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ENUEMERGENCY NUTRITION UPDATE

April – September 2012 ISSUE 14

Photo by Muhammad Ali/World Vision

In the Spotlight

Mental Health and Psychosocial Support in Emergency Nutrition Programmes

Women- and Infant-Friendly Spaces in Pakistan

FY12 CMAM programme summary

Highlights from Global IYCF-E workshop

New Resources: MAM Decision Tool and

CMAM Forum website

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ENU SPOTLIGHT

Mental Health and Psychosocial Support (MHPSS)

Submitted by Megan McGrath, Mental Health and Psychosocial Support Coordinator, Humanitarian and Emergency Affairs, World Vision Australia

For some time it has been recognised that adequate nutrition alone is not enough to enable a child to develop to his or her full potential. For optimal physical and cognitive development to occur, a child requires both adequate nutrition and physical and emotional stimulation from caregivers. Many of World Vision’s health and nutrition responses focus solely on providing children with nutrition inputs coupled with various health and hygiene messages. However, WHO advises that mental health and psychosocial support must be included within a nutrition response to ensure that children develop to their full potential both intellectually and physically, and do not develop lifelong disabilities as a result of nutritional deficiencies and a lack of stimulation.

The first three years of life form a critical period in which the brain is developing most rapidly. During this period, it is essential that the brain receives physical stimulation through sounds, objects, touch and movement; a positive emotional attachment to a caregiver; and adequate nutrition. If these things are not provided, a child’s brain can develop abnormally, leading to mental disability and vulnerability to mental illness later in life. During a food crisis, it is even more vital that such concerns are considered. A child experiencing nutritional deficiencies may show reduced activity and become apathetic. Therefore, the caregiver may reduce the amount of stimulation provided to the child as the child stops responding to the caregiver, leading to permanent developmental delays and vulnerability to mental health issues (WHO, 2007).

Nutritional deficiencies

and a lack of stimulation

create a vicious cycle

in which deprivation

in one can result in

further deprivation in

the other. For example,

a malnourished infant

may show reduced

psychomotor activity

(e.g. the child is less

likely to crawl and

engage in creative play).

As the child becomes

more apathetic and

less demanding, parents

often provide less

stimulation.

Incorporating MHPSS Considerations within Nutrition

Source: WHO, Mental health and psychosocial well-being among children in severe food shortage, 2007.

Lack ofnutritious food

Insufficientcare/stimulation

Malnutrition

Developmental delays/mental health problems

Severe foodshortage

Poor health

Psychosocialdeprivation

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In addition, a caregiver’s mental health also has an impact on his or her ability to feed and adequately care for a child. Research into mothers experiencing depression showed a strong link between depression and a mother ceasing to breastfeed her infant. In addition, a caregiver experiencing depression is less likely to be able to emotionally and physically stimulate his or her child. Approximately 40% of women in developing countries are likely to experience post-natal depression (Cooper, et al, 1999). Therefore, support should be provided to mothers within a nutrition programme to reduce depressive symptoms and thus enable each mother to provide adequate care to her child. Research suggests that combining nutritional programmes with support for positive parenting and stimulation have a long-term effect on a child’s mental health. In a study on the impact of providing food supplements and stimulation to stunted and non-stunted 9-24 month old children in Jamaica, the stunted children who received both interventions weekly over a two-year period had higher developmental scores than those who received neither intervention, or only the nutrition intervention (Walker, Chang, Powell, Grantham-McGregor, 2005).Integrating such interventions at the field level is not a difficult task. For example, within the Supplementary Feeding Programme in Darfur, Sudan, World Vision has included a women- and infant-friendly space in which caregivers can meet, receive support from each other, and be provided with messages and examples of how to emotionally and physically stimulate their children. Such examples include talking to the child, looking into the child’s eyes, smiling, playing games with the child, telling stories and making toys out of local materials. Support is provided to mothers showing signs of distress or depression through an approach known as ‘Psychological First Aid’ (PFA). PFA is a humane, supportive response to a fellow human being who is suffering and who may need support. PFA includes the following themes: providing practical care and support that is not intrusive; assessing needs and concerns; helping people to access basic needs (e.g. food and water, information); comforting people and helping them to feel calm; helping people connect to information, services and social supports; and protecting people from further harm (IASC, 2007).An integrated nutrition and stimulation programme that emphasises both appropriate feeding practices and responsive parenting has a greater impact than either intervention alone. Nutrition programmes that contain both positive stimulation and support for caregivers are more effective in promoting growth and positive child development than nutrition programmes without a psychosocial component.

References:Cooper PJ, Tomlinson M, Swartz L (1999). Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br. J. Psychiatry; 175:554–558Inter-Agency Standing Committee (IASC) (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: IASC.Walker S, Chang S, Powell C, Grantham-McGregor S (2005). Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet, 366: 1804–1807.World Health Organization(WHO) (2006). Mental health and psychosocial well-being among children in severe food shortage. WHO.

Photo by Muhammad Ali/World Vision

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Incorporating MHPSS Considerations within Nutrition Programmes

Opportunities for World Vision• Include psychosocial stimulation interventions in nutrition programmes and implement and document your experience in order to share

learnings.

• In large-scale emergencies, women- and infant-friendly spaces (WAIFS) or baby-friendly areas can provide opportunities to include MHPSS interventions. See World Vision’s guidance on supporting breastfeeding in emergencies through the use of baby-friendly tents (http://www.wvnutrition.net/home/resources/guidelines/breastfeeding-in-emergencies.html). For more information on WAIFS contact Claire Beck claire_beck@wvi.org.

The important role of psychosocial stimulation in the rehabilitation of children with acute malnutrition has long been recognised. Historically, residential treatment facilities for acute malnutrition where children remained for one month provided a good setting to incorporate psychosocial interventions and training for caregivers on this essential component of child development. With the shift to decentralised treatment for acute malnutrition through CMAM programmes, psychosocial support and stimulation interventions are often overlooked.

Interventions to provide emotional and psychosocial stimulation to children have been identified; however, how to effectively integrate these interventions within the context of CMAM and other nutrition programming given the operational constraints, such as limited staff, high number of beneficiaries and decentralised programme sites, is not well understood.

Emotional stimulation:Interventions to improve child-caregive interactions are important in order to facilitate children’s emotional, social and language development.

Educate caregivers on the importance of emotional communication.

Express warmth and affection to the child in a manner consistent with cultural norms

Encourage caregivers to look into the child’s eyes and smile at him or her, especially during breastfeeding. Express physical affection to the child

Encourage verbal and non-verbal communication between the child and caregiver

Communicate with the child as much as possible. Ask the child simple questions and respond to his or her attempts to talk. Try to get a conversation going with sounds and gestures (smiles, glances). Get the child to laugh and vocalise. Teach the child ‘action words’ with activities. For example, say ‘bye’ when waving goodbye.

Respond to the needs of the childRespond to the child’s sounds and interests. Be attentive to his or her needs as indicated by his or her verbal or non-verbal cues (e.g. crying, smiling).

Show appreciation for what the child manages to do

Provide verbal praise for the child’s accomplishments. Also, show non-verbal signs of appreciation and approval (e.g. clapping, smiling).

Physical Stimulation:Children need a physically stimulating environment in order to develop their psychomotor and language skills and to enhance cognitive development.

Ensure that the environment provides adequate sensory experiences for the child

Provide ways for children to see, hear and move. For example, place colourful objects around the child and encourage the child to reach or crawl to them. Sing local songs and play games involving fingers and toes.

Provide play materials Inexpensive and fun toys such as a puzzle and a rattle can be made out of cardboard boxes and plastic bottles.

Provide meaning to the child’s physical world

Help the child to name, count and compare objects.

Older children can sort objects by colour and learn concepts such as ‘high’ and ‘low’. Describe to the child what is happening around them.

Provide opportunities to practice skills

It is important to play with each child individually at least 15–30 minutes per day, as well as to provide opportunities for play with other children.

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World Vision is implementing 16 Women- and Infant-Friendly Spaces (WAIFS) in three provinces in Pakistan. The purpose of WAIFS is to provide a space where a woman and her child feel safe and comfortable, participate in structured activities and experience healing from any trauma and loss they have experienced.

A variety of services are provided at the WAIFS, including:

•Psychosocial support to women in psychological distress

•Screening of children 6 months to 59 months for malnutrition and referral to nutrition clinics

•Screening of pregnant and lactating women for malnutrition and referral to nearest health facility

•Health and hygiene education sessions on common diseases, environmental health and prophylactic measures

•Awareness and education on correct breastfeeding technique

•Health education on birth spacing and modern and conventional contraceptive methods

•Awareness on gender issues, such as domestic violence, gender-based violence, seeking reproductive health services, sexual abuse.

•Empowering women through skills development, such as sewing and embroidery, and coaching and guidance on educational needs

•New birth registration

•Celebrating national and international events, such as International Women’s Day and World Breastfeeding Week

WAIFS provide a platform for women of different ethnic and tribal backgrounds to come together, thereby promoting understand and harmony among different groups. It is also a forum to discuss sensitive social and domestic issues and provides a social outlet for women who are often isolated.

ChallengesAlthough WAIFS are transitional supports, contributing to the short- to medium-term relief effort, there is a risk that organisations fail to consider issues of transition and sustainability. Past experiences show that meaningful community participation in the planning, design and operational stages of WAIFS has been weak. As a result, getting community understanding, acceptance and meaningful participation was initially challenging.

The way forwardAfter the emergency phase, WAIFS can become a sustainable programme if community volunteers are trained to take over the activities. World Vision Pakistan envisions WAIFS as centres of innovation and creativity, including a mini-library and kitchen gardening activities. Such centres also provide the opportunity to integrate child protection, health, nutrition, livelihoods, education, advocacy, and water, sanitation and hygiene sectors.

Submitted by Dr. Rasheed Ahmed

Photo by Mahammad Ali

WAIFSWomen- and infant-friendly spaces is

one approach used to ensure support

to mothers and breastfeeding women.

It provides a safe place for young

children and mothers immediately

after an emergency. WAIFS (or similar

spaces) have been used by many

organisations (UNICEF, SAVE, ACF) in

emergencies and should be part of

World Vision’s early response in an

emergency. World Vision operational

guidelines for WAIFS are forthcoming.

Women- and Infant-Friendly Spaces (WAIFS) in Pakistan

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NEWS FROM THE FIELD

Integrating Mental Health and Psychosocial Support into the Sahel Nutrition and Refugee Crisis

Photo by Megan McGrath

World Vision’s Megan McGrath was seconded as a consultant to UNICEF in July 2012, to ensure the inclusion of mental health and psychosocial support in the West African region’s response. The purpose of this consultancy was to develop a strategy of interventions on providing emotional/psychosocial stimulation to children and their caregivers and to strengthen the capacity of partners to initiate such activities within their nutritional and conflict responses in five countries in the region (Burkina

Faso, Niger, Mauritania, Chad and Senegal). As part of this consultancy, a series of six training sessions were provided on the following topics: Demystifying MHPSS, Infant and Child MHPSS in Nutrition Programmes, Maternal Mental Health, Psychological First Aid, MHPSS in Formal and Non-formal

Education, MHPSS in Child Protection. Along with other partners, World Vision staff from Niger, Chad and Senegal attended these trainings.

In order to practise emotional and physical stimulation techniques, participants learned how to make a woollen doll, and then used the dolls to practise various emotional and physical stimulation techniques using the WHO Mental Health in Food Shortages intervention table (2007) and the UNICEF Care for Development Counselling Cards.

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Severe acute malnutrition(SAM) (non-oedematous) in children under 5 years of age is defined by WHO and UNICEF as a mid-upper arm circumference (MUAC) less than 115 mm or by a weight-for-height z-score (WHZ) less than -3. Children with SAM are at high risk of death; up to 20 times higher than a well-nourished child (WHO). The objective of the study was to assess whether there was any benefit to identify malnourished children with a high risk of death by combining these two diagnostic criteria—MUAC and weight-for-height. Data of a longitudinal study examining the relationship between anthropometry and mortality in rural Senegal and predating the development of community-based management of SAM were used for this study. The study found that MUAC identifies high-risk children better than WHZ. It concluded that to identify high-risk malnourished children, there is no benefit in using both WHZ less than -3 and/or MUAC less than 115 mm, and that using MUAC alone is preferable.

Cost-Effectiveness of CMAM by Community Health Workers in Southern Bangladesh

What are DALYs?A Disability-Adjusted Life Year (DALY) is a measure of overall disease burden. One DALY can be thought of as one lost year of ‘healthy’ life. The sum of these DALYs across the population can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

Source: WHO

Identifying children at high risk of mortality due to malnutrition – weight-for-height or MUAC?

Research Updates

Puett C, Sadler K, Alderman H, Coates J, Fiedler JL, Myatt M. (2012). Cost-effectiveness of the community-based management of severe acute malnutrition by community health workers in southern Bangladesh. Health Policy Plan.

This study assessed the cost-effectiveness of adding the community-based management of severe acute malnutrition (CMAM) to a community-based health and nutrition programme delivered by community health workers (CHWs) in southern Bangladesh. The cost-effectiveness of community-based treatment of severe acute malnutrition (SAM) was compared with the cost-effectiveness of the ‘standard of care’ for SAM, that is, inpatient treatment, augmented with community surveillance by CHWs to detect cases.

The community-based strategy cost US$26 per disability-adjusted life year (DALY) averted, compared with US$1,344 per DALY averted for inpatient treatment. The average cost to participant households for their child to recover from SAM in community treatment was one-sixth that of inpatient treatment. These results suggest that this model of treatment for SAM is highly cost-effective and that CHWs, given adequate supervision and training, can be employed effectively to expand access to treatment for SAM in Bangladesh.

Briend A, Maire B, Fontaine O, Garenne M. (2012). Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr 8(1): 130-133.

Photo by Muhammad Ali/World Vision

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New SMARTwebsite launched in

English, French and Spanish SMART (Standardized Monitoring and Assessment of Relief and Transitions) is an inter-agency initiative launched in 2002 by a network of organisations and humanitarian practitioners. SMART Methodology is an improved survey method that balances simplicity (for rapid assessment of acute emergencies) and technical soundness. It draws from the core elements of several methodologies with continuous upgrading informed by research and current best practices. The new user-friendly website, featuring SMART capacity building tools, FAQs and a discussion forum, is managed by Action Against Hunger Canada and was launched in July 2012. http://smartmethodology.org/

Tools, Guidelines and Recommendations

CMAM FORUM Website has launched!

The CMAM Forum was established in 2012 by a group of experts with the aim to provide a robust information-sharing mechanism that expands the knowledge base on acute malnutrition to improve health outcomes for vulnerable populations. It will build upon and link with existing initiatives. Specific objectives are to:

1. Facilitate information and resources sharing on the management of acute malnutrition

2. Promote and support advocacy efforts on the management of acute malnutrition

The CMAM Forum is a ‘one-stop shop’ for everything related to acute malnutrition. Training materials, including video, technical resources and updates, as well as country-specific protocols and advocacy materials are available on this site. Check out the website and join the CMAM Forum today. http://www.cmamforum.org/

MAM Decision Tool available The MAM Taskforce, a working group made up of cluster partners and led by UNICEF, developed a decision tool to support emergency practitioners in deciding which type of intervention is most appropriate for the prevention and treatment of moderate acute malnutrition. The tool provides guidance on what type of programme, for whom, for how long and contains a useful product information sheet describing the various food types e.g. RUFs, blended foods and LNS that may be used in MAM programming. Feedback on the usefulness of this tool is welcome. Please provide your comments to colleen_emary@worldvision.ca

http://oneresponse.info/GlobalClusters/Nutrition/publicdocuments/MAM%20DecisionTool%20July%202012%20with%20Cover.pdf

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For questions or contributions to the WV ENU, please contact the WV Nutrition Centre of Expertise loria_kulathungam@worldvision.ca NCoE is hosted by WVCanada.

Global Health & WASHNutrition Centre of Expertise

The Next ENU

If you have any suggestions, stories or

reports which you think would be helpful for ENU readers, please email to

loria_kulathungam@worldvision.ca

by February 8, 2013

WE ARE ALWAYS

LOOKINGfor WV emergency nutrition staff to profile in ENU.

All you have to do is send an email to loria_kulathungam@worldvision.ca with answers to the following questions and a

profile picture of yourself.

Name

Years with WV

Current position

Current work location Main work responsibilities/

activitiesBest part of your job/working in

emergenciesWhen you’re not working, what

do you enjoy doing?

The purpose of the workshop was to strengthen infant and young child feeding (IYCF) and infant and young child feeding in emergency (IYCF-E) in programming and planning for emergency preparedness and response both in developmental and emergency contexts. The workshop was organised by Save the Children UK in collaboration with UNICEF and Global Nutrition Cluster. It was held in London, UK from June 25–29, 2012. Over sixty delegates from the UN family (UNICEF and FAO), international NGOs, donors, universities and Ministry of Health participated in the workshop. Workshop proceedings are now available. http://www.unicef.org/nutritioncluster/files/IYCF_-_IYCF-E_workshop_report_2012.pdf

The workshop identified the following key constraints to IYCF/IYCF-E programming:•Poor understanding of indicators •Lack of dedicated funding •No policy / policy not implemented •Lack of knowledge / understanding of what is good programming •Few trained frontline staff •Urgent need for a IYCF-E How To guide for different contexts •Lack of global leadership for IYCF-E

The key lessons relevant for World Vision nutrition programmes at regional and national level are summarised as follows:

•Work with the Humanitarian and Emergency Affairs (HEA) and People & Culture to include IYCF-E in the staff orientation package before emergency programme deployment to address issues related to feeding practices that could arise during emergency response, including orientation to World Vision’s Milk Policy and the Operational Guidance on Infant Feeding in Emergencies

•Collaborate with HEA to ensure emergency programme assessment tools include IYCF/IYCF-E indicators to identify the gaps and appropriately inform emergency preparedness and response plan

•Support NOs to strengthen the collaboration with nutrition cluster coordination at the country level to access technical and financial resources that will leverage programmes

•Collaborate with the Communications and HEA teams to coordinate and harmonise IYCF messages and World Vision Milk Policy communication during emergency

To address the global leadership gap on this issue it was proposed that a consortium of interested partners, such as IFE Core Group, NGOs, UNICEF, Global Nutrition Cluster and academics, unite to move this agenda forward. World Vision will be following the global developments on this issue.

Workshop Debrief:Strengthening Infant and Young Child Feeding Programming and Planning for Emergency Preparedness and Response

June 25th to 29th, 2012, London, UK

Meeting Report Prepared by: Sisay Sinamo, Nutrition Advisor, EARO and Colleen Emary, Emergency Nutrition Technical Advisor, NCoE

Research and Global Participation