweight(WFA<2Zscores) A3.%Wasted(WFH<2Zscores) A4.%withSAM(WFH<3Zscores,MUAC<115 mmorbilateralpittingedema)22 <20 <10 <5 LevelofPublicHealthSignificance21 Medium 2029 1019 59 >.5% High 3039 2029 1014 1% VeryHigh 40 30 15

ConsidertheabovecutoffsalongwiththeanswerstothequestionsinSynthesisofData sectiononpage17intheWorkbooktodetermineifpreventioninterventionsand approachesarecalledforandwhetherrecuperativeinterventionsareneededto complementpreventiveinterventions. Ifyouhavedeterminedthatapreventiveorpreventive+recuperative communitybasednutritionprogramisnecessary,recordyourrationaleand answerintheConclusionBoxinSectionAoftheWorkbookandproceedto SectionB.InfantandYoungChildFeedingPractices.Ifyouhavedetermined thatacommunitybasedprogramnutritionprogramisnotnecessary,thenthe teammaystophereandlooktootherpriorityareasforimprovingchild health.

SectionB.SynthesizingDataonInfantandYoungChildFeedingPractices
Step1PartIIISectionBbeginsonpage20oftheWorkbook.
AtthispointtheteamshoulddiscussthedatagatheredonIYCFpractices(pages35inthe Workbook)todeterminewhetherIYCFisapriorityinterventionarea.Prioritizationwithin thesubcategoriesofIYCF(breastfeeding,youngchildfeeding,andfeedingofsickchildren asoutlinedintheENAs)willinfluenceotheraspectsofprogramdesign.

21

WHOExpertCommittee.1995.PhysicalStatus:TheUseandInterpretationofAnthropometry,TechnicalSeries ReportNo.854.Geneva:WorldHealthOrganization. 22 Consultationswithseveralemergencynutritionexperts.Publichealthsignificancecutoffsnotyetestablished.

20

GUIDESTEPONE

GuidanceforDataSynthesis
Inpractice,programsseektoachievetargetsofatleast80percentormoreofthetarget populationpracticingarecommendedbehavior.Anyrecommendedbehaviorpracticed belowan80percentcutoffisgenerallyconsideredtobeanutritionpriority.Any negativebehavior(e.g.,prelactealfeeding)wouldbeconsideredtobeanutrition priorityifpracticedbymorethana20percentcutoff.23Whenseveralbehaviorsare classifiedasnutritionprioritiesandtheprogramdoesnothavetheresourcestoaddressall ofthem,designteamswillprioritizethemrelativetoeachother,consideringwhich behaviorswillhavethelargestimpactonchildrenshealthandnutritionandaremost feasibletochange,andfocusonthosehigherprioritiesduringprogramdesign.Discussas agroupwhethertodesignatebehaviorsaslow,medium,highorveryhighpublichealth significance. Anexampleofdatasynthesis,basedonDHSdata,isincludedintheCountryExample below.Thecomments,levelofpublichealthsignificanceandsubsequentsynthesisofdata provideamodelforthelevelofinformationandagreementthatshouldcomeoutofyour groupdiscussion. AfterrecordingyourrationaleandanswerintheWorkbookinSectionB, proceedtoSectionC.MaternalNutrition.

CountryExampleofPrioritizingIndicatorsofIYCFPractices
INDICATOR:BREASTFEEDING B1.%ofchildrenborninthelast24 monthswhowereputtothebreast withinonehourofbirth B2.%ofchildren023monthsofage whoreceivedaprelactealfeeding DATA 35.1% COMMENTSONDATA Mostweretothebreast within24hours LEVELOFPUBLICHEALTH SIGNIFICANCE HIGH

67.5%

Stronglocalbeliefsand HIGH practiceofgivingherbaltea Plainwateristhemost commonitemconsumedin addition COMMENTSONDATA MEDIUM/HIGH

B3.%ofinfants05monthsofagewho 60.1% arefedexclusivelywithbreastmilk INDICATOR:YOUNGCHILDFEEDING DATA

LEVELOFPUBLICHEALTH SIGNIFICANCE

B4.%ofchildren1215monthsofage not whoarefedbreastmilk avail able B5.%ofinfants68monthsofagewho not receivesolid,semisolidorsoftfoods avail able

Medianduration:21months Unknownatthistime will needtoconductfurther investigationaspartof formativeresearch Introductionoffoodsisoften Unknownwillneedtodo delayed,accordingtokey furtherinvestigationaspart informants offormativeresearch

23

ENAapproachaimstoachieveatleast80%coverageatnationalorsubnationalscale(AcharyaK,SanghviT, DieneS,StapletonV,SeumoE,SrikantiahS,AminuF,LyC,DossouV.2004.UsingENAtoAccelerateCoveragewith NutritionInterventionsinHighMortalitySettings.Washington,DC:BASICSIIProject). 21

GUIDESTEPONE

B7.%ofchildren623monthsofage whoreceivefoodsfromfourormore foodgroups

48.7%

Majorityofdietisstaplefood HIGH

B8.%ofchildren623monthsofage 32% whoreceiveaminimumacceptablediet INDICATOR:FEEDINGOFSICK CHILDREN DATA COMMENTSONDATA

HIGH LEVELOFPUBLICHEALTH SIGNIFICANCE HIGH

B9.%ofchildrenaged023monthsof 32.3% agewithdiarrheainthelasttwoweeks whowereofferedmorefluidsduring theillness (Note:fluidisbreastmilkonlyin childrenunder6months) B10.%ofchildren623monthsofage not withdiarrheainthelasttwoweekswho avail wereofferedthesameamountormore able foodduringtheillness

Unknown,butbasedonthe smallnumberofferedmore fluids,thispracticemaybea problem

SYNTHESISOFDATAONINFANTANDYOUNGCHILDFEEDING
Doanyoftheindicatorsortrendsconcernyou?Ifso,whichandwhy? Alloftheindicatorresultsinthetableabovefallsignificantlybelowthe80percentcutoffandhighlightthat poorIYCFisacauseforconcernandalikelycontributortohighlevelsofundernutritioninthearea.Thevery importantpracticesofearlyinitiationandexclusivebreastfeedingaredefinitelysuboptimal.Whilewedonot knowhowmanychildren1215monthsofagearestillfedbreastmilk,wedoknowthatmediandurationis 21months,soitlookslikemanywomencontinuebreastfeeding.Theageofintroductionofcomplementary foodsisunknown,butkeyinformantdataindicatethatcomplementaryfoodsareintroducedlaterthan6 monthsofage.Finally,practicesregardingfeedingofsickchildrenseemtobelackingoverallandthereis opportunitytoimprovethesepractices.Formativeresearchwillbeimportanttodeterminethebarriersto optimalpracticesinthisarea. Whatfurtherinsightdoesdisaggregateddataprovide?(Note:Thisdetailwouldbefoundinthe QuantitativeDataCollectionTablesandisnotlistedabove) Thesexdisaggregateddatashowlittledifferencebetweenboysandgirls.However,intheDHSreportthere aregeographicdifferences,withthesoutherndistrictshavingmuchlowerratesofexclusivebreastfeeding andhigherratesofprelactealfeedsthantheeasterndistricts.Culturaldifferencesmayexplainthis,asthe districtsareofdifferentethnicgroups.Additionally,thesouthernareaismoreurban,sothismayreflect mothersleavingtheirchildrenwhiletheyworkoutsidethehome.Finally,practicesdovaryabitby socioeconomicgroup,withpoorermothersmuchlesslikelytoprovidetheminimumnumberofsolidorsemi solidfoodsthanwealthiermothers.Formativeresearchwillneedtofocusonbetterunderstandingthese differences. Whicharethemostvulnerablegroups?Why? Intheaftermathofthewar,therearemanyhouseholdsthatarefemaleheadedoryouthheadedthathave lessaccesstoresourcesthanthoseheadedbyanadultmale.Women,ingeneral,havefewerrightsthanmen andarefrequentvictimsofviolence. 22

GUIDESTEPONE

B6.%ofbreastfedandnonbreastfed 39.2% children623monthsofagewho receivesolid,semisolidorsoftfoods theminimumnumberoftimesormore

611months:28% 1227months:43% 1823months:47%

HIGH

Aretheregenderissuestoconsider? Yes.Drawingfromqualitativedatacollectedbyourdatateam,wehavelearnedthatwomenarevulnerable andtendtohavelittlevoice,andasmentionedabovehavefewerlegalrightsthanmenandaresubjectto frequentviolence.Inhouseholds,womenhavemanyresponsibilities,yetneedpermission(fromthemale headorotherdesignatedmalefamilyleader)totaketheirchildrentohealthservicesorattendthemarket. Theprogramwillneedtobesensitivetothesechallenges. Otherthoughts? Intermsofearlyinitiation,mostbabieswereatthebreastwithin24hours,sothereishopetoimprovethis practicetohavethemfeedingsoonerclosertoonehour.Thetwogeographicareasareabitdifferentand thestrategywillneedtobetailored.

CONCLUSIONonthesynthesisofdataonInfantandyoungchildfeeding
AreinterventionsinIYCFindicated?Checkallareasthatapply: Breastfeeding Youngchildfeeding Feedingofsickchildren

SUMMARYOFRATIONALEFORTHECONCLUSIONONTHESYNTHESISOFDATA ONINFANTANDYOUNGCHILDFEEDING
Ataglance,theinformationinthistableindicatesthatsuboptimalinfantandyoungchildfeedingpractices areaseriousissueandthattheprojectsdesignshouldincludeinterventionsandapproachestoimprove thesepractices.Moreindepthformativeresearchwillfollowintheprogram. AlloftheIYCFindicatorsinthetableabovearesignificant.Althoughexclusivebreastfeedinginchildren05 monthsofageisrelativelyhigherat60.1percent,itissuchanimportantandlifesavingpracticeforchild nutritionthattheteamgavethisamedium/highlevelofpriorityforemphasis.AsitappearsthattheENAof providingsickchildrenwithincreasedfluidduringillnessisverylow(32percent)feedingpracticesduring illnessshouldbelookedatverycarefullywhenformativeresearchisbeingcarriedoutintheprogram. Becausefeedingofsickchildrenisproblematic,werevieweddataonkeychildhoodillnessesandfoundhigh ratesofdiarrheainbothdistricts,meaningthatoptimalfeedingofthesickchild,inadditiontopreventing diarrhea,willbecrucialtoimprovingchildrensnutritionalstatus. DHSsurveyresultsindicatedthatintheeasterndistricts,EBFandprelactealfeedswillbeofhigherpriority thantheyareinthesouth,andtheprogram,ingeneral,mustreachthosewhoinfluenceandsupport womensdecisionsonhowtofeedtheirchildren.Inresearchingbarrierstooptimalfeeding,wewillneedto carefullyexaminesocioeconomicstatusandseehowthisaffectsfeedingdecisions. Becausetheredoesnotseemtobeonekeypracticeofconcerntofocuson,butrathermany,itlookslikea comprehensiveIYCFstrategyfocusedonmultiplebehaviorsatmultiplecontactpointsmaybedevelopedfor thisproject.However,totrulyachievebehaviorchange,theprogramwillfocusonkeyprioritybehaviorsin whichimprovementsareachievable,including:exclusivebreastfeeding,avoidanceofprelactealfeeds, qualityandquantityofcomplementaryfoods,andfeedingofsickchildren.

23

GUIDESTEPONE

SectionC.SynthesizingDataonMaternalNutrition
Step1PartIIISectionCbeginsonpage23oftheWorkbook.
Atthispoint,theteamwilldiscussthedatagatheredonthenutritionalstatusofnewborns andwomenanddeterminewhetherthisisapriorityinterventionarea.

GuidanceforDataSynthesis
WHOClassificationofPublicHealthSignificanceofLowBirthWeight
Indicator:Anthropometry C1.%ofnewbornswithlowbirthweight(<2500grams)

24

PublicHealthSignificance IFPREVALENCEIS 15%

AlternateIndicator:%ofnewbornswithlowbirthweight(mothersreportof babybeingverysmallatbirth)25

DataSynthesisNote:Dataontheprevalenceoflowbirthweightmaybedifficultto interpretbecauseitoftenrepresentsonlythosechildrenborninlocalhealthfacilities.If available,complementwiththepercentofhospitalbaseddeliveries.DHSalsoasks mothersinterviewedtoretrospectivelycategorizethesizeoftheirlastbornasbeingvery small,smallerthanaverageoraverageorlarger.Ifpossible,programplannersshould lookatinformationfrombothindicators. WHOClassificationofPublicHealthSignificanceofLowBodyMassIndex26andStunting27

Indicator:Anthropometry C2.%ofnonpregnantwomenofreproductiveage (1549 years)withlowBMI(<18.5kg/m2) C3.%childrenstunted(HFA<2Zscores) LevelofPublicHealthSignificance Low 59.9% <20 Medium 1019.9% 2029 High VeryHigh

2039.9% 40% 3039 40

WHOClassificationofPublicHealthSignificanceofVitaminADeficiency28
Indicator:VitaminA LevelofPublicHealthSignificance Normal C4.%ofwomenofreproductiveage(1549years)with vitaminAdeficiency(serumretinolvalues.70mol/l) <2% Low Medium High

2.09.9% 10.019.9% 20%

24

WHOExpertCommittee.1995.PhysicalStatus:TheUseandInterpretationofAnthropometryWHOTechnicalReportSeries #854.Geneva:WHO. 25 Ibid. 26 Ibid.Note:theaboveisbasedonBMIinadultpopulationandisappliedheretowomen. 27 Ibid. 28 WorldHealthOrganization.1996.IndicatorsforassessingvitaminAdeficiencyandtheirapplicationinmonitoringand evaluatinginterventionprograms.WHO/NUT/96.10.Geneva:WorldHealthOrganization.

24

GUIDESTEPONE

ClassificationofPublicHealthSignificanceofVitaminADeficiencyandProgramCoverage
Indicator:VitaminA C4.AlternateIndicator:%ofmothersofchildren023monthswithnight blindnessduringlastpregnancy29 C5.%ofmothersofchildren023monthswhoreceivedhighdose vitaminAsupplementwithineightweekspostpartum30(6weeksifnot exclusivelybreastfeeding) PublicHealthSignificance 5% <80%

WHOClassificationofPublicHealthSignificanceofAnemia
Indicator:Iron LevelofPublicHealthSignificance Normal C6.%ofwomenofreproductiveage(1549 years)withanemia(Hb<11g/dlforpregnant women;<12g/dlfornonpregnantwomen)31 4.9% Low 5.019.9% Medium 20.039.9% High 40%

ClassificationofPublicHealthSignificanceofWomensAccesstoIronSupplementation andUseofIodizedSalt
Indicator Iron C7.%ofmothersofchildren023monthswhoboughtorreceivediron/folic acidsupplementswhilepregnantwithyoungestchild32 Iodine C8.%ofhouseholdsconsumingadequatelyiodizedsalt(2040ppm) <90%33 <80% PublicHealth Significance

Usetheguidanceabovetodeterminethepublichealthsignificanceofmaternalnutrition inyourprogramarea.Then,answerthequestionsintheSynthesisofDatasectionin WorkbookSectionC(page25)todetermineif(andwhat)interventionsaremost appropriaterelatedtomaternalnutrition. AfterrecordingyourrationaleandanswerintheWorkbookinSectionC, proceedtoSectionD.MicronutrientStatusofChildren.

29

InternationalVitaminAConsultativeGroup(IVACG).2002.IVACGStatement:TheAnnecyAccordstoAssessandControlVitamin ADeficiency.SummaryofRecommendationsandClarifications. 30 Inpractice,projectsseektoachievetargetsofatleast80%ormore.Anythingbelowthis80%cutoffisusuallyconsideredtobea nutritionpriority. 31 AdaptedfromWHO/UNICEF/UNU,2001.and Stoltzfus,R,Dreyfuss,M.,1998.Guidelinesfortheuseofironsupplementstopreventandtreatirondeficiencyanemia.INACG, WHO,UNICEF.Note:theaboveisbasedonanemiaintheoverallpopulation,andisappliedheretowomen. 32 Inpractice,projectsseektoachievetargetsofatleast80%coverageormore.Anythingbelowthis80%cutoffisusually consideredtobeanutritionpriorityandneedsfurtherattention/action. 33 WHO,UNICEF,ICCIDD.2007.AssessmentofIodineDeficiencyDisordersandMonitoringTheirElimination:AGuideforProgram Managers.ThirdEdition.http://whqlibdoc.who.int/publications/2007/9789241595827_eng.pdf

25

GUIDESTEPONE

Step1PartIIISectionDbeginsonpage27oftheWorkbook.
Atthispoint,theteamshoulddiscussthedatagatheredonmicronutrientstatusin childrenanddeterminewhethermicronutrientsareapriorityinterventionarea. GuidanceforDataSynthesis TheWHO,UNICEFandMicronutrientForumprovideguidanceoninterpretingthe prevalenceofmicronutrientdeficienciesandrankingtheirlevelofpublichealth significance. ClassificationofPublicHealthSignificanceofVitaminADeficiency
Indicator:VitaminA D1.%ofchildren659monthswith vitaminAdeficiency (serumretinolvalues0.70mol/l)34 LevelofPublicHealthSignificance Low Medium 2 9.9% 10 19.9% High 20%

ClassificationofPublicHealthSignificanceofAccesstoVitaminASupplementation
Indicator:VitaminA D1.AlternateIndicator:%ofchildren2471monthswithnightblindness35 D2.%ofchildren659monthswhohavereceivedvitaminAsupplementinprevious6 months36 PublicHealth Significance >1% <80%

Althoughtheguidanceinthenexttablereferstothepercentageofanemiainthegeneral populationinsteadofspecificallyforchildren659months,pleaseusethistabletorate thepublichealthsignificancerelatedtochildren.

ClassificationofPublicHealthSignificanceofAnemia
Indicator:Iron LevelofPublicHealthSignificance Normal/Adequate D3.%ofanemiainthepopulation37 4.9% Low 5.019.9% Medium High

20.039.9% 40%

34WHO.1996.IndicatorsforassessingvitaminAdeficiencyandtheirapplicationinmonitoringandevaluatingintervention programmes,WHO/NUT/96.10.Geneva:WorldHealthOrganization. 35 Sommer,Alfred.1995.VitaminADeficiencyanditsConsequences:Afieldguidetodetectionandcontrol.ThirdEdition.Geneva: WorldHealthOrganization. 36 Coverageof80%fordeliveryofseveralmicronutrientinterventionswereselectedbasedontheideathatENAapproachaimsto achieveatleast80%coverageatnationalorsubnationalscale(AcharyaK,SanghviT,DieneS,StapletonV,SeumoE,SrikantiahS, AminuF,LyC,DossouV.2004.UsingENAtoAccelerateCoveragewithNutritionInterventionsinHighMortalitySettings. Washington,DC:BASICSII. 37WHO.2001.IronDeficiencyAnemia:Assessment,Prevention,andControl.AGuideforProgramManagers.Geneva:World HealthOrganization.(WHO/NHD/01/3)http://whqlibdoc.who.int/hq/2001/WHO_NHD_01.3.pdf

26

GUIDESTEPONE

SectionD.SynthesizingDataonMicronutrientStatusofChildren

ClassificationofPublicHealthSignificanceofAccesstoIronandIodine

Iron38 D4.%ofchildren623monthsofagereceivingironsupplementsormicronutrient powdersyesterday D5.%ofchildren1259monthsreceivingdewormingmedicationintheprevious6 months Iodine D6.%ofhouseholdsconsumingadequatelyiodizedsalt(2040ppm) D7.Medianurinaryiodineconcentrationinchildren059monthsyearsofage(g/l)

<80% <90%39 <100g/l40

AfterrecordingyourrationaleandanswerintheWorkbookinSectionD, proceedtoSectionE.UnderlyingDiseaseBurden.

SectionE.SynthesizingDataontheUnderlyingDiseaseBurden
Step1PartIIISectionEbeginsonpage30oftheWorkbook.
Atthispoint,theteamshoulddiscussthedataontheunderlyingdiseaseburdenand determinewhethertoprioritizeanyoftheseinterventionareas.Theunderlyingdisease burden,reflectedinratesofdiarrhea,acuterespiratoryinfection(ARI),malaria,vaccine preventablediseases,tuberculosis(TB)and/orHIVcanseverelyimpactnutritionalstatus. And,undernutritioncanexacerbatetheunderlyingdiseaseburden.Datarelatedtothe underlyingdiseaseburdenhelpsprogramstaffdeterminetheneedforprogram approachesspecifictodiseaseinadditiontoinadequatedietaryintakeandfeeding practices. Althoughinfectionwithparasiticwormscontributestotheunderlyingdiseaseburden,the NPDAdiscussesprovisionofdewormingmedicinesunderthemicronutrientsection becauseofitsimpactonironabsorption. GuidanceforDataSynthesis Nointernationalstandardsexisttodetermineatwhatlevelofprevalencepublichealth nutritionprogrammingshouldbeadaptedfororincludeinterventionstoaddressillnesses suchasdiarrhea,ARI,malariaorHIV.Yourprogramplanningteam,throughexamination ofquantitativeandqualitativedataanddiscussionswithlocalexpertswillneedto
Coverageof80%fordeliveryofseveralmicronutrientinterventionswereselectedbasedontheideathatENAapproach aimstoachieveatleast80%coverageatnationalorsubnationalscale(AcharyaK,SanghviT,DieneS,StapletonV,SeumoE, SrikantiahS,AminuF,LyC,DossouV.2004.UsingENAtoAccelerateCoveragewithNutritionInterventionsinHighMortality Settings.Washington,DC:BASICSII. 39 WHO,UNICEF,ICCIDD.2007.AssessmentofIodineDeficiencyDisordersandMonitoringTheirElimination:AGuideforProgram Managers.ThirdEdition.http://whqlibdoc.who.int/publications/2007/9789241595827_eng.pdf 40 Ibid.
38

27

GUIDESTEPONE

Indicator

PublicHealth Significance <80%

determinethelevelofpublichealthsignificanceandwhethertheunderlyingdisease burdenintheprogramareawarrantsconsiderationinprogramdesign. AfterrecordingyourrationaleandanswerintheWorkbookinSectionE, proceedtoStep2.DetermineInitialProgramGoalandObjectives.

28

GUIDESTEPONE

Step2beginsonpage34oftheWorkbook. InStep2,youwillbedraftingtheinitialprogramgoaland objectivesbasedondatainterpretationandsynthesisinStep1. TheinitialgoalandobjectiveswillberevisitedinStep6,after collectingandreviewingadditionalinformationinSteps35.

FORMINGPROGRAMGOALSANDOBJECTIVES

TheinformationbelowisadaptedfromtheProgramDesign,Monitoring,andEvaluation ParticipantsGuidecreatedbytheChildSupportTechnicalServicesProjectofOpinion ResearchCorporationMacroInternational,Inc(ORCMacro)andSavetheChildren.41 Therearemanywaystopresentthekeyelementsofprogramdesign.Wepresentaresults frameworkheretofocusonthekeyresultsrequiredforachievingthedesiredgoalrelated tochildhoodnutrition.Agoodframeworkwillshowachainofresultsthatclearlyidentifies howandwhyaprogramiseffectingchangewithinaspecifiedpopulationandtowardwhat greaterpurpose.Programplannersshoulddemonstratethecausallinksintheframework sothatthefinalapproachesselectedcausetheintermediateresults(IRs),whichleadto thestrategicobjectives(SOs),which,inturn,allsupportthegreaterprogramgoal. Thedefinitionsbelowarefollowedbytwoprogramexamples.Step2intheWorkbook providesspacetodevelopinitialgoalsandSOs.ThesewillbemodifiedandIRswillbe addedinStep6.

Goals

Definition:Bigpicture,longterm,ultimateambitions

Goalsareatthehighestlevelandaretypicallynotmeasuredintheprogramcontext,but rathergobeyondasingleprogram(e.g.,reducingmortalityorimprovingthequalityoflife inthegeneralpopulation).Whilethefulfillmentofagoalmaynotbepossibleorverifiable withinthelifespanoftheprogram,theachievementoftheprogram'smorespecific objectivesshouldcontributetotherealizationofthegoal.

41

http://www.mchipngo.net/lib/components/documents/usaid/PDME_Participants_Guide.pdf

29

GUIDESTEPTWO

STEP2.DetermineInitial ProgramGoaland Objectives

StrategicObjective

Definition:Astatementofwhattheprogramplanstoachieveduringthelifeofthe program

IntermediateResults

Definition:Adiscreteresultoroutcomenecessarytoachieveanobjectiveoranotherresult criticaltoachievingtheobjective

InStep6,yourteamwilldeveloptheIRsthatwillcausetheprogramtoachievetheSOs andgoal.AnIRisincludedintheexamplebelowforillustration. Twoexamplesofresultsframeworksareincludedhere. ResultsFrameworkExample1 Goal: StrategicObjective: IntermediateResult1: IntermediateResult2: IntermediateResult3: Childmortalityreduced Nutritionalstatusofchildrenunder5improved IYCFpracticesimproved Healthcareprovidernutritionknowledgeandskillsimproved Accesstopreventiveandcurativehealthandnutritionservicesfor womenandchildrenimproved

ResultsFrameworkExample2
GOAL

Underfivemortalitydecreased t t t )
Useofkeymaternalandchildhealthandnutritionservicesimproved

STRATEGIC OBJECTIVE INTERMEDIATE RESULTS

Accesstoservices increased

Qualityofservices improved

Demandforhealth andnutrition servicesincreased

Enabling environmentfor healthandnutrition services improved

30

GUIDESTEPTWO

Thisachievementisthehighestlevelresultthataprogramcanmateriallyaffectwithits effortswithinthegivenrestraints(e.g.,time,funding).Resultsarestatedintermsof changesinconditionoftargetedbeneficiariesorchangesinconditionsthataffectthem. Resultsstatementsshoulddescribethedesiredendcondition,nottheactivitiesthatare goingtobeimplemented.

STEP3.ReviewHealth andNutritionServices

Step3beginsonpage38oftheWorkbook.
Mappingexistinghealthandnutritionpolicies,programsand activitiesisanimportantpartofprogramdesign.This informationwillguideyourteamtoconsiderwhichactivitiescanbestrengthenedorbuilt upon,thelocalcapacityforresponse,andthebestuseoflimitedavailableresources. ThemappinginformationgatheredinStep3oftheWorkbook(pages3948)willbeused throughouttherestofthistoolformakingprogrammaticdecisions.Thisinformationisa minimumsettofacilitatediscussionandprogramplanninganddoesnotreplacea comprehensivehealthfacilityassessmentorgapanalysis,whichcanbeconductedaspart ofsubsequentprogramdesignorprogramimplementation.NDPAusersalsomayfind opportunitiestocoordinateandintegratewithothersectorsbeyondhealth(e.g., agriculture,microenterprise,foodsecurity). Areviewofhealthandnutritionservicesisdividedintothefollowingareas:42 Nationalpolicies Serviceavailability,accessanduptake Qualityofservicedelivery AvailabilityofhealthandnutritionIECmaterials

GATHERINGDATAONHEALTHANDNUTRITION SERVICES

NationalPoliciesforNutritionProgramming
Gatherinformationonexistingnationalpoliciesandprotocolsforhealthandnutrition servicesandadvocacyactivities.Existingpoliciesorplanstoupdatepoliciesmayaffectthe programdesignortheoveralleffortrequiredbyaprogramtoimplementanutrition approach.Providebriefsummariesofkeyelementsofthepoliciesthatarelikelyto influenceanutritionprogramandconsiderifthereisaparticularpolicybarrierthatwill limittheprogram.InformationonpoliciesshouldbeavailablefromthenationalMOH.
Marsh,D.R.,Alegre,J.C.,andWaltensperger,K.Z.2008.Aresultsframeworkservesbothprogramdesignanddeliveryscience. TheJournalofNutritionSymposium:FromEfficacyTrialtoPublicHealthImpact:ImprovingDeliveryandUtilizationofNutrition Programs.
42

31

GUIDESTEPTHREE

ServiceAvailability,AccessandUptake
Potentialservicesareorganizedbytechnicalareasinthemappingexercise.Document existingnutritionactivitiescarriedoutbyeitherlocalhealthservicesorotheragencies. Considerwhatservicesareavailable,whoprovidesit,thecoverageandcostforservices. Coveragecouldincludedistancetohealthservices,numberofwomen/childrenseen individuallypermonthandfrequencyofoutreachvisits.Programdesignteamsmayfind thisinformationfromDHSServiceProvisionAssessment(SPA)surveys,thenational MinistryofHealth,localanddistricthealthservices,communityleaders,donoragencies andNGOs.

QualityofServices
Considerboththeactualandperceivedqualityoftheseservices.Determiningperceived qualitymaybedonethroughexitinterviews,focusgroups,groupinterviewsorkey informantinterviewsconductedwithbothhealthprovidersandclients.Theremayalsobe incountryreportsavailableonthequalityofspecifichealthcareservices.Attheprogram designphase,thekeyistounderstandthegeneralstrengthsandweaknessesregarding thequalityofthehealthservicestoinformprogramdesign.Indepthqualityassessments canbeconductedoncetheprogramisawarded.

HealthandNutritionIECMaterials
Identifyandgathermaterialsusedforhealthandnutritioneducationorbehaviorchange fromtheMOHandothersources,includingUNagencies,technicalassistanceproviders andpotentialpartnerorganizations.

OTHERRESOURCES
Asnotedabove,Step3isasimplereviewtoidentifykeystrengthsandweaknessesthat willfactorintoselectionofnutritionprogramapproaches,ratherthananindepth assessment.Forguidanceonmorecomprehensivehealthfacilityassessments,capacity assessmentsorgapanalyses,considerthefollowingresources.

HealthFacilityAssessments
Healthfacilityassessmentsinvolveadditionalquestionsandobservationsofthequalityof serviceprovision.TheMaternalandChildHealthIntegratedProgramatUSAIDhasatool withaminimumlistofindicators,includingsomefocusedonnutritionservices,forRapid HealthFacilityAppraisal.Goto: http://www.mchipngo.net/controllers/link.cfc?method=tools_rhfa.

32

GUIDESTEPTHREE

ENACapacityAssessment
Iftheprogramplanstoalsodirectsignificanteffortstostrengtheningnutritionservicesat healthfacilities,acomprehensivehealthfacilityassessmenttooltodeterminethecapacity fortheENA,ProgramReviewofEssentialNutritionActions:ChecklistforDistrictHealth Services,canbefoundat: http://www.basics.org/documents/pdf/Program%20review_Checklist.pdf#search="ena".

GapAnalysis
Toolsandmatricesexisttohelporganizationsandinstitutionsconductgapanalysesto determinewhatnutritionservicesandinputsareinplaceandwherethereareareas(or gaps)thatcouldbeimproved.Examplesofimportantfactorstoconsiderarefoundin NutritionEssentials:AGuideforHealthManagers(WHO/BASICS/UNICEF1999).This documentincludesguidelinesandexamplesonneedsassessmentandgapanalysisin nutritionprograms.(Pleasenote,however,thatanumberofthetechnicalprotocolscited inthe1999documentarenowoutdated.)Goto: http://www.basics.org/documents/pdf/NutritionEssentials_English.pdf#search="nutrition essentials".

33

GUIDESTEPTHREE

STEP4.Preliminary ProgramDesign: Prevention

Step4beginsonpage50oftheWorkbook.Annex1on page73oftheWorkbookprovidesasidebysidecomparison ofthefollowingapproachesforeasyreferencewhenyoufill outStep4intheWorkbook.

Notethatpreventionofundernutritionhasafocushereonstuntingandunderweight. Youhavedeterminedthathighlevelsofstuntingand/orunderweightinchildrenareof publichealthsignificanceinyourprogramareaandthatapreventivenutritionprogramis necessary.Inaddition,youhaveidentifiedpriorityinterventionareas.Next,youwillstart thinkingaboutthebestwaystodeliverthepriorityinterventions.Thisstepprovides guidanceonconsideringpotentialpreventiveprogramapproaches.Step5willguideyou throughpotentialrecuperativeapproaches,ifnecessary.Step6willguideyouthrough narrowingdowntheoptionsyoudevelopinSteps4and5. Programstopreventundernutritionwilllikelyrequireacombinationofinterventions outlinedintheENA,dealingwithimprovingIYCF,maternalnutrition,micronutrientsand theunderlyingdiseaseburden.Thecombinationofinterventionswillbedeterminedbased onthepriorityareastheteamhasidentified(Step1),theprogramgoalandobjectives (Step2),andmappingofservices(Step3).Itisanticipatedthattheprogramapproaches chosentodelivertheseinterventionswillbecommunitybased,includecomponentsthat linktohealthservices(andothersectorsifappropriate/feasible)andincludeaSBC approach. Thefollowingcategoriesofpreventiveapproachestoreduceundernutritionarediscussed inStep4: SectionA:Crosscuttingapproachestoimprovenutritionalstatus SectionB:Infantandyoungchildfeeding SectionC:Maternalnutrition SectionD:Micronutrientstatusofchildren SectionE:Underlyingdiseaseburden

34

GUIDESTEPFOUR

STEP4SECTIONA.CROSSCUTTINGAPPROACHES TOIMPROVENUTRITIONALSTATUS
Step4SectionAbeginsonpage51oftheWorkbook.
AfterreviewingyouranswerstothequestionsinSteps13intheWorkbook,discuss potentialcrosscuttingprogramapproacheswithyourteam.Recordyourconclusionsin theWorkbookinStep4SectionA. Thereareanumberofprovencrosscuttingapproachesthatadvanceandsupportmultiple interventionareasinnutritionprograms.Fourcrosscuttingapproachesaredescribedhere andwillbereferredtooftenintheinterventionspecificsections(SectionsBE): Socialandbehaviorchangeapproaches(includingcommunitymobilization) Foodbasedapproaches(FBAs) Growthmonitoringandpromotion(GMP) Linkingtohealthservices

SocialandBehaviorChangeApproaches
SBCapproachesarecriticaltoincreasingtheadoptionanduseofthenutrition interventionscoveredinthistool.Manyofthenutritionoutcomesarerelatedtoindividual practicesofcaregiversinahouseholdandcommunitycontext.Itisalmostimpossibleto developaneffectivecommunitybasednutritionprogramthatdoesnotincludeSBC approachesinitsdesign. ThissectionprovidesguidanceonapproachesrelatedtoSBCthatapplytoallofthe interventionareas.Itspurposeistohelpprogramplannersenvisionwhatwillbenecessary toincludeinacomprehensiveSBCapproachduringtheprogramdesignphasesothat designopportunitiesarenotoverlooked,adequatestaffingandcoverageofcommunity healthworkers(CHWs),communityhealthvolunteers(CHVs)orcommunitynutrition volunteers(CNVs)isplannedforandthatthebudget(e.g.,fortrainings,developmentof materialsandsupervision)isrealistic.Amorethoughtful,detailedSBCstrategywould needtobedevelopedduringtheinitialphasesofprogramimplementation. ThissectionwillcoveronlyafewpointersandapproachesrelatedtoSBCtosupport decisionmakingaboutoverallprogramdesign.Manytoolsexisttoguideprogramstaffin conductingformativeresearchanddevelopingeffectivemessagesandSBCstrategies. PleaseseetheResourceGuidesResourcessection(page80). Ingeneral,NGOscandevelopSBCprogramsthat: Ensurethatkeynutritionmessagesareincorporatedintoallcounselingand counselingmaterialsatkeycontactpoints Providenutritioneducationandcounselingtocaregiversandwomenof reproductiveage
35

GUIDESTEPFOUR

Trainandprovidesupportivesupervisiontocounselors,CHWsandhealthcare providers Promotehealthandnutritionbehaviorsthroughmultiplechannelsandcontact points,includingtraditionalbirthattendantsandcommunitysourcesof information Mobilizewomen,caregiversandcommunitiestoaccesstheservicesprovided Establishasupportivehouseholdandcommunityenvironmentthatfacilitates behaviorchange Workwiththechallengesandbarriersthatcaregiversface

WhendevelopingacomprehensiveSBCapproach,programplannersshoulddiscussthese fourkeydecisions:43 Whosebehaviorneedstochangetobringaboutthedesiredhealthoutcomes? Whoaretheaudiences?(E.g.,parents,neighbors,healthworkers.) Whatdoyouwanttohelpthemtodo?Isittechnicallycorrect?Isitfeasible(can theydoit)?Isitaneffectivepractice? Whyaretheynotdoingitnow?Howcanyoubestinfluenceandsupportthose behaviors?Whatbarriersexisttopeopleadoptinganimprovedbehavior?Consider bothinternalandexternalbarriers.Whatincentivesandfactors(inthebroadest sense)existthatwouldhelpmotivatepeopletochangetheirbehavior?Whyare somepeoplecurrentlydoingitandothersnot?Whatmakesthedifference? Whatapproachescanyouincludeinyourprogramthatwouldhelpyouto addressthosefactorsthatyouveidentifiedasmostinfluentialinchangingthe behavior?(SeedescriptionofSBCapproachesbelow.)Doyouneedmaterialsor trainingstosupportthoseapproaches? PotentialSBCApproaches TherearemanypotentialSBCapproachesandagoodprogramwillincorporatea combinationofthese.Ageneralrulerelatedtobehaviorchangeisthatthereshouldbea limitednumberofmessagestransmittedthroughmultiplechannels. Communitymobilizationshouldbeconsideredanessentialaspectofalleffective, sustainablechildnutritionprograms.Thefirsttableonthenextpagesummarizesthis approachandprovidesseveralresourcesformoreinformation. ThereareseveralotherSBCapproachestobeconsidered: Counselingatkeycontactpoints Homevisits Supportgroups Massmedia Caregroups Communityinfotainment,e.g.,drama,communitytheatre
43FromTechnicalReferenceMaterialsonBehaviorChangeInterventions.2007.ChildSurvivalTechnicalSupportPlus Project/USAID.

36

GUIDESTEPFOUR

Inadditiontotheapproacheslistedhere,consideranyotherapproachesorcontactpoints thathavebeensuccessfulintheprogramarea.
CommunityMobilization44
BriefSummary Description Objectives Acapacitybuildingprocessthroughwhichcommunitymembers,groups,or organizationsplan,carryoutandevaluateactivitiesonaparticipatoryandsustained basistoimprovetheirhealthandotherconditions,eitherontheirowninitiativeor stimulatedbyothers Buildgreatercommunityparticipation,commitmentandcapacityforimprovingchild nutrition Strengthencivilsociety TargetGroup Everyoneinthecommunity Criteria Communitymembersmostaffectedbyandinterestedinchildnutritionareinvolved fromtheverybeginningandthroughouttheprocess Defining Buildsonsocialnetworkstospreadsupport,commitment,andchangesinsocial Characteristics normsandbehaviors Buildslocalcapacitytoidentifyandaddresscommunityneeds Helpstoshiftthebalanceofpowersothatdisenfranchisedpopulationshaveavoice indecisionmakingandincreasedaccesstoinformationandserviceswhileaddressing manyoftheunderlyingsocialcausesofpoornutritionandhealth Motivatescommunitiestoadvocateforpolicychangestorespondbettertotheirreal needs Playsakeyroleinlinkingcommunitiestohealthservices,helpingtodefine,improve on,andmonitorqualityofcare,therebyimprovingtheavailabilityof,accessto,and satisfactionwithhealthandnutritionservices Needed Stafftrainingincommunitymobilizationtechniques Elementsfor Organizationalandpoliticalcommitmentandsupport Quality Adequatetime:Itwillgenerallytake23yearstobegintoseeimprovementsin Programming nutritionandseveralmoreyearstostrengthencommunitycapacitytosustain improvements Communityparticipation,ownershipandcollectiveaction Organizationalvaluesandprinciplesthatsupportempoweringpeopletodevelopand implementtheirownsolutionstohealthandotherchallenges Resources DemystifyingCommunityMobilization AnEffectiveStrategytoImproveMaternaland NewbornHealth http://www.savethechildren.org/publications/technicalresources/savingnewborn lives/publications/ACCESS_DemystCM.pdf HowtoMobilizeCommunitiesforHealthandSocialChange http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/pdf/index.php

44

AdaptedfromDemystifyingCommunityMobilization:AnEffectiveStrategytoImproveMaternalandNewbornHealth.

37

GUIDESTEPFOUR

CounselingatKeyContactPoints
Brief Summary Description Counselingisprovidedbyahealthcareprovidertoacaregiverduringthedeliveryof healthservices.Counselingmessagescanbepersonalizedtotheneedsofthe mother/caregiverorchild.Withinthisapproach,consideropportunitiestoimprovethe qualityandtimelinessofthecounseling,inadditiontoreinforcingthesamemessage acrossvariouscontactpoints. Contactpointsinclude: IMCIorsickchildvisits Wellchildvisits Immunizations PMTCTclinics Antenatalorprenatalcarevisits Babydelivery(potentiallyviatraditionalbirthattendants) Postpartumcare GMPsessions Childhealthdays Recuperativefeedingsessions Schoolsorcommunitymeetingsformotherandfatherinvolvement Rallypoints Mobileclinics Localshops,wellsandmarketplaces Objectives Improvecareandfeedingpracticesforpregnantandlactatingwomenandchildren under5yearsofage Targetgroups Pregnantandlactatingwomen Mothers/caregiversofchildren023monthsorupthrough59months Influencersofcaregiversofchildrenunder5 Criteria Timeavailableforcounseling Adequatecoverage:communitywherewomenaccessservicesatthehealthfacility Defining Messagestargetedtothechildsdevelopmentalstagewhenthemother/caregiver Characteristics seekstheservice Individuallytailoredguidance Needed Trainingoncounselingandnegotiationskills Elementsfor Counselingmaterialsdevelopedthroughformativeresearch,appropriateforalow Quality literatepopulation,ifnecessary Programming Timeandspaceavailableforcounseling Continuoussupportivesupervision Resources Diene,Serigne,KindaySambaandIsmaelThiam,TrainingManualforHealthandSocial WorkersinsubSaharanAfrica:ImplementationofEssentialNutritionActions http://www.basics.org/publications/Training_Manual_Implementation_of_ENA.pdf#sea rch="counseling"

HomeVisits(e.g.,AuxiliaryNurses,CHWs,CareGroups)
Summary Homevisits,conductedbyCHWs,auxiliarynurses,orspecializedcommunityCNVs, provideanopportunityforoneonone,personalizedcounseling,outreach,followup andsupporttopregnantwomen,lactatingwomen,caregiversofchildrenandtheir families.Visitsmayincludecheckingonthehealthofababy,counselingcaregivers,or followingupwithachildwhohasexperiencedgrowthfaltering,acutemalnutrition and/orillness. Ensurechildshealthorgrowthisimproving Improvecareandfeedingpractices Supportfamily 38

Objectives

GUIDESTEPFOUR

Targetgroup Criteria Defining Characteristics

Needed Elementsfor Quality Programming

Pregnantandlactatingwomen,mothers/caregiversofchildren023orupto59 months Willingandavailablevolunteers Communitywherehomesarelocatedashortdistanceofeachother Opportunitytotailormessagestoindividualneedsandtoengageindialogueto negotiatechange Communitymembersprovidesupportandcounseling Individuallytailoredguidanceandsupport Counselingmaterialsdevelopedthroughformativeresearch,appropriateforalow literatepopulation,ifnecessary Trainingoncounselingandnegotiationskills Continuoussupportivesupervision

SupportGroups(e.g.,Mothers/Grandmothers,OtherCommunityAffinityGroups)
BriefSummary Description Supportgroupsprovidecomfortable,respectfulenvironmentswherepeerscanlearn fromandsupporteachothertopracticeoptimalchildcareandfeedingpractices. Supportgroupsmaybuildonexistinggroupswithinthecommunityorbeorganizedfor specificpurposes.Commonsupportgroupsincludebreastfeedingsupportgroups, womensgroupsandgrandmothersgroups.Supportgroupsmaybefacilitatedbya memberofthegroup,ahealthcareproviderorothercommunitymember. Objective Promoteoptimalchildcareandfeedingbehaviors Targetgroups Mothersofyoungchildren(<2,<3or<5yearsofage) Pregnantwomen Firsttimemothers Adolescentmothers Criteria Groupmemberswillingandabletomeetandsharewitheachother Communitymobilized Defining Groupsarecomposedofpeers Characteristics Safeenvironmentformotherstolearnandshare Researchshowsthelevelofinfluenceofpeersonbehaviorchangeisstrong45 Requiresminimaloutsideresources Needed Groupleadermusthavestrongfacilitationskills Elementsfor Trainingmaybenecessary Quality Variationinmethodologyfromveryinteractivetolecturedriven Programming Canlinkintothenonhealthsector Resources Linkages.TrainingofTrainersforMothertoMotherSupportGroups http://www.linkagesproject.org/media/publications/Training%20Modules/MTMSG.pdf FreedomfromHunger.FreedomfromHungerintegratesmicrofinancewithhealthand lifeskillsservicestoequipverypoorfamiliestoimprovetheirincomes,safeguardtheir health,andachievelastingfoodsecuritythrougharangeofgroupbasedmodels.For moreinformationvisit:http://ffhtechnical.org/ LaLecheLeague.MothertoMotherSupportHandbook www.lalecheleague.org LaLecheLeagueInternationalPeerCounselingProgram http://www.llli.org/ed/PeerAbout.html#pc

LinkagesandWorldHealthOrganization.2003.CommunitybasedStrategiesforBreastfeedingPromotionandSupportin DevelopingCountries.
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MassMedia
BriefSummary Description Massmediaincludesoptionssuchasradio,billboards,busadvertisingandpostersin additiontocommunitygatheringssuchashealthfairsormarketdays.Massmediacan transmitmessagestoawideaudienceandeducateandentertainthem,butwill generallynotchangebehaviorbyitself.Sinceitisgenerallyanexpensivestrategy,a programmaywanttoconsidercollaboratingwithothersconductingmassmediaefforts toalignmessagesforgreaterrepetitionandsupport. Tocreateawarenessofspecificbehaviorsordrawattentiontoongoingactivitiesor healthissues Communitiesinareacantargetallmemberswithbroadmessages Peopleneedaccesstothemediabeingused Simplemessagescangeneratediscussion Highinputsatbeginningandthenmessagecarriedbyadvertisingchannel Canreachmanypeopleinlittletime Carefulselectionofappropriatemessages Goodunderstandingandpilottestingofthemessage Creativity

Objective TargetGroup Criteria Defining Characteristics Needed Elementsfor Quality Programming

CareGroups
BriefSummary Description Caregroupsareanapproachfororganizingcommunityhealthvolunteers.Itisa communitybasedstrategyforimprovingcoverageandbehaviorchangethrough buildingteamsofwomenwhoeachrepresent,serveandpromotehealthandnutrition amongwomenin1015householdsintheircommunity.Volunteersmeetweeklyorbi weeklywithapaidfacilitatortolearnanewhealthmessage,reportontheincidenceof diseaseandsupporteachother.Caregroupmembersvisitthewomenforwhomthey areresponsible,offeringsupport,guidanceandeducationtopromotebehaviorchange. Improvecoverageofhealthprograms Sustainablebehaviorchange Mothersofchildren059monthsofage Communitywithhousescloseenoughtogethersothatvolunteerscanwalkbetween themandtomeetings Needasufficientvolunteerpool Trainedleadermothervolunteersprovidesupporttoothermothers Smallnumberofpaidstaffreachlargepopulation(throughleadermothers) Peersupport Cansupportmultiplehealthinitiatives Timeavailableleadermothersmusthave5hoursperweektovolunteer Comprehensiveandongoingtrainingofleadermothers Longstartuptime(duetotraining)programshouldbeof45yearduration Supervisortopromoterratioshouldbe1:5 AGuidetoMobilizingCommunityBasedVolunteerHealthEducators:TheCareGroup Difference http://www.coregroup.org/diffusion/Care_Manual.pdf www.CareGroupInfo.org

Objectives Targetgroup Criteria

Defining Characteristics

Needed Elementsfor Quality Programming Resources

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FoodBasedApproaches
FBAs46areacombinationofapproachestoimprovedietaryqualityanddietarydiversity. MostcommunitybasednutritionprogramsincludesomeFBA.Themostcommon approachescanbeorganizedaroundthosethatwillincreasethe:a)productionand availabilityofandaccesstoavarietyofmicronutrientrichfoods;b)consumptionof micronutrientrichfoods;andc)bioavailability(abilityofthebodytoabsorb)of micronutrients.FBAsareconsideredsustainableandcomprehensiveapproachesbecause thefocusisonthedietasamainwaytoimprovenutrition.Thedecisionsandactionsto improvedietaryquality,productionandconsumptionpracticestakeplaceatthe community,householdandindividuallevels.AbriefsummaryofFBAfollows. Increasingproduction,availabilityandaccesstoavarietyofmicronutrientrichfoodscan includelocallyappropriateneedsbasedfoodsecurityandagricultureprogramsand policies.Examplesoftheseareprogramstopromotehomeproductionoffruitsand vegetablesand/orsmalllivestockproductionandaquaculture,anduseofpreservation methodslikesolardryingtoextendtheavailabilityofseasonalfruitsandvegetablesand fortifyingstaplefoodstoimprovethemicronutrientcontentofthedietforthegeneral population(seeboxonFoodFortificationonthenextpage).Infoodinsecure environments,foodsupplementationmaybeincludedaspartofaprogramstrategy. Programmersmayalsoconsiderapproachesthatimprovehouseholdaccesstofoods, includingsupportingvillagebasedsavingsgroups,linkingtomicroenterpriseservices and/orconditionalcashtransfers(CCTs). ProvisionofFood
Onemeanstoincreasetheavailabilityoffoodinfoodinsecurelocationsand/orincontextsof highpovertyisthroughfoodsupplementation.Ideallythefoodsupplementwillalsoincrease thediversityoffoodsandthenutrientsthatwouldbeconsumedinthelocaldiet.Food supplementationshouldalwaysincludewelldesignedSBCandnutritioneducationactivities (formoreinformation,seeStep5).Thereareseveraldifferentmodelsthatcanbeused.Please seetheResourcessectionattheendofthisdocument(page84)formoreinformation.

IncreasingtheconsumptionofmicronutrientrichfoodscanincludeSBCandnutrition educationapproachestoincreasethedemandforandconsumptionofmicronutrientrich foods(seeStep4SectionAonSBCapproaches).ThisincludesSBCapproachestargeted tospecificgroups,suchaspromotingappropriatedietsforwomenduringpregnancy, promotingbreastfeedingandtheconsumptionoffortifiedcomplementaryfoodstoyoung children,(seeboxonFoodFortificationonthenextpage).

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MuchofthissectiononfoodbasedstrategiesdrawsfromRuel,MTandLevin,C.2000.AssessingthePotentialforFoodbased StrategiestoReduceVitaminAandIronDeficiencies:AReviewofRecentEvidence.IFPRI.FCNDDiscussionPaperNo.92.Formore backgroundinformation,pleaseseehttp://www.ifpri.org/sites/default/files/publications/fcndp92.pdf.

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FoodFortification Foodfortificationisoneapproachtoimprovethemicronutrientcontentoffoods. Fortificationofcommonlyconsumedfoods,suchasflour,sugar,oilsandsalt,canbean effectiveapproachforreducingmicronutrientdeficienciesinpopulations.Guidelinesformass productionofcentrallyprocessedfortifiedfoodsarenotcoveredintheNPDA.Manycountries haveapolicyonfoodfortification;othershavefortifiedfoodsonthemarket,evenwithouta policy.Iftherearefortifiedfoodsavailable,yourteammayconsider: PromotingtheconsumptionofvitaminA,ironormultiplemicronutrientfortifiedfoods withinalargerbehaviorchangeapproach Promotingtheuseofhomebasedfortificationmethodsandproducts,suchasSprinkles, thatpermitthefortificationoflocalfoodsinthehometoincreasethecontentofmultiple micronutrients,includingiron,folicacid,zinc,vitaminAandvitaminC:Thehomebased fortificationmethodsaremostappropriateincontextswherecentrallyfortifiedfoodsare notavailabletothetargetpopulationordonotmeettheirnutritionalneeds(e.g.,foryoung children). Moreover,thereisongoingresearchtestingtheformulationsandoutcomesofusinglipidbased nutrientsupplement(LNS)asaneffectivehomebased(orpointofuse)fortificationmethod invariouscontexts. Iffortifiedfoodsarenotavailable,consider: Advocatingtothespecificcountrysgovernmenttopromotefoodfortificationwithneeded nutrients Partneringwiththeprivatesectortopromotefoodfortification:Theprivatesectorcouldbe animportantpartnereitherformarketingfortifiedfoodsorforincreasingtheavailabilityof fortifiedfoodsinthemarketplace.Fortificationcanbedoneatalargeormediumscale. Settingupcommunityfacilitiesmayalsobepossible. Establishingfoodfortification,withmassproductionofaqualitycontrolledfortified productispossible,thoughitrequiresahighlevelofspecializedskill Iodinedeficiencyisalsoaddressedthroughafortificationstrategy.Universalsaltiodizationis recommendedandsaltiodizationisthemajorapproachtoreduceiodinedeficiencydisorders. Ifiodizedsaltisavailable: Promoteconsumptionofiodizedsaltand(ifpossible)seafoodbytheentirehousehold withinalargerbehaviorchangeapproach. Duringmonitoringandevaluationactivities,considersimpletoolstotestthelevelof iodizationinhouseholdsalt.Thisisusefulwhencomplementedwithotheractivitiesforthe advocacyofreliablesaltiodization. Ifiodizedsaltisnotavailable,consider: Partneringwithotherorganizationstoconductadvocacyefforts.

Increasingthebioavailabilityofmicronutrientstoimprovethequalityofthedietincludes approachessuchashomeprocessingmethods(e.g.,fermentation,germination)anduse ofdietaryfoodcombinationsthatpromoteabsorption/increasethebioavailabilityof

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certainmicronutrients(e.g.,consumptionofcitrusfoodswithironrichfoods)orreduce consumptionofdietaryinhibiters(e.g.,drinkingteawillreduceabsorptionofdietaryiron whentakensoonbeforeorwithameal).Animalfleshisamongthebestsourcesofheme iron,whichisthemostabsorbableformofiron,andenhancestheabsorptionofnonheme iron.Programmersshouldresearchtheavailable/commonsourcesofhemeironinthe communityandlookforwaystoincorporatemoreofthesefoodsintothediet.

GrowthMonitoringandPromotion
GMPisapreventivestrategyfocusedon improvingchildgrowththatincorporates elementsofcommunitymobilization,SBC,IYCF, micronutrients,underlyingdiseaseburdenand linkstohealthservices.ThetableonGMPand subsequenttextprovideconsiderationsthat shouldbereviewedindecidingwhetherto includeorleverageaGMPcomponentinyour program.GMPcanbeconductedatfacilities and/orincommunities.BecausetheNPDA focusesoncommunitybasedstrategies,wewill focusoncommunitybasedgrowthmonitoring andpromotion(CBGMP)here.
Brief Summary Description

CommunityBasedGrowthMonitoringandPromotion(CBGMP)
Approachimplementedatthecommunityleveltopreventundernutritionandimprovechild growththroughmonthlymonitoringofchildweightgain,althoughthereisgrowing consensusthatmonitoringheight/lengthgainmaybemorecritical,oneononecounseling andnegotiationforbehaviorchange,homevisits,andintegrationwithotherhealthservices. Actionistakenbasedonwhetherachildhasgainedadequateweight,notbyanutritional statuscutoffpoint,andthenidentifyingandaddressinggrowthproblemsbeforethechild becomesmalnourished.Amajorbenefitofhighqualityprogramsincludesthatcaregivers witnesstheirchildsweightgainandtherebyreceivereinforcementforimprovingtheir practices.Additionally,CBGMPprovidesanopportunityforadvocacywithcommunityleaders andotherpersonsofinfluencetobecomeinvolvedinseekinglocalsolutionstotheproblem ofgrowthfalteringandundernutrition. Objectives Improvechildgrowth Preventundernutrition Earlydetectionofgrowthfalteringandundernutrition TargetGroup Children023months Criteria(when Bestusedincommunitieswithhighprevalenceofmildormoderateunderweightor tousethis stunting
approach)

Defining Createscommunitymotivation/sensitizationtoreduceunderweight Characteristics Usestrainedcommunityselectedvolunteers

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WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.Lancet371(9610):41740. Ashworth,A,etal.,GrowthMonitoringandPromotion:reviewofevidenceandImpact.Journalcompilation.2008Blackwell PublishingLtd.MaternalandChildNutrition(2008),4,pp.86117. 43

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GMPhasamixedevidencebaseand wasnotlistedamongtheeffective approachesinthe2008LancetSeries onMaternalandChild Undernutrition.47However,growth monitoring,invariousforms,is conductedinanumberofnational nutritionprograms48andthushas potentialasausefulcontactpointfor nutritioncounselingmessages focusedontheimprovedgrowthof thechild.

CommunityBasedGrowthMonitoringandPromotion(CBGMP)
Usesinadequateweightgainasearlyindicatorofgrowthfaltering Referralandcounterreferralsystemwithhealthposts/centers Usescounselingandnegotiationspecifictotheindividualchild Homevisits Activecommunityinvolvementinproblemsolvingandplanning PotentialcontactforMUACandedemascreeningandSAMreferral Addressesmanycausesofpoorgrowth,notjustthesymptoms,andiscloselytiedto promotingevidencebasedinterventions Needed Fortheindividualchild: Elementsfor Routinemonthlyassessmentofgrowthstatus Quality Feedbackongrowthandonassessmentofhealthandfeeding Programming Individualizedcounselingonfeedingandchildcarepracticesandnegotiatingadoptionof by improvedpractices Implementers Followupandreferralfollowingprogramstandards Acrossthewholeprogram: Qualitycounseling Analysisofcausesofinadequategrowthwithguidelinesfortakingactions Alargenetworkofcommunitybasedworkersorvolunteers(23communityworkersper 20children)tobeeffective Supportiveandqualitymonitoringandsupervision Communityparticipationinplanning Caretakerinvolvementinmonitoringthechildsweightgain Acentrallocationwithinareasonablewalkformostcommunitymembers Resources Griffiths,Marcia,KateDickinandMichaelFavin.1996.PromotingtheGrowthofChildren: WhatWorks.RationaleandGuidanceforPrograms.Tool#4,TheWorldBankNutrition Toolkit.Washington,DC:TheWorldBank.http://www.worldbank.org(SearchforNutrition Toolkit)

Fiedler.2003.AcostanalysisoftheHondurasCommunitybasedIntegratedChildCare Program.Washington,DC:WorldBankHNPDiscussionPaper. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627 1095698140167/FiedlerACostAnalysiswhole.pdf Ashworth,etal.2008.GrowthMonitoringandPromotion:AReviewoftheEvidence. MaternalandChildNutrition(February2008). http://www3.interscience.wiley.com/journal/119424907/abstract?CRETRY=1&SRETRY=0

Participation:Ifthereisadequateaccessbutlowparticipation(lessthan80percentofthe targetpopulationparticipatingregularlyintheprogram),anNGOcanworktomobilizethe communitytoincreaseparticipation. Consistencyofservice:ThestandardfrequencyforCBGMPismonthlysessions,althoughit isdonelessfrequentlyinsomelocations.CBGMPshouldbedoneconsistently,andNGOs canworkwithstakeholderstoincreasethefrequencyandqualityofsessions,as necessary. Materials:NGOscanassistgovernmentsbyensuringthattheappropriatescales,growth charts,registersandcounselingmaterialsareavailableinbothfacilityandcommunity basedservices.
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Qualityofmeasuring/weighing:Ifthequalityofanthropometricmeasurementsor recordingneedsimprovement,NGOscanassistgovernmentstoprovidegoodquality trainingforstaffandvolunteersinweighingandmeasuringchildrenandkeepingcorrect records. Counselingandnegotiation:ThisisakeyareawhereNGOscanimprovethequalityof programsandbuildcapacityforgoodqualitycounselingandnegotiationthroughcreating appropriatecounselingguides,strengtheningnutritioncounselingskillsofhealthfacility staffandvolunteers,and/orimprovingtheircapacitytonegotiateadoptionofimproved practicesamongmothersandcaregivers. Growthfaltering:Ifcurrentservicesfailtoaddresstheneedsofchildrenastheirgrowth beginstofalter,NGOscanimprovecounselingandnegotiationskillsandadvocatewith governmenttoensurethatcounselingprotocolsaddresschildrenbeforetheybecome malnourished. Communityownershipofdata:NGOscancreatevisualchartstoenablethecommunityto understandtheprevalenceofundernutritionandtrendsinthecommunity,andmobilize thecommunitytodecideoncommunityandindividualbasedactionstoimprove childhoodnutritionalstatus. Followupandreferral:Followupandreferralisoftenaweaklinkinthesystemandone whereNGOscanstrengthenexistingservicestobetterservechildren.Thereshouldbea goodsysteminplacetoreferchildrenwhoneedadditionalcaretoahealthfacilityandto providefollowupandhomevisitswithcaregiversontheirchildsstatus. Complementaryservicesforchildrenandwomen:NGOscanhelpthegovernment connectgrowthmonitoringandpromotionsessionswithotherservicesforchildren,such asimmunization,CommunityIntegratedManagementofChildhoodIllness(CIMCI), vitaminsupplementation,anddewormingandlinkintocommunityhealthprogramsfor women.Thehealthserviceslinkscanalsoserveasanothercontactpointforconsistent messagedelivery. IfthereisnoGrowthMonitoringandPromotionprogramcurrentlyoperating,carefully considerwhethertheprogramyouaredesigningwouldhavethefinancialandtechnical resourcesneededtoimplementaprogramthatwouldmeetthequalitystandards summarizedaboveinthetableonCBGMPandtheimplicationsforsustainabilitywhenthe programfinishes.IfthereisnotaGMPplatformtobuildupon,considerfocusingon programapproachestoincreasethequalityandcoverageofageappropriatenutrition counselingatallchildhealthcontacts(wellchildandsickchildvisits)andduringhome visitsfromCHWsandCHVs.49
Ashworth,etal.2008.GrowthMonitoringandPromotion:AReviewoftheEvidence.MaternalandChildNutrition.(February 2008.)http://www3.interscience.wiley.com/journal/119424907/abstract?CRETRY=1&SRETRY=0.
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LinkingtoHealthServices
Toexpandthepotentialcoverageandimpactoftheprograminterventions,program designersshouldlookforallpossiblewaystointegrateandlinkcommunitybased nutritionactivitiesandmessagesintoexistinghealthservices.TheENAframework recommendsintegratingtheessentialnutritionactionsintothehealthservicessector,in particularatsixcommonlyfoundcontactpoints:antenatalcare,deliverycare,post partumcareofmotherandchild,immunization,sickchildvisitsandwellbabyvisits (includingcounselingandGMP).Thesehealthsectorcontactpointsoccuratthefacility andcommunitylevels.WithintheSBCstrategy,itisrecommendedtointegratenutrition counselingintoallpossiblecontactpoints.

Anelementoflinkingandintegratingcommunitybasedprogramseffectivelyintoexisting healthservicesisthroughdevelopment,maintenanceandrefinementofstrongreferral andcounterreferralmechanisms.Whenachilddoesbecomesickand/ormalnourished, earlydetectioninhouseholdsandcommunitiesandtimelyreferralandtreatmentare criticalelementsofprogramdesign,evenwithinpreventionprograms.Functionalreferral andcounterreferralcoordinationbetweenthecommunityandfacilitylevelsisessential, andNGOprogramscanprovideguidance,trainingandtoolstohealthandnutrition providers(e.g.,traditionalbirthattendants,counselors,CHWs)onwhenandwhereto referwomenandchildrenforspecificservices. Programdevelopmentshouldincludeasolidreviewandunderstandingofthestrengths andweaknessesofthehealthsysteminwhichaprogramisoperatingandopportunitiesto leveragecontactpointsfornutrition.Aplanorstrategytoworkwithandstrengthenthat healthsystem50isanimportantdevelopmentobjectiveandwillhelptheprogramto achieveitsgoals.Althoughchangingtheentirehealthsystemisbeyondthescopeofa communitybasedprogram,theNGOcaninfluenceandimprovethehealthsystem throughpolicyadvocacy;improvingfinancialandphysicalaccesstohealthservices throughcommunitybasedprogrammingthatislinkedwiththepublichealthsystem; supportingtrainingandothercapacitybuildinginitiativesatlocalordistricthealth facilities;providingguidanceonsupervision;helpingtodevelopguidelinesandprotocols tosupporttheestablishmentorimprovementofsystemsforreferral,supervision,training andtracking;andmanaginghealthandnutritioninformation. Integrationofnutritionwithinthehealthsectorandacrosstoothersectorsisencouraged. Nutritionisanexpansiveandmultisectoralfield,andNPDAusersareencouragedtolink nutritionactivitiesandmessagestodeliveryplatformsinothersectors,asfeasibleand appropriate,includingfoodsecurity,agriculture,education,emergency,waterand sanitation,and/orlivelihoodsprograms. KeepthesecrosscuttingapproachesinmindasyoumovethroughsectionsBE ofStep4,inwhichyouwillindicateintheworkbookwhichprogram
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AdaptedfromCSHGPTechnicalReferenceMaterials.HealthSystemsStrengthening,2005.

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approaches,includingcrosscuttingapproaches,youareconsidering.Please remember,amuchmorethoughtfulandcompleteSBCstrategywillbe developedduringtheinitialphasesofprogramimplementation.

STEP4SECTIONB.INFANTANDYOUNGCHILD FEEDING
Step4SectionBbeginsonpage54oftheWorkbook.
UsethissectionifyourdatashowthatprevalenceofsomeoralloftheIYCFindicatorsare atlessthan80percent(orgreaterthan20%fornegativebehaviors)andneedtobe addressedtoimprovechildhoodnutritionalstatus. IYCFapproachesarespecificallytargetedtotheagerangeof024monthsandare composedoftheENApracticesofimmediate,exclusiveandcontinuedbreastfeeding,and anumberofchildfeedingpracticesforwellandsickchildren.ImprovingIYCFpractices contributestoreducedchildmorbidity,stuntingandmortality.Breastfeedingisrecognized asthemosteffectiveofthepreventivepublichealthinterventionsforchildsurvivaland hasthepotentialtoreducechildmortalityby13percent.51Wherechildrenare undernourished,oneormoreaspectsofIYCFpracticeswillmostlikelybesuboptimalanda contributingfactortoundernutrition. AfterreviewingyouranswerstothequestionsinSteps13andStep4SectionAinthe Workbook,discusstheoptionsinthissectionwithyourteam.Recordyourconclusionsin theWorkbookinStep4SectionB. Theapproachesaddressedinthissectioninthissectionare: Traininghealthproviders Socialandbehaviorchange o Influencingcaregiverpractices o Strengtheningfamilyandcommunitysupport o Organizingpeersupportgroups o BuildingIYCFmessagesintootherprograms Increasingthenutritionaladequacy(quantityandquality)ofcomplementaryfoods Addressingwaterandhygieneissues ResourceTransfer Advocacyandpolicyenvironment

Black,REetal.2008.MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequences.TheLancet MaternalandChildUndernutritionSeries.January2008.
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TrainingHealthProviders
Healthcareprovidersatthefacilityandcommunitylevelprovideavaluablesourceof counselingandadvicetocaregivers.Considerthepotentialcontactpointsforpregnant womenandcaregiversandhowtrainingandprovisionofcounselingcardscanhelp providersdeliverandreinforcethesamemessageacrossvariouscontactpoints.Essential IYCFmessagescandeliveredthroughvarietyofprovidersinadditiontotrainingspecific providersasIYCFcounselors.Formoreinformation,pleaserefertothesectionon counselingatkeycontactpointswithinStep4SectionA,CrossCuttingApproaches, SocialandBehaviorChange. Additionally,healthprovidersatboththefacilityandcommunitylevelsarecriticalalliesin addressingissuesrelatedtothefeedingandcareofsickchildren.Programmersshould ensurethatthefollowingservicesforsickchildrenareavailableandaccessible: Promotingrecommendedfeedingpracticesduringillness,includingcontinued breastfeeding(seeKeyConcepts,ENA#3onpage8) ORSandzinctreatmentfordiarrhea Antibioticsforpneumonia Antimalarialsformalaria VitaminAtreatmentformeasles

SocialandBehaviorChange
ManyofthepracticestoimproveIYCFrelyonSBCapproaches.SBCiscoveredinmore detailinStep4SectionA,butseveralrelevantapproachesarementionedhere, including:a)influencingcaregiverpractices;b)strengtheningfamilyandcommunity support;c)organizingpeersupportgroups;andd)buildingIYCFmessagesintoother programs. InfluencingCaregiverPractices AccordingtotheWHO/UNICEFGlobalStrategyforInfantandYoungChildFeeding, caregivershavearighttohaveaccesstoobjective,consistent,andcompleteinformation, freefromcommercialinfluence.Specifically,theyneedtoknowabouttherecommended periodofexclusiveandcontinuedbreastfeeding,timingofintroductionofcomplementary foods,whattypesoffoodtogive,howmuchandhowoften,andhowtofeedthesefoods safely.52Step4SectionA,CrossCuttingApproachesincludesmoreinformationon influencingcaregiverknowledgeandpractices.Oneimportantstepisconductinggood formativeresearchtogainabetterunderstandingofthebarrierstosuccessfulnutrition practicesinprogramimplementation.Severalpotentialapproachestoformativeresearch includeTrialsofImprovedPractices,PositiveDevianceInquiries(PDIs),Doer/NonDoer

WHO.2003.GlobalStrategyforInfantandYoungChildFeeding. http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html.
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analysisandBarrierAnalysis.53Samplequestionstoconsiderindesigningappropriate messagesinclude: When,howandwhatdopeoplenormallyfeedtheirchildren? Whatareexamplesofpositivelocalfeedingpractices? Howarefoodspreparedforinfantsandyoungchildren? Whatdootherfamilymemberseatthatinfantsdonot? Howareinfantfeedingpracticestodaydifferentfromwhatgrandmothers practiced? StrengtheningFamilyandCommunitySupport Familiesandcommunitiesprovideacriticalsupportsystemforpregnantand breastfeedingmothersandmothersofyoungchildren.Theculturalnormsand expectationsof,e.g.,fathers,grandmothersandmothersinlawinfluencethepracticesof mothers.AnySBCapproachtochangeculturalnormsorinfluencecaregiversneedstotake intoconsiderationthesekeyinfluencers.Sinceacommonbarriertobreastfeedingisthe inabilitytobreastfeedwhileworking,thefamilyandcommunityarekeyadvocateswho canhelpnegotiatechangesinpracticesandnorms.Communitymobilizationapproaches areextremelyimportantinengagingthecommunityforchange.Formoreinformation, pleaserefertothetableoncommunitymobilizationwithinStep4SectionA,Cross CuttingApproaches. OrganizingPeerSupportGroups Especiallyinthecaseofbreastfeeding,peersupportgroupshavebeenaneffective approachinprovidingsocialsupportandhelpingmothersovercomesomeofthebarriers tobreastfeeding.Formoreinformation,pleaserefertothetableonpeersupportgroups inStep4SectionA,CrossCuttingApproaches. BuildingIYCFMessagesIntoOtherPrograms ManyoftheotherapproachescoveredintheNPDAlendthemselvestotheincorporation ofIYCFmessages.IYCFmessagescanbeincorporatedasappropriatein,e.g.,Positive Deviance(PD)/Hearthsessions,CBGMP,CIMCI,caregroupsandchildhealthweeks.

IncreasingtheNutritionalAdequacyofComplementaryFoods
TheENArecommendfeedingavarietyoffoodsdailytoyoungchildrentoensureadequate nutrientintake,includinganimalproducts,fortifiedfoods,andvitaminArichvegetables andfruits.Increasingthenutrientcontentandadequacyoffoodsfedtoinfantsandyoung childrencutsacrossalloftheinterventionareascoveredintheNPDA,includingSBC,FBAs, IYCF,micronutrientapproaches,maternalnutrition,andtreatmentofthesickchild(which iscoveredintheReferenceGuideStep4SectionA,CrossCuttingApproaches,Linksto HealthServicesandStep4SectionE,UnderlyingDiseaseBurden).
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Formoreinformation,seeChildSurvivalandHealthGrantsProgram.2007.TechnicalReferenceMaterials:Nutrition.

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ProgramstoImproveChildFeedingPractices:LessonsLearned
Applyinglessonslearnedinthefieldleadstomoreeffectiveprogramsandhelpsresearchers identifythekeyissuesthatneedtobeaddressedduringconsultativeresearchandprogram planning.Thefollowingpointssummarizeconclusionsdrawnfromreviewsofeffortstoimprove childfeedingpracticesinAfricaandotherpartsoftheworld. 1. Formativeresearchhasshownthatagespecificfeedingproblemsaresimilarinmost countries,despiteindividualandregionalvariationinfoodsgiven.Beingawareofthe particularproblemforanagegrouphelpstofocustheformativeresearchandtheprogram actions. 2. Programsshouldemphasizeimprovingchildfeedingpracticesratherthanonlythefoods consumedbyyoungchildren. 3. Feedingachildwhoissickoranorexicisamajorproblemthatrequiresdifferentsolutionsfor improvedfeedingofthechild.Donotomitthisaspect. 4. Motivationsforfeedingpracticesmustbeunderstoodbeforebehaviorcanbechanged.In mostculturesfeedinghasmeaningsandpurposesbeyondsimplynourishingthebody: practicesmayberelatedtosocialorganization,religiousbeliefsandfamilydynamics. Promotingimprovedpracticesshouldreferencetheimportantmotivationsreportedby familieswithyoungchildren. 5. Commonconstraintsthatmaylimitwillingnessorabilitytochangebehaviormustbe addressed.Programsmustberealisticaboutwhatcanbeaccomplishedif,forexample, economicconstraintsaregreatormothersfeeltheyhavenotimetodomore. 6. Theinfluenceoffamilymembersandknowledgeablecommunitymembersonchildfeeding practicesshouldbeassessed.Theseindividualsshouldbeconsideredintheformative researchandtheprogram. 7. Methodsofcounselingandcommunicationareasimportantasthemessagesconveyed,so attentionmustbepaidtofacilitatingthedevelopmentofcounselingskillsandprovidingthe timetoapplythem.Formativeresearchalsoneedstoassesstheknowledge,motivationsand constraintsofserviceproviders.

From:Dickin,Kate,MarciaGriffiths,EllenPiwoz.1997.DesigningbyDialogue:AProgramPlanners GuidetoConsultativeResearchforImprovingYoungChildFeeding.TheSaraProject.

AddressingWaterandHygieneIssues
Iftherearewaterandsanitationprogramsoperatinginthesamearea,considerhowyou canworktogethertopromotecleanwater,handwashingandhygiene.Poorwaterand sanitationarethecauseofasignificantproportionofdiarrheacasesinyoungchildren.For moreinformation,refertoStep4SectionE,UnderlyingDiseaseBurden.
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ResourceTransfer
Iffoodavailabilityandaccessarelimitedintheprogramarea,SBCalonemaynotbe sufficienttoachieveimpact.Itmaybeappropriatetoconsideradditionalresource transfers54withintheprogramthroughactionssuchasaddingfoodsupplementation(see tablebelow)55orCCTs56tothebehaviorchangeapproach.Theseapproachesworkto improveIYCFbyconditionallytransferringandensuringresourcestohouseholdswith childrenunder2yearsofage,providingshorttermsupporttoprotectandensure adequateconsumptionandrequiringparticipationinessentialhealthandnutrition activitiesthatwillimprovenutritioninthelongterm.Theconditionsmayinclude participationinSBCprograms,accessingessentialhealthandnutritionservices,orother activitiesdeemedessentialtoimprovingnutrition. Nochildunder6monthsofageshouldbethedirectrecipientoftargetedfoodassistance. Rather,programsshouldtakeactionstosupportandpromoteimmediateandexclusive breastfeedingand,whenappropriate,providepregnantandlactatingmotherswithfood assistanceuntilthechildis6monthsofage.Infoodinsecurecontexts,programmerscan considerassistingchildren623monthsofageandtheirvulnerablehouseholdswithfood supplementation/foodassistance.Guidelinesareprovidedinthetablebelow.
FoodSupplementation/FoodAssistance:Prevention
BriefSummary Infoodinsecureenvironments,programsmaychoosetosupplementthedietsofwomen, Description childrenand/orhouseholdstohelpthemmeettheirmacroandmicronutrientneeds.Food supplementsmaybeintheformofinternationalfoodaid,includingfortifiedblended foodsandvitaminAfortifiedoil,orlocallyorregionallypurchasedfoods.Thefoodrations aregenerallydistributedonamonthlybasis.Tobemosteffective,foodsupplementation shouldbeaccompaniedbyessentialhealthandnutritionservicesandSBCprogramming. Onefoodsupplementationprogram,thePreventingMalnutritioninChildrenUnder2 Approach(PM2A)isaspecific,testedpackageofactionsaimedatpreventing undernutrition.AlthoughPM2Ahasbeenfoundtobemoreeffectiveinreducingchronic malnutritionthanrecuperativeprograms,itmaynotbeappropriateinallprogram contexts.Thereisalsoagreatdealofexperiencewiththeuseoffoodsupplementationto meetgapsinthedietinemergencysituations;somelessonsareapplicableindeveloping contexts. Objective Reduceprevalenceofchronicmalnutrition TargetGroups Allchildren623monthsofage Pregnantwomen Lactatingwomenfromdeliveryuntilthechildis6monthsofage Householdsoftheparticipantwomenandchildren Criteria Foodinsecureenvironment Evidencethattheareacanabsorbthequantityoffoodsupplementationneededand

54 55

Gentilini,U.2007CashandFoodTransfers:APrimer.Rome,Italy:WorldFoodProgram. PleaserefertotheFANTAwebsite(www.fanta2.org)forinformationonthePreventingMalnutritioninChildrenUnderTwo Approach. 56 Bothfoodsupplementationandconditionalcashtransferprogramswithnutritioneducationareidentifiedasinterventionswith sufficientevidencetoimplementinspecificsituationalcontextsinBhutta,Z.A.,T.Ahmed,R.E.Black,S.Cousens,K.Dewey,E. Giugliani,andothers.2008.WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.Lancet371(9610): 41740.

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FoodSupplementation/FoodAssistance:Prevention
thatthefoodsupplementationwillnotdisplacelocalfoodproduction.(Bellmon EstimationforTitleIIisaresourceforthis) Logisticalcapacityfortransport,storageandmanagementoffoodcommodity Healthservicesavailable(orabilitytoworktostrengthenhealthservices) Childstuntingand/orunderweightshouldbehigh(>30%or20%,respectively) Foodisprovidedtovulnerablepeoplewhocouldnototherwiseaccessit Opportunitytolinkwithagricultureandlivelihoodsectorsandimprovefoodaccess whilealsoimprovingutilization Foodsupplementationmayalsobetargetedonaseasonalbasis,whenthefoodneeds arethegreatest Provisionoforaccesstobasicessentialhealthservices ComplementarySBCprogrammingfocusedonmaternalnutrition,IYCF,hygieneand healthseekingbehaviors Closecoordinationwithhealth,nutritionandfoodsecurityprogramsandservices Formativeresearchtoadaptprogramtolocalconditions,includingaseasonalcalendar ofwhenfoodneedsaregreatest USAIDOfficeofFoodforPeace: http://www.usaid.gov/our_work/humanitarian_assistance/ffp/ FANTA2:www.fanta2.org WorldFoodProgramme:www.wfp.org

Defining Characteristics Needed Elementsfor Quality Programming Resources

ConditionalCashTransfers(CCTs)57
BriefSummary CCTprogramsprovidecashpaymentstopoorhouseholdsthatfulfillprogrammandated Description requirements,suchasparticipationincertainnutritionprograms(e.g.,BCC,GMP, supplementation,attendinghealthservices).CCTsaimtoalleviatepovertyintheshortand longtermthroughsimultaneouscashtransfersandinvestmentsinhealth,education,social servicesandwomensempowerment.Thecashpaymentgiventothehouseholdencourages participationinhealthandnutritionprograms,reducesresourceconstraints/improves purchasingpower,andencourageslongterminvestmentinhumancapital.Program evaluationshavefoundthatCCTprogramshaveimprovednutritionalstatusinchildren (stunting)andschoolenrollment,andhavereducedillness.CCTprogramstendtobelarge scale,governmentrunprograms.Resultsareverydependentonthequalityofprogram implementationandtargeting.AdministeringandmonitoringCCTcanbecostly. Objectives Breaktheintergenerationalcycleofpoverty Provideincentivetoparticipateinessentialhealthandnutritionservices Promotebehaviorchange Targetgroups Poorhouseholdswithchildrenunderagetwo Womenaregenerallytherecipientsofthecashbecausetheyaremorelikelytoinvestit inthewellbeingoftheirfamily Criteria Nutritionandhealthservices/programsthatbeneficiariesmustparticipateinareinplace, accessibleandofgoodquality Government/communitysupporttheprogram Programtakesplaceinareaswherefamiliesareunlikelyorunabletoinvesttheirown resourcesinchildrenslongtermhumancapital(e.g.,healthservicesareavailableandof goodquality,butunderutilized)

Bassett,Lucy.2008.CanConditionalCashTransferProgramsPlayaGreaterRoleinReducingChildUndernutrition?SPDiscussion PaperNo.0835,SocialProtectionandLabor.Washington,DC:TheWorldBank.
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AdvocacyandPolicyEnvironment
Iftherearesignificantpolicybarrierstoimplementingtheaboveapproaches,itmaybe necessarytogetinvolvedinadvocacyefforts.Oneinfluencerofbreastfeedingpracticesis thepromotionofbreastfeedinginthehospitalsandthelevelofinfluencebyhealthcare providersormassmediapromotingformulafeeding.InStep3,youdeterminedifthe countryhadsignedtheInternationalCodefortheMarketingofBreastmilkSubstitutes,if theyhadBabyFriendlyHospitalsandiftheyhavetheBabyFriendlyCommunities Initiative.Iftheanswertoanyofthesequestionsisno,considerpartneringwithother organizationsworkingtoinfluencekeydecisionmakers. Whichapproacheswillyouuse?FilloutyourthoughtsintheboxesinStep4 SectionBoftheWorkbook.

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Defining Resourcetransferiscash Characteristics Conditionsforreceivingthecash Comprehensiveprogramaddressingresourceconstraints,poverty,healthseeking behaviorsandbehaviorchange Needed Closemonitoringofprogramoperations,targetingandconditionality Elementsfor Strongadministrativesupervision Quality Linksbetweenallrelatedsectors(health,education,socialservices) Programming Formativeresearchtounderstandreasonswhypeopledoordonotparticipateinhealth andnutritionservices HealthsystemstrengtheningtosupportincreaseddemandfromCCT Resources Bassett,Lucy.2008.CanConditionalCashTransferProgramsPlayaGreaterRolein ReducingChildUndernutrition?SPDiscussionPaperNo.0835,SocialProtectionand Labor.Washington,DC:TheWorldBank.October2008. http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/SPDiscussion papers/SafetyNetsDP/0835.pdf Son,HyunH.2008.ConditionalCashTransferPrograms:AnEffectiveToolforPoverty Alleviation?AsianDevelopmentBank,EconomicsandResearchDepartmentPolicyBrief SeriesNo51.July2008. http://www.adb.org/Documents/EDRC/Policy_Briefs/PB051.pdf Lindert,Kathyetal.2007.TheNutsandBoltsoftheBolsaFamiliaProgram:Implementing CCTsinaDecentralizedContext.SPDiscussionPaperNo.0709.Washington,DC:The WorldBank.May2007. http://siteresources.worldbank.org/INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamili aDiscussionPaper.pdf

STEP4SECTIONC.MATERNALNUTRITION
Step4SectionCbeginsonpage56oftheWorkbook. Usethissectionifyouhavedeterminedthatthematernalhealthandnutritionindicators areatalevelofpublichealthsignificanceandneedtobeaddressedtoimprovematernal, newbornandchildnutritionalstatus. Step1focusedonbothmaternalandnewbornindicatorsinthetargetareatodetermine theirimportanceinanapproachtoaddresschildhoodnutrition.Thissectionisfocusedon potentialapproachesformaternalnutritionthatsupportinfantandchildhoodnutrition. UsersshouldalsorefertoStep4SectionA.
AfterreviewingyouranswerstothequestionsinSteps13andStep4SectionAinthe Workbook,discusstheoptionsinthissectionwithyourteam.Recordyourconclusionsin theWorkbookinStep4SectionC.
There are several maternal nutrition approaches to be considered: SBCrelatedtomaternalnutrition Foodbasedapproachestoimprovethediet Micronutrientsupplementationofwomen Complementarymaternalhealthservicesforanemiaprevention Developandstrengthenreferralsystems

SocialandBehaviorChangeRelatedtoMaternalNutrition
SBCtosupportwomenandfamiliesinpracticingoptimalnutritionbehaviorsisessentialto achievingimprovedmaternalnutritionalstatus.Someofthekeypracticeshavealready beenbrieflymentionedabovewithinfoodbasedstrategies.Thissectiondescribessome topicsthatmaybeincorporatedintotheSBCstrategytoimprovematernalnutrition status.RefertoStep4SectionAformoreguidanceonpotentialSBCapproachesand contactpoints,includingcommunitymobilization,caregroups,massmedia,support groups,homevisits,counselingandcommunityinfotainment. SomekeymaternalnutritionSBCtopicsinclude: Increasecalorieandproteinconsumptionforpregnantandlactatingwomenbased onnationalrecommendations Promotedietarydiversity: o Nutritioneducationtopromoteconsumptionoflocal,nutrientrichfood sources,especiallythosehighinvitaminA,ironandiodine o Promotingconsumptionoffoodsthatenhanceabsorptionofironsuchas citrusfruitsorotherfoodswithvitaminC Promoteconsumptionoffortifiedfoods: o Advocatefortheincreasedavailabilityofandaccesstothesefoodsatthe communitylevel
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o Workwithcommunitytocreatedemandforfortifiedfoods(identifywhat thebarrierstoconsumptionmightbe) Promoteuptakeofkeymaternalnutritionservices,including: o Antenatalcare o Nutritioncounseling o Micronutrientsupplementation o Malariapreventionandtreatment o Preventionandtreatmentofparasiticworminfections Promoteothercommunity/householdsupportforpregnant/lactatingwomen, including: o Reducedworkload o Careseeking

FoodBasedApproachestoImprovetheDiet

MicronutrientSupplementationforWomen
VitaminA:Manycountrieshavepoliciesand/orprogramsforlargescale,preventive,high dosevitaminAsupplementationofpostpartumwomen(withinsixweeksofdelivery). SomewomenmayalsoneedtherapeutictreatmentforxerophthalmiaorBitotsspots. Iron:Aspartofaminimumpackageofmaternalcareduringpregnancy,mostcountries haveprotocolsinplacefortheprovisionofIFAsupplementstopregnantandpostpartum women(especiallyinsettingswhereanemiaprevalence40percent). Ifyourcountryofoperationhasamicronutrientsupplementationpolicyinplace,consider includingsomeorallofthefollowing: Communityorganizationandawarenesspromotiontoincreaseparticipation Logisticalsupportandtransportationforoutreachfromhealthfacilities Supporttoaddressanymicronutrientsupplyissues Activitiesmaybealsoneededtostrengthentherapeuticsupplementationofironfor womenwithsevereanemia.Thistreatmentiscomplicatedandrequiresaccesstoand referralmechanismstoskilledtechnicalassistanceand/orclinicalcare. Ifthereisnotapolicyineffect,considerpartneringwithotherorganizationstoconduct advocacyefforts.
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Akeystrategytoimprovematernalnutritionalstatusistoimprovethequalityofwomens dietsbyimprovingaccesstoandconsumptionofproteinandmicronutrientrichfoods. Theseincludeapproachestoincreaseproductionandseasonalavailabilityofnutrientrich foods,topromoteconsumptionofnutrientrichfoods(includingfortifiedfoods),andto improvethebioavailabilityofnutrientsinfoodsconsumed.Detailsontheseapproaches werediscussedinStep4SectionA,CrossCuttingApproaches,FoodbasedApproaches.

ComplementaryMaternalHealthServicesforAnemiaPrevention
Insomelocations,recurringboutsofmalariaorahighprevalenceofhookworminfection maybekeycausesofmaternalanemia.58Intheseareas,programsshouldlookat approachesforthepreventionandtreatmentofmalariaandhookworminfectionto reducetheprevalenceofanemia.Governmentsoftenhavepoliciesorprogramsinplace regarding: Intermittentpreventivetreatmentofmalaria(IPT)duringpregnancyinendemic areas ProvidingaccesstoLLINs Dewormingafterthefirsttrimesterofpregnancy Iftherearepoliciesinplace,consider: Promotingtheservices Providingtrainingtohealthservicestaff Communitymobilizationandawarenesscampaigns Supportinghealthfacilitiestoaddresssupplyissues

SocialandBehaviorChangeRelatedtoMaternalNutrition
SBCtosupportwomenandfamiliesinpracticingoptimalnutritionbehaviorsisessentialto achievingimprovedmaternalnutritionalstatus.Someofthekeypracticeshavealready beenbrieflymentionedabovewithinfoodbasedstrategies.Thissectiondescribessome topicsthatmaybeincorporatedintotheSBCstrategytoimprovematernalnutrition status.RefertoStep4SectionAformoreguidanceonpotentialSBCapproachesand contactpoints,includingcommunitymobilization,caregroups,massmedia,support groups,homevisits,counselingandcommunityinfotainment. SomekeymaternalnutritionSBCtopicsinclude: Increasecalorieandproteinconsumptionforpregnantandlactatingwomenbased onnationalrecommendations Promotedietarydiversity: o Nutritioneducationtopromoteconsumptionoflocal,nutrientrichfood sources,especiallythosehighinvitaminA,ironandiodine o Promotingconsumptionoffoodsthatenhanceabsorptionofironsuchas citrusfruitsorotherfoodswithvitaminC Promoteconsumptionoffortifiedfoods: o Advocatefortheincreasedavailabilityofandaccesstothesefoodsatthe communitylevel o Workwithcommunitytocreatedemandforfortifiedfoods(identifywhat thebarrierstoconsumptionmightbe)
R.Galloway.2003.AnemiaPreventionandControl:WhatWorks?Part1andPart2.USAID,WorldBank,PAHO/WHO, MicronutrientInitiative,FAOandUNICEF. http://siteresources.worldbank.org/NUTRITION/Resources/2818461090335399908/Anemia_Part1.pdf http://siteresources.worldbank.org/NUTRITION/Resources/2818461090335399908/anemia_Part2.pdf
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Promoteuptakeofkeymaternalnutritionservices,including: o Antenatalcare o Nutritioncounseling o Micronutrientsupplementation o Malariapreventionandtreatment o Preventionandtreatmentofparasiticworminfections Promoteothercommunity/householdsupportforpregnant/lactatingwomen, including: o Reducedworkload o Careseeking

DevelopandStrengthenReferralSystems
Evenwithpreventiveactivitiesinplace,somewomenwillrequiretreatmentfornutritional deficiencies.NGOprogramscanprovideguidanceandtrainingtotraditionalbirth attendants,counselorsandCHWsonwhenandwheretoreferwomenforspecific services.MoredetailedguidanceonlinkingwithhealthsystemsisprovidedinStep4 SectionA,CrossCuttingApproaches,LinkingwithHealthSystems. Whichapproacheswillyouuse?FilloutyourthoughtsintheboxesinStep4 SectionCoftheWorkbook.

STEP4SECTIOND.MICRONUTRIENTSTATUSOF CHILDREN
Step4SectionDbeginsonpage58oftheWorkbook. Usethissectionifyoudeterminedthatmicronutrientstatusofchildrenmaybeapriority issueintheprogramareaandyouareconsideringincorporatingmicronutrient approaches. AfterreviewingyouranswerstothequestionsinSteps13andStep4SectionAinthe Workbook,discusstheoptionsinthissectionwithyourteam.Recordyourconclusionsin theWorkbookinStep4SectionD. Muchlikethedetailedapproachescoveredinothersectionsofthistool,thereareseveral childmicronutrientapproachestobeconsidered: Socialandbehaviorchangerelatedtochildmicronutrients Foodbasedapproachesforchildren Micronutrientsupplementation Delayedcordclamping
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SocialandBehaviorChangeRelatedtoChildMicronutrients
SBCeffortstopromoteconsumptionoflocallyavailableandaccessiblemicronutrientrich foodsourcesshouldbepartofacomprehensivenutritionbehaviorchangestrategyfor longtermandsustainableimprovements.

VitaminA
IfvitaminArichfoodsareavailable,consider: Workingwithcommunitiestodevelopafoodcalendaroflocallyavailablefoods richinvitaminA PromotingconsumptionwithintheoverallSBCapproach,withspecialtargetingto changebehaviorsofvulnerablegroups: o ConsumptionofanimalsourcevitaminA,especiallyforchildren623months ofageaspartofcomplementaryfeedingmessagesforbehaviorchange o Consumptionofdietsandrecipesthatincludefoodsthataredarkgreen, yellowandorange IfvitaminArichfoodsarenotavailable,considerfoodbasedapproacheswithinaSBC strategysuchaspromotingvitaminArichfoodproductioninhomegardens,withafocus onconsumptionatthehouseholdlevel. Iron Ifironrichfoodsareavailable,consider: Workingwithcommunitiestodevelopafoodcalendaroflocallyavailablefoods richinironandvitaminC Promotingtheconsumptionoffoodshighinironinsuchawaytomaximize absorptionwithinalargerbehaviorchangeapproach PromotingtheconsumptionoffoodswithvitaminCalongwithfoodshighiniron, whichpromotesabsorption Promotinghotbeverageoptionsotherthanteaandcoffee,theingestionofwhich inhibitsabsorption Promotingtheconsumptionofanimalsourcefoodsbychildren,especially624 monthsofage Ifironrichfoodsarenotavailable,considerintroducingananimalhusbandryprojectwith afocusonconsumptionatthehouseholdlevel.

Zinc
Animalproductsarethebestsourceofzinc.Inhibiters,suchasfoodswithhighphytate contentincludinggrains,limitzincabsorption.Consideraddingfoodbasedapproaches suchascooking,fermentationandsproutingtoimprovethebioavailabilityofzinc(and reducephyticacid)withintheSBCstrategy.

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FoodBasedApproachesforChildren
FBAs59aremadeupofacombinationofapproachestoimprovedietaryqualityanddietary diversity,acommonmeasureofdietaryquality.Themostcommonapproachescanbe organizedaroundthosethatwillincreasetheproductionandavailabilityofmicronutrient richfoods;dietaryintakeofmicronutrientrichfoods,includingthepromotionandsupport ofbreastfeeding,recommendedIYCFpractices,andconsumptionofiodizedsalt;and bioavailability(abilityofthebodytobetterabsorb)ofmicronutrients.Formore informationonfoodbasedapproaches,pleaseseeStep4SectionA,CrossCutting Approaches,Foodbasedapproaches.

MicronutrientSupplementation
VitaminA
Manycountrieswherechildmortalityratesarehigh(>70deaths/1,000livebirths)have policiesfortwiceyearlyvitaminAsupplementationofchildren659monthsofage. Successfulimplementationofthislevelofsupplementationshouldresultinanaverage23 percentreductioninchildmortality.Largescalesupplementationisoftencombinedwith outreacheffortsforimmunizationwithperiodiccampaignsconductedbyallhealth services.ThisapproachmaybecalledtheChildHealthDayorChildHealthWeek. Ifthecountryhasamicronutrientsupplementationpolicyinplace,onlyamodestlevelof effortwillbeneededtoprovidesupportforthepolicy.Considerproviding: Communityorganizationandawarenesspromotiontoincreaseparticipation Logisticsupport,includingthecoordinationoftransportationforoutreachfrom healthfacilities Supportandadvocacytoaddressanymicronutrientsupplyissues Ifthereisnopolicyineffect,considerpartneringwithotherorganizationstoconduct advocacyeffortsinmicronutrientsupplementation Evenwiththeaboveapproaches,somechildrenwillneedtherapeutictreatmentfor potentiallycomplicatedillnesses,suchasxerophthalmiaorBitotsspots.Additionally, therapeuticvitaminAsupplementationisalsoprovidedtoaddressmeaslesandother severeinfections.Activitiesmaybeneededtostrengthenclinicalcareuseoftherapeutic supplementation.Thistreatmentiscomplicatedandrequiresaccesstoskilledtechnical assistanceand/orclinicalcare. Iron Whetherthereareperiodiccampaignsfordewormingandironsupplementationof children659monthsofagevariesbycountry.Inareasendemicformalaria,WHOdoes
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MuchofthissectiononfoodbasedstrategiesdrawsfromRuel,MTandLevin,C.2000.AssessingthePotentialforFoodBased StrategiestoReduceVitaminAandIronDeficiencies:AReviewofRecentEvidence.IFPRI.FCNDDiscussionPaperNo.92.2000.For morebackgroundinformation,pleaseseehttp://www.ifpri.org/sites/default/files/publications/fcndp92.pdf.

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notrecommendroutineironsupplements(includingpointofusefortificantslike Sprinkles)forchildrenunder2yearsofage.Iron(orIFA)supplementsinendemicareas shouldbetargetedtochildrenwithanemiaoratriskofirondeficiencyanemia.These childrenshouldalsoreceiveconcurrentprotectionfrommalariaandotherinfectious diseases.Therapeuticsupplementationwithironforcasesofmalariainchildrenunderfive inendemicareasisunderreviewduetopotentialadverseoutcomes. Givingchildren15yearsofageroutine,twiceyearlydewormingtreatmentimproves nutritionalstatusforanumberofmicronutrients,includingiron;improveschild development;andreducesundernutrition. Ifthecountryhasanironsupplementationpolicyinplace,onlyamodestlevelofeffort willbeneededtoprovidesupportforthepolicy.Considerproviding: Communityorganizationandawarenesspromotiontoincreaseparticipation Individualcounselingtomothersofindividualchildrenreceivingironsupplements toensurechildrenreceivetheentirecourseofsupplementation Logisticsupportforoutreachfromhealthfacilities Supporttoaddressanymicronutrientsupplyissues Ensuringtrainingandjobaidsareavailabletoassisthealthworkerswithcorrectly identifyingandscreeningforanemia Ifthereisnotapolicyineffect,considerpartneringwithotherorganizationstoconduct advocacyefforts. Zinc TheLancetSeriesonMaternalandChildUndernutrition60hasreportedthatthereis sufficientevidenceforrecommendinglargescalesupplementationofzincforinfantsand children.Checkforrecentpolicydevelopmentswithrelevantministriesbeforepursuing anyefforts.Notethattodate,dataarenotroutinelygatheredonzincstatusandtheuse ofpreventivezincsupplementation.TheMicronutrientInitiativetracksprogressandposts recentdevelopmentsonitswebsite.61Theuseofzinctoaddressdiarrheaisaddressedin thesectionrelatedtotheunderlyingdiseaseburden.TheCountdownto2015:Maternal, Newborn,andChildSurvivalReportstrackpolicyadoptionofzincprotocolsforthe managementofdiarrhea. Iodine Incountrieswithiodinedeficiencydisorder,supplements(iodizedoilcapsules)maybe targetedtochildren724monthsofage,especiallywhereiodizedsaltisnotavailable. Checknationalpolicies.

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Whatworks?Interventionsformaternalandchildundernutritionandsurvival.TheLancet,Vol.371,February2,2008. http://www.micronutrient.org/english/view.asp?x=1

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DelayedCordClamping

Delayingcordclampingduringchildbirthhasbeenfoundtopreventinfantanemia.Ifyou areworkingwithbirthattendants,considerincorporatingtrainingonthepropercord clampingprocedure.Thecorrecttechniqueistowaittoclampthecorduntilthepulsing hasstoppedandthemaximumamountofblood(andthereforeiron)haspassedtothe newborn.

ChildHealthWeeks/Days
Brief Summary Description Objectives Theyshouldoccureverysix monthstodelivervitaminAsupplementsandotherpreventive healthservicestochildrenatthecommunitylevel.InadditiontovitaminA,serviceshave included:catchupimmunization,providingIFAtopregnantwomen,deworming,iodizedsalt testing,distributionofLLINsandpromotionofinfantandyoungchildnutrition. IncreasecoverageofvitaminAsupplementation Increasecoverageofothernutritionapproaches Providedeworming Children059monthsofage VitaminAprogramincountry Highcoveragerates Feasibleindiversesettings Communitycensusandsocialmobilization BestsuitedforareaswithhighprevalenceofvitaminAdeficiency Requirescoordinationwithdistricthealthplan Needtoassureadequatesupply Volunteersandsupervisorsneedtobetrained Substantialsocialmobilization Followup/recordkeepingimportant Partofalargernutritionstrategy

TargetGroup Criteria Defining Characteristics Needed Elementsfor Quality Programming

Whichapproacheswillyouuse?Filloutyourthoughts intheboxesprovidedin Step4SectionDoftheWorkbook.

STEP4SECTIONE.UNDERLYINGDISEASEBURDEN
Step4SectionEbeginsonpage60oftheWorkbook. Usethissectionifyouhavedeterminedthatthelevelsofillnesssuchasdiarrhea,ARI, malaria,andHIVareatalevelindicatingthattheremustbeafocusonpreventionand treatmentofunderlyingdiseasetoaddresschildhoodundernutritionrates. Acomprehensivereviewofprogrammingapproachestodiarrhea,ARI,malaria,HIV,and waterandsanitationisbeyondthescopeofthistool;however,theResourceGuides Resourcesectionprovidessomereferencesformoreinformation.
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AfterreviewingyouranswerstothequestionsinSteps13andStep4SectionAinthe Workbook,discusstheoptionsinthissectionwithyourteam.Recordyourconclusionsin theWorkbookinStep4SectionE. Ingeneral,programsshouldconsiderincorporatingthefollowingapproachestoaddress theunderlyingdiseaseburden: Linkingnutritionprogrammingwithexistinghealthprogrammingtoensurethat nutritionaspectsoftheunderlyingdiseaseburdenareaddressed Implementingcommunitybasedhealthprograms,suchasCIMCIorCCM,to addresstheunderlyingdiseaseburden Providingtrainingtocommunityandfacilitybasedhealthworkersonprevention andtreatmentofcommonillnessesandnutritionmanagementofcommon illnesses IncorporatingSBCapproachestopromotehealthypracticesandhealthseeking behaviorwithinbothnutritionandhealthservicesactivities Promotingtimelyidentificationofdangersignsforchildhoodillnessesandwhen andwheretoseektreatment Waterandsanitationimprovementstopreventdiarrhea Referringfortreatment Advocacyifthereareclearpolicybarrierstoimplementingpriorityinterventions Thefollowinghygienepracticesshouldbepromotedinnutritionprograms: Safestorageandtreatmentofwateratthepointofuse Optimalhandwashingtechniques Sanitarydisposalofhumanfecesinbasic,lowcostsanitationfacilities WithahighprevalenceofHIVinapopulation,theENAstillapply,butthemessagesneed tobemodifiedtofocusontheneedsofHIVinfectedindividuals.Programsshouldfollow nationalHIVandIYCFguidelinesandconsultthemostrecentWHOguidance.62 Thefollowingtableprovidesasummaryoftwoapproachestoaddressingtheunderlying diseaseburden,CIMCIandCCM.
Nutrition CommunityIntegrated Managementof Program ChildhoodIllness(CIMCI) BriefSummary Communitybasedprogramtoaddress Description diarrhea,malaria,undernutrition,measles andpneumonia.Fourkeyelementsare: facility/communitylinkages;careand informationatthecommunitylevel; promotionof16keyfamilypractices;and coordinationwithothersectors. CommunityCaseManagement(CCM) CCMisanapproachtodelivercommunitybased, lifesavingcurativeinterventionsforcommon, seriouschildhoodinfectionsincluding: pneumonia,diarrhea,malariaandnewborn sepsis.Itreliesontrained,supervisedcommunity memberstoprovidehealthservices.The interventionsare:antibioticsforpneumonia, dysenteryandnewbornsepsis;oralrehydration therapy(ORT);antimalarials;zinc;andvitaminA.

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WHO.HIVandInfantFeeding:RevisedPrinciplesandRecommendations.November2009.Geneva:WorldHealthOrganization. http://www.who.int/child_adolescent_health/news/archive/2009/30_11_09/en/index.html

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Nutrition Program Objectives

CommunityIntegrated Managementof CommunityCaseManagement(CCM) ChildhoodIllness(CIMCI) Reducemorbidityandmortalityof Reducemortalityfromcommonchildhood childrenunder5yearsofage illnessesamongchildren059monthsofage Addressdiarrhea,malaria,undernutrition, Improveaccesstocurativeservices measlesandpneumonia Addresspneumonia,diarrhea,newbornsepsis Improveaccesstocurativeservices andmalaria TargetGroups Children059monthsofage Children059monthsofage Criteria NationalIMCIpoliciesandprotocols HighmortalityfromillnessestreatedbyCCM Collaboratinghealthfacilityimplementing Lackofcontinualaccesstocurative IMCIforpatientreferral interventions Cadreofavailablecommunityhealth Lowuseofhealthfacilities workersorvolunteers PolicyenvironmentsupportsCCM(e.g.,CHWs abletoadministermedications) Highprevalenceofcommonchildhood illnesses:undernutrition,diarrhea, Treatmentprotocolsavailable malaria,pneumoniaand/ormeasles Defining Integratedapproachfocusesonwhole Usestrained,supervisedcommunitymembers Characteristics child,notindividualdiseases todelivertheservices Communitylevelpreventionand Designedtorespondtolocalneedsisseldom treatment anationalprogram Linkedwithhealthfacilities Focusonareaswithlimitedaccesstohealth facilities Evidencebasedprotocolsforprevention andtreatment Usedtoimproveaccess,qualityanddemandof treatmentatthecommunitylevel Addressesinterrelationshipsamong illnesses AllENAmessagesarepartofIMCIkey familypractices Mostlyappliedtochildrenwhopresentat healthfacilitiesortoCHWswithillness Needed Involvementandcommitmentofthe Requiressoundtrainingandsupervision Elementsfor healthsectorneeded Stronglinkswithfunctionalhealthfacilitiesfor Quality Trainingofhealthstaff training,supervisionandreferral Programming Refreshercourses Requiresaccesstosupplyofcurativeproducts: medicines,ORT,vitaminAandzinc Supplies Promotionoftimelycareseekingand Supervision improvedfeedingduringillness Resources HouseholdandCommunityIMCI. CommunityCaseManagementEssentials.2010. Washington,DC:COREGroup Washington,DC:COREGroup. Available: Available: http://207.226.255.123/working_groups/im http://www.coregroup.org/storage/documents/C ci_cimci.cfm CM/ccm%20essen%20final%20dec%2009.pdf

Whichapproacheswillyouuse?Filloutyourthoughtsintheboxesprovidedin Step4SectionEoftheWorkbook.

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STEP5.Preliminary ProgramDesign: Recuperation

DEVELOPANDSTRENGTHENREFERRALSYSTEMS
Referralbetweenpreventiveandrecuperativeprogramsisessentialtoensurethat childrenwhobecomeacutelymalnourishedreceivetreatmentandthechildrenrecovered fromacutemalnutritionreceiveservicestopreventthemfromrelapse.

Recuperation:MAM,SAMorunderweight
HighlevelsofMAM,SAMorunderweightindicateaneedtoaddorstrengthen recuperativeapproachesinadditiontosupportingastrongpreventiveprogram. ModerateAcuteMalnutrition IftheprimaryproblemisrelatedtoMAM,werecommendaprogramthatincorporates thefollowingminimumelements:63 Communityoutreachforactivecasefinding,referralandfollowupatthe communitylevel
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Asofthewritingofthisdocument,WHOguidelinesforaddressingMAMareunderdevelopment.

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Step5beginsonpage62oftheWorkbook. NotethatrecuperationprogramsherefocusonMAM,SAM and/orunderweight. Youhavedeterminedthathighlevelsofacutemalnutrition(MAMorSAM)and/or underweightareofpublichealthsignificanceandthatyourcommunitybasednutrition programwillincorporatebothpreventiveandrecuperativeapproaches.Inadevelopment setting,recuperativeprogramsshouldbeintegratedintotheoverallpreventiveprogram asopposedtobeingimplementedasseparate,parallelinterventions.Thissectionprovides informationonrecuperativeapproachesthatcanbeaddedtoyourpreventiveprogram. AfterreviewingyouranswerstothequestionsinSteps13intheWorkbook,discussthe optionsinthissectionwithyourteam.RecordyourconclusionsintheWorkbookinStep5. Annex2onpage82oftheWorkbookprovidesasidebysidecomparisonofthefollowing programsforeasyreferencewhenfillingoutStep5intheWorkbook.

Medicalreferralandtreatmenttoaddressunderlyingdiseaseburden,routine deworming(mebendazole/albendazole),micronutrientsupplementation(vitamin Aandiron)andvaccinations Dailysupplementalmealswithaminimumnumberofcaloriesandproteinbased onWHOguidance64 Education,trainingand/orcookingdemonstrationsonhowtopreparethefood,if supplementalfoodsareunfamiliar Amechanismforfollowupandmonitoringweightgain Medicalreferral,treatment,andnutritionsupportandcounselingforchildrenwho arenotgainingappropriateweightorarelosingweightinrecuperativeservices Behaviorchangeandnutritioncounselingtoimprovefeedingandcarepractices

SevereAcuteMalnutrition IftheprevalenceofSAMisofpublichealthsignificance,aprogramtodirectlyaddress childrenwithSAMisneededinadditiontoaprogramthatincorporatesthecomponents toaddresschildrenwithMAM.Ideally,theprogramwouldbecommunitybasedwith stronglinkstohealthservicesincludinginpatientandoutpatientmanagementofSAM. AnyprogramfortreatmentofSAMshouldfollowthenationalprotocolforthe managementofacutemalnutritionand/orinternationalWHOorCMAMprotocols. Incorporatethefollowingminimumelements: Communityoutreachforactivecasefinding,referralandfollowupatthe communitylevel Initialmedicalevaluationfordiagnosisofmedicalcomplications,dangersignsand assessmentofappetite Routinetreatmentofchildrenaccordingtostandardmedicalandnutrition protocolsformanagingSAM65 o Medicalprotocolsinclude:Amoxicillinorsecondlineantibiotic,vitaminA supplementationforchildrenwithnoedemawhohavenotreceivedadosein theprevious30days,dewormingafterweekoneoftreatment,measles vaccinationandmalariatreatmentinmalarialareas o Nutritionprotocolsinclude:Therapeuticfeeding(RUTFforchildren659 monthsofagewithnomedicalcomplications,therapeuticmilk[F75orF100] forchildrenwithmedicalcomplications,noappetiteorunder6monthsofage) OutpatientcareprovidedusingestablishednationalprotocolsorCMAMprotocols (ifnonationalprotocolsexist)forchildrenwithSAMandnomedicalcomplications Referraltoinpatientfacilitieswith24hourcareandstafftrainedinthe managementofSAM,accordingtoestablishednationalguidelinesorWHO guidelines(ifnationalguidelinesdonotexist)forchildrenwithSAMwithmedical complications,IMCIdangersignsorafailedappetitetest,orwhohavenotgained weightinoutpatientcare
CurrentWHOguidancesuggeststhatsupplementalfeedingrationsforthetreatmentofMAMshouldprovide10001200 kcal/person/dayifthereisatakehomerationtoaccountforfamilysharing.Thereareongoingdiscussionsaboutthebest treatmentsforMAMandguidancemayevolve.TheManagementofNutritioninMajorEmergencies.2000.Geneva:WHO. 65FANTAProject,ConcernWorldwide,UNICEF,andValidInternational.TrainingGuideforCommunitybasedManagementof AcuteMalnutrition.November2008.http://fanta2.org/;andValidInternational.CommunitybasedTherapeuticCare:AField Manual.2006.
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Appropriatecounselingandbehaviorchange Mechanismtomonitorweightgainandfollowup toensurecontinuedweightgain Clinicalprogramsupervisionandmedical expertise Linkageswithothernutrition,healthorfood securityinitiatives

Underweight

Iftheprevalenceofunderweightisofpublichealth significance,youwillneedaprogramthatincorporates thefollowingelements: Amechanismforactivecasefinding,referraland followupatthecommunitylevel Amechanismformonitoringweightgainand followuptoensurecontinuedweightgain Screeningtomeasuretheheightofenrolled childrenidentifiedasunderweighttodetermineif theunderweightisaresultofstunting,wastingor both(seetextbox) Communityoutreachforactivecasefindingof childrenwithSAMandreferralofthesechildren totherapeuticservices Medicalreferralandtreatmenttoaddress underlyingdiseaseburden,dewormchildren, providemicronutrientsupplementation,and addresschildrenwhoarenotgainingappropriate weightorarelosingweightinrecuperativeservices Adailysupplementalmeal(Hearth)withaminimumof500700 kilocalories/beneficiary/dayand1525gofproteinfortwoweeksoruntilthechild hasgained400gandiscontinuingtogainweight66 Behaviorchangeandnutritioncounselingtoimprovefeedingandcarepractices LinkstoExistingServices Ifappropriaterecuperativeservicesareavailableandaccessible(seeWorkbook,Step3, ServiceAvailabilityAccessandUptake: Focusyoureffortsonstrengtheningexistingservicesthroughpartnershipswhere needed. Ensurethatthenutritionalstatusofchildrenisregularlymonitored. Refermalnourishedchildrentoavailablerecuperativeservices,andensurea medicalevaluationfordiagnosisandreferral.
66

NutritionWorkingGroup,COREGroup,PositiveDeviance/HearthEssentialElements:AResourceGuideforSustainably RehabilitatingMalnourishedChildren(Addendum).June2005.Washington,DC:COREGroup.

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Thereisrecognitionbynutrition practitionersthatawastedchild participatinginarecuperative nutritionprogramismorelikely torecoverthanastuntedchild participatinginthesame program(seeTerminology),and thisisanimportant considerationforresource allocationandmotivationof caregivers.Theevidencefor programmaticsolutionsforthe recuperationofstuntedchildren isextremelyweakatthistime. Hence,itisrecommendedthat programmersidentifyandtrack inprogrammonitoringplansnot onlyunderweightratesasapart ofprogramenrollmentbut stuntingandwastingrates(or MUAC)asisfeasible.Havingthis informationwillenable programmers,researchersand policymakerstobetter understandprogramtrendsand moreeffectivelyallocate resources.

Ensurethatafollowupmechanismisinplacethatprovidesforfollowupand familysupport,suchashomevisits,ifnecessary.

Ifservicesarenotavailable: Incorporateapproachesbelowforrehabilitatingmalnourishedchildreninto programdesign. Focusprogrameffortsonadvocacyandcapacitystrengtheningtoensurethat servicesandsupplieswillbeavailableinthefuture.

PotentialRecuperativeApproaches
Thereareanumberofpotentialrecuperativeapproaches,severalofwhicharelisted below.Thekeypointistoensurethatwhicheverapproachyouuseincludestherelevant listofelementsabove.

ToaddressMAMorunderweight,consider: PositiveDeviance(PD)/Hearth RecuperativeSupplementaryFeedingProgramswithbehaviorchange programming Otherapproachesthatcontainthelistedelements

PositiveDeviance(PD)/Hearth BriefSummary PD/Hearthisanapproachtorehabilitateunderweightchildren.PDIsidentifysuccessful Description practicesandstrategiesofpoorlocalfamiliesthathavehealthychildren.Inatwoweek intensivebehaviorchangeinitiative(Hearthsessions),volunteersandcaregiversprepareand feedarecuperativemealoflocallyavailablefoodsandlearnandpracticeaffordable, acceptable,effectiveandsustainablePDcarepractices.Themealingredientsareprovidedby participatingfamiliessothattheylearnthattheycanaffordthefoods,wheretoacquirethem andhowtousethem.Familiesarefollowedupwithhomevisitsaftergraduatingfromthe Hearthsessiontoensurecontinuedgrowth. Objectives Rehabilitatemoderatelyunderweightchildren68 Enablefamiliestomaintainchildsimprovednutritionalstatus Preventundernutritionamongotherchildrenborninthefamily Improvecareandfeedingpractices Avoidcommunitydependenceonsupplementalfoodprograms TargetGroup Children636monthsofagewithmoderateunderweight(WFA<2Zscores) Note:Childrenunder6monthsofageshouldbeexclusivelybreastfedandifmalnourished, needtobereferredtoahealthcenter

68

RecentevidenceindicatesthatPD/Hearthismosteffectiveinrehabilitationwhereunderweightisreflectingwastingratherthan stunting.

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ToaddressSAM,consider: CMAM67inareasof>1percentprevalenceofSAMinchildren659monthsofage Referralcombinedwithtrainingtoimprovefacilitybasedcare Otherapproachesthatcontainthelistedelements

PositiveDeviance(PD)/Hearth Criteria ConsiderPD/Hearthifyoucanansweryestothefollowingquestions: Areatleast30percentofchildren636monthsmoderatelyorseverelyunderweight(WFA <2Zscores)? Isnutrientrichfoodavailableandaffordable? Arehomeslocatedwithinashortdistanceofeachother? Isthereisacommunitycommitmenttoovercomeundernutrition? Isthereaccesstobasiccomplementaryhealthservicessuchasdeworming,immunizations, malariatreatment,micronutrientsupplementationandreferrals? Isthereasystem(orcanasystembecreated)foridentifyingandtrackingmalnourished children? Defining Caregiverscontributelocalfoods Characteristics Communitylevelrehabilitation Useslocallyavailablefoodsandfeasiblepractices Engagescommunityinaddressingundernutrition Recuperationandpreventionoffutureundernutrition Followuphomevisits Intensivebehaviorchange Needed PDIdoneineverycommunity Elementsfor Growthmonitoringorscreeningmechanismtoidentifymalnourishedchildren Quality SBCstrategiesforHearthparticipantsandlargercommunity Programming Healthservicestoaddresscommonchildhooddiseases Communitymobilization QualitativeskillsetstoengagecommunityinconductingandanalyzingPDI Skillsinanthropometricmeasurement AbilitytoidentifychildrenwithSAMforreferral Abilitytoidentifychildrenwhoarestuntedonly,whoarelesslikelytobenefitfromthe program,andscreenthemout TechnicalassistancefromsomeoneskilledinthePD/Hearthapproach Goodsupervisionskills Accesstobasiccomplementaryhealthservices(immunization,deworming,micronutrients) Resources CORENutritionWorkingGroup. 2002.PositiveDeviance/Hearth:AResourceGuidefor SustainablyRehabilitatingMalnourishedChildren.Washington,DC:COREGroup. Available:http://www.coregroup.org/working_groups/pd_hearth.cfm

FoodSupplementation/FoodAssistance:Recuperation BriefSummary Inarecuperativefoodsupplementationprogram,children(usually659monthsofage,but Description targetagesvary)withmoderateunderweightorMAMreceiveasupplementaryfoodration alongwithhealthservicesandBCCforasetperiodoftimeoruntilrecovery.Recentresearch hasfoundthatapreventiveprogramthattargetsallchildrenunder2andpregnantand lactatingwomenwiththesameservicesismoreeffectiveatreducingprevalenceof undernutritionthanarecuperativeprogramthatonlytargetsthemalnourished.

Objectives TargetGroup Criteria

Supplementaryfeedingprogramsarealsooftenestablishedinemergenciestofilldietarygaps, protectlivesandprotectnutritionalstatusofwomenandchildren. ManageMAM Managemoderateunderweight Children659monthsofagewithMAM Lactatingmothersofmalnourishedchildren<6monthsofage Foodinsecureenvironment 68

GUIDESTEPFIVE

FoodSupplementation/FoodAssistance:Recuperation Evidencethatfoodsupplementationwillnotdisplacelocalproduction Logisticalcapacityfortransport,storageandmanagementoffoodcommodity Veryhighprevalenceofunderweight(>30percent)orhighprevalenceofMAM(>10 percent,>5percentwithaggravatingfactors) Defining Opportunitytolinkwithagricultureandlivelihoodsectorsandimprovefoodaccesswhile Characteristics alsoimprovingutilization Foodsupplementationmayalsobetargetedonaseasonalbasis,whenthefoodneedsare thegreatest Foodisprovidedtochildren659monthsofagewithMAM Needed Provisionoforaccesstobasicessentialhealthservices(andtreatmentofSAMif Elementsfor appropriate) Quality ComplementarypreventiveSBCprogrammingfocusedonmaternalnutrition,IYCF,hygiene Programming andhealthseekingbehaviors Closeprogrammaticcoordinationwithhealth,nutritionandfoodsecurityprogramsand services Formativeresearchtoadaptprogramtolocalconditions,includingseasonalcalendarof whenfoodneedsaregreatest Resources USAIDOfficeofFoodforPeace: http://www.usaid.gov/our_work/humanitarian_assistance/ffp/ FANTA2:www.fanta2.org WorldFoodProgramme:www.wfp.org CommunityBasedManagementofAcuteMalnutrition(CMAM)69 BriefSummary CommunitybasedapproachformanagingSAMcases,whichincludesoutpatientcareforSAM Description withoutmedicalcomplications,inpatientcareforSAMwithmedicalcomplicationsandinfants< 6months,andcommunityoutreach.CommunityworkersaretrainedtouseMUACandassess edematoactivelyseekandreferSAMcasestotheCMAMprogram.Basedonamedical evaluationandusingroutinemedicationandRUTF,CMAMtreatsthemajorityofSAMcasesat home.SAMcaseswithmedicalcomplicationsarereferredtoinpatientcareforstabilization beforebeingreleasedtooutpatientcareforfullrecovery.CMAMprogramsmayalsoincludea componenttomanageMAMwithroutinemedicationsandsupplementaryfeeding,oftenwith fortifiedblendedfoods. Objectives Treatacutemalnutritioninthecommunity

Reducemorbidityandmortalityofchildrenwithacutemalnutrition TargetGroup Children659monthsofagewithSAM(MUAC<115mm,WFH<3Zscoresand/orbilateral pittingedema) Children659monthsofagewithMAM(MUAC<125but>115mm,WFH<2Zscores)may beincludedifthereisasupplementaryfeedingprogram Childrenunder6monthsofagewithSAM(inpatientcare) Criteria Availabilityofnationalprotocolsforthemanagementofacutemalnutrition AvailabilityofRUTF,therapeuticmilk(F75/F100)androutinemedication Availabilityoftrainedstaff PrevalenceofSAMinchildrenunder5exceeds1percentofpopulationofchildren659 months Communitieswith>10percentwastingamongchildren659months
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CMAMoriginatedasanemergencycaremodelknownasCommunitybasedTherapeuticCare(CTC).

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Maybeconsideredforuseinpostemergencycommunitiesorwithfrequentperiodic
emergenciesinadditiontodevelopmentcontexts Defining Communitybasedapproachfortreatingacutemalnutritiononanoutpatientbasis Characteristics UseofRUTFinsteadofmilkbasedformulasforcasesofSAMwithnomedicalcomplications andchildrenover6monthsofage CommunityoutreachforactivecasefindingandreferraltocatchchildrenwithSAMorMAM asearlyaspossible Needed ActivecommunitycasefindingusingMUACandassessmentofedema Elementsfor SBCstrategiesforsustainableprevention Quality Healthservicestoaddresscommonchildhooddiseases Programming Skillsinanthropometricmeasurement Trainedcommunitymemberswhocanidentifycasesofsevereorcomplicatedacute malnutritionforreferral TechnicalassistancefromsomeoneskilledintheCMAMapproach Resources(financial,inkind)forasupplyofRUTFandmedications Trainedclinicalstafftoconductmedicalevaluation,identifymedicalcomplications,referand treatcases Inpatientservicesavailable Resources FANTA,ConcernWorldwide,UNICEF,andValidInternational.2008.TrainingGuidefor CommunitybasedManagementofAcuteMalnutrition.Washington,DC:AED. Available:http://www.fanta2.org/

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Whatapproachwillyouuse?Filloutyourthoughtsintheboxesprovidedin Step5oftheWorkbook.

STEP6.PuttingItAll Together

Step6beginsonpage65oftheWorkbook.
Congratulations!Youhavearrivedatthisstepaftercollecting andanalyzinginformationonthenutritionsituationand resources,determiningpriorityinterventionareas,and exploringthepotentialapproaches.Youshouldhavealistof optionsidentifiedintheWorkbook. Atthispoint,basedonyourteamdiscussionsfromSteps15,youwillputthevarious optionstogethertoprioritizeanddecideonthebestcombinationofapproachesto implementintheprogramarea.UseStep6intheWorkbookforfinalanalysisanddecision makingonyourpotentialprogram.

COSTINGOUTTHENUTRITIONPROGRAMMING PLAN
Thereareanumberofelementsthatmustbetakenintoaccountwhenmakingrough estimatesofcost.Thefollowingtextboxprovidesconsiderationstoassistwithdeveloping programcostestimates.

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CostingConsiderations
StaffingNeeds Whattasksandresponsibilitieswillprogramstaffhave?ConsiderneedsforSBC,nutrition, monitoringandevaluation,andcommunitymobilization. Whatnumberandskillsetsofstaffareneededtoimplementtheprogrameffectively? WhattasksandresponsibilitieswillCHWsorCHVshave?Howmanyhoursperweekormonth areneeded?Howmanyvolunteersorworkersareneeded? Whatarethesupervisoryneeds? Howarevolunteersorcommunityworkerscurrentlycompensatedorincentivized? Dostaffneedcapacitybuildingintheskillsneededtoimplementtheprogramapproach? TechnicalAssistanceNeeds Willexternaltechnicalassistancebeneeded?ConsiderneedsforSBC,monitoringand evaluation,communitymobilization,formativeresearchanddocumentation. Cantechnicalassistancebesecuredfromhome/regionaloffice? Cantechnicalassistancebesecuredfromlocalorinternationalconsultants? Doesthehealthsystem(nationalorlocal)orotherorganizationorpartnershaveindividuals withstrongskillsthatcancontributetotrainingothersinspecificnutritionapproaches? DirectProgramImplementationNeeds Whatactivitieswillyoucarryout(e.g.,trainings,supportgroups,SBCstrategy,advocacy, healthdays)? Wherewilltheytakeplace?Whatvehicleorfuelcostswillbeneededtosupportoutreachand programefforts? Howmanycommunitieswillbeinvolved? Howmanypeoplewillbeinvolvedinactivities? ProgramSupplyNeeds Whatinputsandmaterialswillneedtobepurchasedanddistributed? DoestheMOHorotherorganizationorpartnerhaveappropriatenutritioneducational materialswhichcanbeusedormodified? Willyouneed: o Scalesandmeasuringboards o MUACtapes o Childgrowthcards o SBCmaterials o Foodsupplements o Medications o Micronutrientsupplements o Recordkeeping/monitoringmaterials o Officeequipment

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Conclusion

CongratulationsoncompletingtheNutritionProgramDesignAssistant.Wehopethistool hasbeenusefultoyouinplanninganeffectivenutritionprogramforthetargetareaand thatyourprogramsaresuccessfulinimprovingchildhoodnutritionstatus. TheCORENutritionWorkingGroupwouldbeinterestedinlearningaboutyour experiencesandlessonslearned.Ifyouhaveanyadvicebasedonyourexperiencefor improvingguidanceinthistool,pleasesendyourthoughtstocontact@coregroup.org.

CongratulationsandBestofLuck!

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Annex1.Terminology
ANTHROPOMETRICMEASUREMENT Anthropometryisthemeasurementofthehumanbody,andisusedtoassessnutritional statusofindividualsandpopulationgroups.Commonnutritionrelatedanthropometric measuresareheight,weightandMUAC.Trainingandqualitycontrolforconsistently accuratemeasurementisanimplementationchallengeformostfieldprograms. Anthropometricmeasuresarecomparedagainstareferenceorstandardpopulationto determinehowwellanindividualorpopulationismeetingestablishedgrowthand developmentpatterns.From1970sto2006,theNCHS/CDCgrowthreferencewasused internationallyfordeterminingnutritionalprogress.Analysesconductedinthe1990s revealedthatthegrowthpatternsofhealthybreastfedchildrendifferfrompatternsseen intheNCHS/CDCreferencepopulation.Inresponse,WHOconductedacomprehensive studyacrossmultiplecountriestobetterdocumenthowchildrenshouldgrowin environmentswherehealthychildrenareexposedtoimprovednutritionandhealth practices,includingbreastfeeding.70ResultsfromtheWHOstudyledtotheglobal introductionandrolloutofthe2006WHOChildGrowthStandardsastherecommended standardtoagainstwhichtocompareanthropometricdata.Arecentcomparison71of childgrowthpatternsinover50countries,usingthe2006WHOChildGrowthStandards, foundthatgrowthfalteringinearlychildhoodisevenmoreseriousthanindicatedby earlieranalysesusingtheNCHS/CDCreference,andaffirmtheimportanceofscalingup provenprenatalandinfantandyoungchildinterventionsduringthedevelopmentwindow ofopportunity. ANTHROPOMETRICMEASURES Dataonachildsage,weightand/orheightarecombinedtoformindices,whichare comparedtointernationalstandards.72Themostcommonlyusedanthropometric measuresare: LowWeightforHeight(WFH)(Wasting/AcuteMalnutrition):LowWFH(orlength)73 identifieschildrenwhoarewasted,(i.e.,thinnerthanahealthy,wellnourishedchildof thesameheight)becausetheyhavefailedtogainadequateweightorhavelostweight.It reflectsrecent,shorttermoracutemalnutritionorillness.Theamountofwastingpresent inanareamayvarybytheseasonandisaffectedbyperiodsoffoodinsecurityand

DeOnis,M;Garza,C;Onyango,AW;Martorell,R.WHOChildGrowthStandards.ActaPdiatriciaSupplement.2006;450.5101. Victora,C;deOnis,M;Hallal,PC;Blssner;Shrimpton,R.WorldwideTimingofGrowthFaltering:RevisitingImplicationsfor Interventions.Pediatrics2010;125:e473e480. 72 WHOChildGrowthStandards2006,orNCHS/CDC1977GrowthReferences,dependingonwhetherthecountryhasadoptedthe newWHOChildGrowthStandards. 73 Lengthisusedtodescribechildrenundertwoyearsofage,whoaremeasuredlyingdown.Heightisusedtodescribechildren twoyearsofageandolder,whoaremeasuredstandingup.Henceforthinthisdocument,wewilluseheighttorefertoeither heightorlength.
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seasonalillness.Wastingisaddressedthroughrecuperativeandpreventiveapproaches. SeverewastingisoftenusedtodeterminepopulationlevelprevalenceofSAM,because wastingdataismorelikelytobeavailableatthepopulationlevelthanMUACorbilateral pittingedema.WastingdataalonemayunderestimateSAMbecauseithaspartialoverlap withMUACdata(~40percent)anddoesnotreflectbilateralpittingedema. LowHeightforAge(HFA)(Stunting/ChronicMalnutrition): LowHFAidentifieschildren whoarestunted,(i.e.,shorterinstaturethanahealthychildofthesameage)because theyhavenotgrownadequatelyinheight.Itreflectspastgrowthfailure,chronic undernutritionovertimeand/orpoorhealth.HFAdoesnotvarybyseasonsoftheyear. Stuntingisbestaddressedthroughpreventiveapproachesandinterventionsthataddress chronicfoodinsecurity. LowWeightforAge(WFA)(Underweight):LowWFAidentifieschildrenwhoare underweight(i.e.,theyweighlessthanahealthy,wellnourishedchildofthesameage). Thismaybebecausethechildhasnotgrownadequatelyinheight,weight,orboth,orthat heorshehasrecentlylostweight.Underweightreflectsbothstuntingandwasting,but cannotdistinguishbetweenthetwo.Underweightisaddressedthroughpreventive approachesandmaybeaddressedthroughrecuperativeapproachesaswell. BilateralPittingEdema:Alsoknownasnutritionaledema,kwashiorkororedematous malnutrition,bilateralpittingedemaisasignofSAM.Itisidentifiedwhenthumbpressure, appliedtothetopsofbothfeetforthreesecondsleavesanindentationinthefootafter thethumbislifted.Itisconsideredmildwhenitisonlyinbothfeet(canincludeankles) (Grade+);moderatewhenitisinbothfeet,lowerlegs,handsorlowerarms(Grade++); andseverewhenitisinbothfeet,legs,hands,armsandface(Grade+++). BodyMassIndex(BMI):CalculationoftheBMI(weightinkgdividedbyheightinmeters squared)ismostoftenusedtoassessadultnutritionalstatusandidentifiesbodythinness asaresultofweightlossorfailuretogainweight.Avaluebelow18.5kg/m2indicates chronicenergydeficiencyorthinness.LowprepregnancyBMIandinadequateweightgain duringpregnancyincreasestheriskoflowbirthweight.ABMIbetween18.5and25is considerednormal,aBMIof25to30isconsideredoverweightandaBMI>30isclassified asobese.Obesity,achronicdisease,isbecomingmoreprevalentinthedevelopingworld andmaybeacommunitynutritionissue.Obesityprogramsarenotaddressedinthistool. LowBirthWeight:Lowbirthweightiswhenaninfantweighslessthan2,500g(5.5 pounds)atbirth.Lowbirthweightisanoutcomeofintrauterinegrowthretardation and/orprematurebirth.Itisestimatedthatfourmilliondeaths,or38percentofallchild deaths,occurduringthefirst28daysoflife.Sixtyto80percentofchildrenwhodieinthe neonatalperiodhavelowbirthweight,and28percentofneonataldeathsaredirectly attributabletolowbirthweight.74Lowbirthweightisnotonlycloselyassociatedwithfetal
74

LawnJE,CousensS,ZupanJ.4millionneonataldeaths:When,Where?Why?TheLancet:NeonatalSurvivalSeries,March 2005.

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andneonatalmortalityandmorbidity,butalsowithinhibitedgrowthandcognitive development,andchronicdiseaseslaterinlife.75 MidUpperArmCircumference(MUAC):Anindicatorforwastingthatisusedforchildren 659monthsold.MUAC<115mmindicatesseverewastingorSAM.MUAC115mmand <125mmindicatesmoderatewastingorMAM.

COMMONLYUSEDINDICATORS GlobalAcuteMalnutrition(GAM):Anindicatorreferringtooverallacutemalnutritionin thepopulation.GAMincludesbothSAMandMAMandisdefinedbypresenceofbilateral pittingedemaorwasting(WFH<2Zscores).GAM=SAM+MAM. ModerateAcuteMalnutrition(MAM):MAMisindicatedbymoderatewasting:WFH3 Zscoresand<2Zscores,orMUAC115and<125mm.ChildrenwithMAMhaveahigher riskofdeaththanwellnourishedandatriskchildrenandneednutritionsupport. SevereAcuteMalnutrition(SAM):SAMisindicatedbybilateralpittingedemaorsevere wasting:WFH<3ZorMUAC<115mm(MUACusedonlyonchildren>6monthsofage). ChildrenwithSAMarehighlyvulnerableandhaveahighmortalityrisk.Thesechildren needimmediatemedicalandnutritionintervention. OTHERKEYANTHROPOMETRICTERMS GrowthFaltering:Growthfalteringoccurswhenachildfailstogainadequateweight, comparedtotheamountofweightheorshewouldbeexpectedtogainduringaspecified timeperiod,basedoninternationalreferences.Growthfalteringismeasuredbyweighing childrenatregularintervals,andcomparingtheirweightgaintoadequateweightgain tables,orgrowthcurves.Thepurposeofidentifyinggrowthfalteringistorecognizea childsvulnerabilitybeforeheorshebecomesmalnourished.Thefalteringisthen addressedthroughcounselingandappropriateinterventions,whichmayinclude treatmentforillness,preventivebehaviorchangeapproaches,orrecuperativeprograms tohelpthechildregainlostweight.
ZScores:AZscoreisacommonlyusedstatisticalmeasurementtodeterminehowfarand inwhatdirectionananthropometricmeasuredeviatesfromthereferencemedian, measuredinstandarddeviations.Cutoffsforclassifyingcategoriesofundernutrition(mild, moderateorsevere)arebasedonnegativeZscores:
LowBirthweight:Country,regionalandglobalestimates,UNICEFStrategicInformationUnit,DivisionofPolicyandPlanning, NewYork,NewYork;December2004.
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ClassificationsofUndernutritionforIndividuals76
Cutoff <1to2Zscores <2to3Zscores <3Zscores UndernutritionClassification Mild Moderate Severe

AnthropometrySummary
Measure HeightforAge(HFA) TypeofUndernutritionDetected Stunting/ChronicMalnutrition Failuretogrowadequatelyinheightor length Reflectschronic,longterm undernutritionorpoorhealth Indicator77 %ofchildren059months withHFA<2Zscores

WeightforHeight(WFH) Wasting/ModerateAcuteMalnutrition (MAM) Failuretogainsufficientweightrelative toheightorlength,orweightloss Reflectsmorerecentundernutritionor weightloss WeightforAge(WFA) Underweight Failuretogainsufficientweightrelative toage,orweightloss Reflectsstunting,wastingorbothbut doesnotdistinguishbetweenthetwo BodyThinness/ChronicEnergyDeficiency Failuretogainsufficientweight,or weightloss Associatedwithbodyfatandprotein stores AcuteMalnutrition Failuretogainsufficientweight,or weightloss Reflectswasting

%ofchildren059months withWFH<2Zscores

%ofchildren059months withWFA<2Zscores

BodyMassIndex(BMI)

%ofwomen1549years withBMI<18.5kg/m2

MidUpperArm Circumference(MUAC)

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Cogill,Bruce.2003.AnthropometricIndicatorsMeasurementGuide.Washington,DC:FoodandNutritionTechnicalAssistance Project,AcademyforEducationalDevelopment. 77 Note:Agerangesforwhichdataareavailablecanandwillvary.

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GAM:%ofchildren659 monthswithMUAC<125 mm MAM:%ofchildren659 monthswithMUAC<125 mmand115mm SAM:%ofchildren659 monthswithMUAC<115 mm

COMMONMICRONUTRIENTTERMS Anemia:Anemiaisaconditioninwhichthehemoglobin(Hb)concentrationinthebloodis belowadefinedlevel,78resultinginareducedoxygencarryingcapacityofredbloodcells. Abouthalfofthetwobillioncasesofanemiaworldwidecanbeattributedtoiron deficiency,whichoccurswhentherearelowironreservesinthebodybecauseoflow dietaryintake,poorabsorptionofironorbloodloss.Othercausesincludemalaria, hookwormandhighfertility.Pregnantwomen,infantsandyoungchildrenareparticularly vulnerabletoanemia.Anemiaofallseveritiesincreasesrisksofmaternalandperinatal mortality,pretermbirthandlowbirthweight,impairedcognitivedevelopmentinchildren, andreducedadultworkproductivity.79 VitaminADeficiency:VitaminAiscriticaltothebodysimmunesystem,necessaryfor healthygrowthanddevelopmentandessentialtothehealthoftheeyeandtheabilityto seeinlowlight.Approximately127millionchildrenunder5yearsofagearevitaminA deficientandapproximately647,000childrendieeachyearfrominfectionswhichwould surviveiftheywerevitaminAreplete.Inaddition,vitaminAdeficiencyistheleadingcause ofpreventableblindnessworldwide.80
IodineDeficiency:Iodineplaysanimportantroleinthedevelopmentandfunctionofthe brainandnervoussystem.Iodinedeficiencymostseriouslyaffectsinfants,children, adolescents,andpregnantorlactatingwomen.Iodinedeficiencyinpregnancycanresultin stillbirthandirreversiblebrainandcentralnervoussystemdamageintheinfant.Itisthe singlelargestdeterminantofpreventablebraindamage,mentalretardation,andlossofIQ pointsintheworld.Duringpregnancyandinfancy,iodinedeficiencycontributestochild mortality.Childrenwhoareiodinedeficienthaveareducedlearningcapacityandlower schoolperformanceandadultswithiodinedeficiencyarelessproductive.81

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Anemiacutoffs:nonpregnantwomenofreproductiveage:<12g/dl;pregnantwomen:<11g/dl;children059months:< 11g/dl 79 InformationonanemiafromWHO:http://www.who.int/topics/anaemia/en/andMaternalAnemia:Apreventablekiller. http://www.fanta2.org/ 80 AdaptedfromCSHGPNutritionTechnicalReferenceMaterials,2007. http://www.mchipngo.net/controllers/link.cfc?method=tools_tech 81 AdaptedfromCSHGP.NutritionTRM2007.http://www.mchipngo.net/controllers/link.cfc?method=tools_tech

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Annex2.Resources
NUTRITIONOVERVIEW
BASICS,UNICEF,WHO.1999.NutritionEssentials:AGuideforHealthManagers.Available: http://www.basics.org/documents/pdf/NutritionEssentials_English.pdf ChildSurvivalandHealthGrantsProgram.TechnicalReferenceMaterials:Nutrition. Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_tech Horton,S.et.al.2010.ScalingupNutrition:Whatwillitcost?Washington,DC:TheWorldBank. Available: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/ScalingUpN utrition.pdf Whatworks?Interventionsformaternalandchildundernutritionandsurvival.2008.TheLancet, Vol.371. KarabiAcharya,TinaSanghvi,SerigneDieneVandanaStapleton,EleonoreSeumo,Sridhar Srikantiah,FrancisAminu,CoudyLy,andVictorDossou.BASICSII.2004.Using'EssentialNutrition Actions'toAccelerateCoveragewithNutritionInterventionsinHighMortalitySettings.Published bytheBasicSupportforInstitutionalizingChildSurvivalProject(BASICSII)fortheUnitedStates AgencyforInternationalDevelopment.Available: http://www.basics.org/documents/pdf/Using%20ENA.pdf

QUANTITATIVEDATACOLLECTION
DemographicandHealthSurvey Available:www.measuredhs.com Knowledge,Practice,CoverageSurvey Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_kpc_modules MultipleIndicatorClusterSurvey Available:www.childinfo.org

QUALITATIVERESEARCH
Dickin,Kate,MarciaGriffithsandEllenPiwoz.1997.DesigningbyDialogue:AProgramPlanners GuidetoConsultativeResearchforImprovingYoungChildFeeding.Washington,DC:Supportfor AnalysisandResearchinAfrica(SARA)Project,AED.Available: http://www.pronutrition.org/files/Designing%20by%20Dialogue%20Young%20Child%20Feeding. pdf

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HowardGrabman,LisaandG.Snetro.2003.HowtoMobilizeCommunitiesforHealthandSocial Change.Baltimore:HealthCommunicationPartnership.Chapter3:ExploretheHealthIssueand SetPrioritiesprovidesinformationaboutvariousqualitativemethodsandcommunity involvement.Available: http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/pdf/index.php SchoonmakerFreudenberger,Karen.1999.RapidRuralAppraisal(RRA)andParticipatoryRural Appraisal(PRA):AManualforCRSFieldWorkersandPartners.Baltimore:CatholicRelief Services.Available:http://www.crsprogramquality.org/2009/10/rrapra/ DeNegri,BerengereandElizabethThomas.2003.MakingSenseofFocusGroupFindings:A SystematicParticipatoryApproach.Washington,DC:AED.Available: http://www.rhrc.org/resources/general_fieldtools/toolkit/otherResources/AED_MakingSenseOf FocusGroupFindings2003.pdf

HEALTHSYSTEMANALYSIS
RapidHealthFacilityAppraisal,MaternalandChildHealthIntegratedProgramatUSAID: http://www.mchipngo.net/controllers/link.cfc?method=tools_rhfa ProgramReviewforEssentialNutritionActions:ChecklistforDistrictHealthServices: http://www.basics.org/documents/pdf/Program%20review_Checklist.pdf#search="ena" WHO/BASICS/UNICEF.1999.NutritionEssentials:AGuideforHealthManagersThisdocument includesguidelinesandexamplesonneedsassessmentandgapanalysisinnutritionprograms (however,pleasenotethatanumberofthetechnicalprotocolscitedinthe1999documentare nowoutdated).Availableat: http://www.basics.org/documents/pdf/NutritionEssentials_English.pdf#search="nutrition essentials"

FOODBASEDAPPROACHESANDFOODSUPPLEMENTATION
FoodforPeace:http://www.usaid.gov/our_work/humanitarian_assistance/ffp/ FoodSecurityNetwork:http://www.foodsecuritynetwork.org/ FoodandNutritionTechnicalAssistance(FANTA2):www.fanta2.org WorldFoodProgramme:www.wfp.org Ruel.MTandLevin,C.2000.AssessingthePotentialforFoodBasedStrategiestoReduceVitaminA andIronDeficiencies:AReviewofRecentEvidence.IFPRIFCNDDiscussionPaperNo.92.2000. Available:http://www.ifpri.org/sites/default/files/publications/fcndp92.pdf Burpee,G.andK.Wilson.2004.TheResilientFamilyFarm:SupportingAgriculturalDevelopment andRuralEconomicGrowth.ITDGPublishing.CRS. Payne,WJAandRTWilson.1999.IntroductiontoAnimalHusbandryintheTropics.Oxford:Wiley Blackwell.

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RECUPERATION
EmergencyNutritionNetwork.2009.IntegrationofIYCFSupportintoCMAM.FacilitatorsGuide. Available:http://www.ennonline.net/pool/files/ife/iycfcmamfacilitatorsusfinal.pdf NutritionWorkingGroup.2002.PositiveDeviance/Hearth:AResourceGuideforSustainably RehabilitatingMalnourishedChildren.Washington,DC:COREGroup Available:http://www.coregroup.org/working_groups/pd_hearth.cfm FANTAProject,ConcernWorldwide,UNICEF,andValidInternational.2008.TrainingGuidefor CommunityBasedManagementofAcuteMalnutrition.Washington,DC:AED Available:http://www.fanta2.org/ AndreBriendandZitaWeisePrinzo,eds.2009.WHO/UNICEF/WFP/UNHCRConsultationonthe ManagementofModerateMalnutritioninChildrenUnder5YearsofAge.FoodandNutrition Bulletin,Vol.30,Number3.SupplementEd. EmergencyNutritionNetwork.2009.ManagementofAcuteMalnutritioninInfants(MAMI)Project. SummaryReport.UniversityCollegeLondonCentreforInternationalChildHealthand Development(CIHD)and

INFANTANDYOUNGCHILDFEEDING
Dicken,K:Griffiths,M;andPiwoz,E.1997.DesigningbyDialogue:AProgramPlannersGuideto ConsultativeResearchforImprovingYoungChildFeeding.Washington,DC:AED.Available: http://www.globalhealthcommunication.org/tool_docs/58/designing_by_dialogue_ _full_text.pdf Guidingprinciplesforfeedingnonbreastfedchildren624monthsofage.2005.Geneva:World HealthOrganization.Available: http://www.who.int/child_adolescent_health/documents/9241593431/en/index.html Guidingprinciplesforcomplementaryfeedingofthebreastfedchild.2004.Washington,DC:Pan AmericanHealthOrganization.Available:http://whqlibdoc.who.int/paho/2004/a85622.pdf StrengtheningActionstoImproveFeedingofInfantsandYoungChildren623MonthsofAgein NutritionandChildHealthProgrammes.2008.Geneva:WorldHealthOrganization. Available: http://www.who.int/child_adolescent_health/documents/9789241597890/en/index.html TheLinkagesProject.2003.FormativeResearch:SkillsandPracticeforInfantandYoungChild FeedingandMaternalNutrition.Washington,DC:AED.Available: http://www.linkagesproject.org/media/publications/Training%20Modules/Formative_Research_ Module_22304.pdf

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MICRONUTRIENTS
R.Galloway.2003.AnemiaPreventionandControl:WhatWorks?Part1andPart2.USAID,World Bank,PAHO/WHO,MicronutrientInitiative,FAOandUNICEF.Available: http://siteresources.worldbank.org/NUTRITION/Resources/281846 1090335399908/Anemia_Part1.pdf http://siteresources.worldbank.org/NUTRITION/Resources/281846 1090335399908/anemia_Part2.pdf WorldBank.PublicHealthataGlance:Anemia. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/ EXTPHAAG/0,,contentMDK:20588506~menuPK:1314803~pagePK:64229817~piPK:64229743~the SitePK:672263,00.html A2Z:theUSAIDMicronutrientandChildBlindnessProject.http://www.a2zproject.org/ TheMicronutrientInitiative:http://www.micronutrient.org/english/view.asp?x=1

UNDERLYINGDISEASEBURDEN
CommunityCaseManagementEssentials:AGuideforProgramManagers.2010.Washington,DC: COREGroup.Available: http://www.coregroup.org/storage/documents/CCM/CCM_Essen_Final_DEC_16_09.doc ChildSurvivalandHealthGrantsProgram.TechnicalReferenceMaterials:IMCI. Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_cross COREGroup,HouseholdandCommunityIMCI.Available: http://www.coregroup.org/storage/documents/Workingpapers/Community_IMCI_Background_ Doc.pdf ChildSurvivalandHealthGrantsProgram.TechnicalReferenceMaterials:ControlofDiarrheal Disease.Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_tech ChildSurvivalandHealthGrantsProgram.TechnicalReferenceMaterials:Malaria. Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_tech

HIV
FANTA2.HIVandNutritionGuide.Available:www.fanta2.org/ ChildSurvivalandHealthGrantsProgram.TechnicalReferenceMaterials:Nutrition. Available:http://www.mchipngo.net/controllers/link.cfc?method=tools_tech

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WorldHealthOrganization.2009.HIVandInfantFeedingRevisedPrinciplesandRecommendations: RapidAdvice.Available: http://www.who.int/child_adolescent_health/news/archive/2009/30_11_09/en/index.html

WATERANDSANITATION
JointPublication8.TheHygieneImprovementFrameworkAComprehensiveApproachfor PreventingChildhoodDiarrhea.2004.EnvironmentalHealthProject.Available: http://www.ehproject.org/PDF/Joint_Publications/JP008HIF.pdf Water,Sanitation,andHygieneImprovementTrainingPackageforthePreventionofDiarrheal Disease.Washington,DC:HygieneImprovementProject.Available: http://www.hip.watsan.net/page/3396

COMMUNITYBASEDGROWTHPROMOTION
Griffiths,Marcia,KateDickinandMichaelFavin.1996.PromotingtheGrowthofChildren:What Works.RationaleandGuidanceforPrograms.Tool#4.TheWorldBankNutritionToolkit. Washington,DC:TheWorldBankAvailable:http://www.worldbank.org(SearchforNutrition Toolkit) Fiedler.2003.AcostanalysisoftheHondurasCommunitybasedIntegratedChildCareProgram. WorldBankHNPDiscussionPaper. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627 1095698140167/FiedlerACostAnalysiswhole.pdf Ashworth,etal.2008.GrowthMonitoringandPromotion:AReviewoftheEvidence.Maternaland ChildNutrition,February2008. http://www3.interscience.wiley.com/journal/119424907/abstract?CRETRY=1&SRETRY=0

SOCIALANDBEHAVIORCHANGE
Dicken,K:Griffiths,M;andPiwoz,E.1997.DesigningbyDialogue:AProgramPlannersGuideto ConsultativeResearchforImprovingYoungChildFeeding.Washington,DC:AED. Available:http://www.globalhealthcommunication.org/tool_docs/58/designing_by_dialogue_ _full_text.pdf SocialandBehaviorChangeWorkingGroup,DesigningforBehaviorChangeCurriculum.CORE Group.Available: http://www.coregroup.org/storage/documents/Workingpapers/dbc_curriculum_final_2008.pdf COREGroupSocialandBehaviorChangeWorkingGroupwebpage:http://www.coregroup.org/our technicalwork/workinggroups/socialandbehaviorchange

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HowardGrabman,Lisa.2007.Demystifyingcommunitymobilization:Aneffectivestrategyto improvematernalandnewbornhealth.Washington,DC:ACCESSProgram/USAID. Available:http://www.savethechildren.org/publications/technicalresources/savingnewborn lives/publications/ACCESS_DemystCM.pdf HowardGrabman,LisaandG.Snetro.2003.HowtoMobilizeCommunitiesforHealthandSocial Change.Baltimore:HealthCommunicationPartnership. Chapter3:ExploretheHealthIssueandSetPrioritiesprovidesinformationaboutvarious qualitativemethodsandcommunityinvolvement.Available: http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/pdf/index.php Linkages.TrainingofTrainersforMothertoMotherSupportGroups.Available: http://www.linkagesproject.org/media/publications/Training%20Modules/MTMSG.pdf FreedomfromHunger:FreedomfromHungerintegratesmicrofinancewithhealthandlifeskills servicestoequipverypoorfamiliestoimprovetheirincomes,safeguardtheirhealth,and achievelastingfoodsecuritythrougharangeofgroupbasedmodels.Formoreinformationvisit: http://ffhtechnical.org/ LaLecheLeague.MothertoMotherSupportHandbook.Available:www.lalecheleague.org LaLecheLeagueInternationalPeerCounselingProgram.Available: http://www.llli.org/ed/PeerAbout.html#pc WorldRelief.2004.AGuidetoMobilizingCommunityBasedVolunteerHealthEducators:TheCare GroupDifference.Available:http://www.coregroup.org/diffusion/Care_Manual.pdf www.CareGroupInfo.org

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The Nutrition Program Design Assistant: A Tool for Program Planners helps program planning teams select appropriate community-based nutrition approaches for specific target areas. The tool has two components: 1) a reference guide that provides guidance on analyzing the nutrition situation, identifying program approaches and selecting a combination of approaches that best suits the situation, resources and objectives and; 2) a workbook where the team records information, decisions and decisionmaking rationale.

www.coregroup.org CORE Group fosters collaborative action and learning to improve and expand community-focused public health practices. Established in 1997 in Washington D.C., CORE Group is an independent 501(c)3 organization, and home of the Community Health Network, which brings together CORE Group member organizations, scholars, advocates and donors to support the health of underserved mothers, children and communities around the world.

Photo Credits
Top left: Laura Lartigue, Courtesy of Photoshare Second: Save the Children Third: Judiann McNulty Fourth: Save the Children Fifth: Save the Children Sixth: International Relief & Development Seventh: Save the Children Bottom: International Relief & Development