Nutrition

Intervention

Reading Assignement- The Sphere Project

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Objectives
• What is nutrition intervention in emergency?
• What are domains in nutrition intervention
• What are the different assessments in nutrition
emergency?
• What are intervention modalities in nutrition
emergency?
• Explain food security interventions for the
different levels of food insecurity
• Shifting from project driven intervention to
development approach
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 Nutrition Intervention
• Nutrition intervention is defined as
purposefully planned actions intended to:
Positively change a nutrition-related
behavior,
Environmental condition, or
Aspect of health status for an individual,
target group, or the community at large.
• It consists of two components: planning and
implementation.
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 The Purpose of a Nutrition Intervention

•To resolve or improve the nutrition diagnosis

or nutrition problem
By provision of advice,
Education , or
Delivery of the food component of a specific
diet or
Meal plan tailored to the patient/client’s*
needs.

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 Determining a Nutrition Intervention
• The nutrition diagnosis and its etiology drives
the selection of a nutrition intervention.
• Nutrition intervention strategies are selected
to change nutritional intake, nutrition-related
knowledge or behavior, environmental
conditions, or access to supportive care and
services.
• Nutrition intervention goals provide the basis
for monitoring progress and measuring
outcomes.

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 Nutrition Intervention Is Organized In 4
Domains
• Food and/or Nutrient Delivery-individualized
approach for food/nutrient provision.
• Nutrition Education-A formal process to
instruct or train a patient/client in a skill or to
impart knowledge
To help patients/clients voluntarily manage or
modify food, nutrition and
Physical activity choices and behavior to
maintain or improve health

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 Continued
• Nutrition Counseling-A supportive process,
characterized by a collaborative counselor-
patient relationship,
To establish food, nutrition and physical
activity priorities, goals, and
Individualized action plans that acknowledge
and foster responsibility for self-care to treat
an existing condition and promote health

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 Continued
• Coordination of Nutrition Care-Consultation
with, referral to, or
coordination of nutrition care with other
health care providers, institutions, or agencies
That can assist in treating or managing
nutrition-related problems

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What are possible intervention options for each
of the nutrition issues ?
Nutrition Issues / Intervention Options
Problems
Low birth weight

Child malnutrition and Growth promotion: growth

growth failure monitoring and counselling

Micronutrient
malnutrition
Household food
insecurity
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 Assessment of Nutritional Status in Emergency
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1-Individual or Community Screening

 Frequently used screening methods at nutrition
intervention centers or outreach mass screening
are:
 Oedema
 Weight for height percent median and
 Mid Upper arm Circumference
 2-Rapid Nutritional Assessment(RNA)
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RNA is a useful tool when the situation is

deemed critical based on information
generated by Early Warning Systems,
When time and/or resources do not allow for
a standard emergency nutrition assessment.
 Its general objective is to obtain an overview
of the nutritional situation,
Determine areas and population groups
affected by an emergency
 Methodology and Activities of RNA
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 A combination of quantitative and qualitative

information on the immediate and underlying
causes of malnutrition (Health, Food Security,
Water and Sanitation, etc) including
quantification of the outcome, i.e. acute
malnutrition.
 Selection of Geographical Areas
 Assessment Implementation
 Key Informant Interviews
 Focus Groups
 Transect Walk
 Screening (MUAC & Edema for U5)
 Continued
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 10 most affected kebeles selected in agreement with

key informants (MoH, MoARD/EWFSS),
 Listed and Kebeles are categorized as worst
affected, close monitoring and normal (based on crop
production, livestock condition, market prices )
 Three worst affected kebeles are randomly selected
by the team
 300 children under 5 are screened house to house
MUAC & Edema + PLW
 Continued
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FGD (8-12 homogeneous group) and Transect walk:

 Gather qualitative information reflecting community
perception and perspective of the situation in
health, nutrition, water and food security
 Visual observation of the prevailing conditions in the
Kebeles and households.
Key informant Interview

 With district level officials from MoH, Agriculture,

EWFSS, Administration, Water office, chair person,
health facility staff
 Rapid Initial Assessment Out Puts
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 Origin of the problem

 Harvest failure

 Civil unrest

 Increased food prices

 Population moment

 Logistic constraints

 Affected population
 How many people are affected

 Who is the most vulnerable group

 Continued
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 How the different socioeconomic groups are

affected
 Logistical problems
 Security
 Roads
 Availability of transport service
 Skills available in the affected/refugee
population
 Continued
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 Mapping
 Rough number of people
 Structure of settlement

 Interviews

 Health professionals
 CHWs
 Local authorities
 3-Surveys
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 Surveys of households
 Wt, Ht, MUAC, edema
 Questions about the previous months deaths
and causes of death
 Distance of water supply

 Malnutrition in < 5 years

 Mortality :IMR, CMR and Crude death rate

 Selection of the 30 children in each of the 30
clusters
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 Having identified the 30 clusters, a team of

data collectors should go to the site of each
cluster.
 At any given cluster, or locality the following
procedure is followed:
 Go to the centre of the selected locality (ask
local people for information).
 Continued
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 Randomly choose a direction by spinning a

pencil or pen on the ground and noting the
direction in which it points when it stops.
 Walk in the direction indicated by the pen,
from the centre to the outer perimeter of the
locality, counting the number of households
along this line.
 Continued
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 Select the first household to be visited by

drawing a random number between one and
the number of households counted when
walking.
 For example, if the number of households

counted was 27, then select a random number

1–27.
 Continued
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 If the number five was chosen, then the fifth

household on the walking line is the first you
should visit.
 Go to the first household and examine all
children aged 6–59 months in the household.
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Nutrition Intervention In Emergency

Disaster
Management
Actors at the
country level Host
Government

Target Bi-lateral
UN system donors
population
and other
Agencies
NGOs, Red Cross & other
A U S T R A L I A

civil society members 24

 Aims of Emergency Intervention
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 Aims at reduction of excess mortality that results

during the first few weeks to months. It involves
provision of :
 Food
 Shelter( if displaced)

 Program to control diarrheal diseases

 Epidemiological surveillance system

 Training of community health workers

 Curative care unit

 Coordination of operational partners
 The Normative Framework
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LEGAL

ETHICAL OTHER
STANDARDS

UNICEF 10
 1. Needs Assessment
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 Health priorities identified on the basis of rapid

collection and analysis of data

 Information collected on background of

displacement, risk factors, resources required etc.

 Use a guideline based on standards (e.g. the

SPHERE Standards)
 2. Water and Sanitation
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Water
 Drinking water is top priority

 Both quality and quantity are important

 During first days 20 litres per person per day is

required
 Poor and inadequate water is associated with
sanitation related diseases
 Continued
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Sanitation
 In the first days of the displacement:

 Emergency latrines for 50-100 persons

 Improve to 1 latrine for 20 persons

 Ideally 1 latrine per family.

 3. Food and Nutrition
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 Population movement both a cause and consequence of

food shortage
 Malnutrition is an important contributory cause of death
 Food distribution should be planned, effective and
equitable
 Energy needs-normal -25-30kcal/kg/d
 Increased needs-35kcal/kg/d in lactating, pregnant
 Protein need- 0.8gm/kg/d
 Increased needs-sepsis, surgery, burn…1-2.5gm/kg/d
 4. Shelter and Site Planning
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 Importance of shelter protection, security and

privacy
 Recommended 3.5 sq metre per person

 Appropriate shelter site

 Secure location away from border

 Availability of land and access to water

 Location should be socially and culturally

agreeable
 5. Health Care
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 Aims to reduce excess mortality in the emergency

phase of displacement
 Curative, preventive and rehabilitative care is crucial
 Manuals and guidelines should be available for
standardization of treatment
 Tier system of health care (hospital, health centre and
outreach services).
 Determine human resource needs, recruit and train
health workers
 6. Control of Communicable Diseases
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 Intervention Strategies
 Attack source of infection (e.g. curative care,
isolation etc)
 Prevent transmission (e.g. environment sanitation,
personal hygiene etc)
 Protect the susceptible (e.g. measles
immunisation, chemoprophylaxis, bed nets etc)
 Continuous surveillance to detect epidemics and
to assess effectiveness of interventions
 7.Co-ordination
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 Rationale: Many actors are usually involved

 Goal is to achieve greatest impact through
integration of activities.
 Establish clear leadership and co-ordination
 Ensure priorities are shared
 Rationalise services by establishing common
standards
 Ensure good communication among stakeholders
 Nutrition Interventions and Strategies
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 The selection of appropriate nutrition interventions

and strategies largely depends on the context.
 Consequently, a fixed intervention blueprint does
not exist.
 However, it is important that there are relatively
equal responses to nutrition emergencies in all
parts of the country, ie nutrition interventions must
be fair.
 Continued
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 To make responses fair, it is important to use the

classification of the severity of population MN rates.
 To chose the right intervention you need to consider:
 The prevalence of GAM and SAM, mortality rates,
coping mechanisms, seasonality & aggravating factors.
 The causes of malnutrition
 The population’s future needs
 What other on-going interventions already exist
 What resources are available and what constraints
exist.
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 Types of Nutrition Interventions
General Food Distribution(GFD)
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 The aim of GFD is to cover the immediate basic food

needs of a population in order to eliminate the need
for survival strategies
 which may result in long-term negative consequences
to human dignity, household viability, livelihood
security and the environment.
 Ideally a standard general ration is provided in order
to satisfy the full nutritional needs of the affected
population.
 The general ration should be calculated in such a
manner as to meet the population’s minimum energy,
protein, fat and micronutrient requirements for light
physical activity.
 The Modes of Food Distribution
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1.General Ration Distribution- It can be as in

 Employment generation schemes (EGS)
 Gratuitous relief (GR) /general [free] food
distribution (GFD).
 Due to the fact that food aid dependency is a
major concern in Ethiopia
 80% of the food aid is distributed through EGS,
especially in areas that are chronically food
insecure.
 Continued
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2. Selective Feeding Programs

 Health care systems and water resources may also

require support.
 In a famine situation, the primary goal is to ensure
survival, to reduce mortality.
 Continued
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 Targeted Supplementary Feeding Programs -

where supplementary food is restricted to only
those individuals identified as the most
malnourished or
 Most nutritionally vulnerable/at risk during
nutritional emergencies (includes pregnant women,
lactating mothers and young children < 5 years).
 The main objective of a Targeted SFP is to prevent
the moderately malnourished from becoming
severely malnourished and consequently, reduce
the prevalence of SAM and associated mortality.
 Continued
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 Blanket Supplementary Feeding Programs -

where supplementary food is distributed as a
temporary measure to all vulnerable members
of a population at-risk of becoming
malnourished without identifying the most
malnourished.
 The general objective of a blanket SFP is to
prevent widespread malnutrition and mortality.
 Continued
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 Therapeustic Feeding Program- provide a rehabilitative

diet together with medical treatment for diseases and
complications associated with the presence of severe
acute malnutrition.
 The specific aim of TFPs is to reduce mortality among
acutely severely malnourished individuals and to restore
health through rehabilitating them.
 TFPs may be administered through the following venues:
 Therapeutic Feeding Center (TFC)
 Nutrition Rehabilitation Unit (NRU) at a hospital or
health facility
 Community-Based Therapeutic Care (CTC/OTP)
 Example of Recommended Ration(Full Basket)
(Source: Ethiopian Emergency Nutrition Assessment Guideline)
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 Monitoring of General Ration Distributions

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 Continued
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 Anthropometric data can be used to monitor

and evaluate nutrition interventions,
 However , the other non-anthropometric data is

also required.
 Monitoring and Evaluation of GFD
Interventions
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A good monitoring system should determine:

 Appropriate targeting: Whether the decision to target
food within a certain geographical area is appropriate.
 Verify if the most vulnerable received the food aid:
Whether the groups in greatest need were identified in the
assessment and received the food aid.
 Realistic objectives: Whether the objectives of the GFD
were achievable and realistic. Monitoring should ensure
that food effectively reaches intended beneficiaries in the
agreed quantities and measure its impact on food security
and nutrition.
 Allows review of the system itself
Who are most nutritionally vulnerable in emergency
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 The population groups most nutritionally

vulnerable in emergencies can be categorised
according to their:
 Physiological vulnerability

 Geographical vulnerability

 Political vulnerability

 Internal displacement and refugee status

 Who are the Vulnerable/Marginalized People?
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 Children
 Females
 OVC
 Disabled
 Elderly
 Poor
 Pregnant and lactating
 People in remote areas and Pastoralists
 Shifting From Emergency Response To
Development Approach
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 There is a critical need to shift from project-

driven approach to a systems approach that
addresses the root causes of development failure.
 There was broad agreement that livelihoods
approach might best help use resources during an
emergency to move away from a food-first
approach toward a broad, more complex
definition of famine, emphasizing a multi-sectoral
approach to drive an earlier and more
appropriate response.
The Six Principles Central To Livelihood Strategies In
Crisis Response
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1) Rigorous assessment
2) Appropriate market support
3) Protecting essential assets
4) Easing vulnerable peoples ’ burdens
5)Timely interventions
6)Increasing protection for populations at risk of
displacement.
 These principles can guide the need for a shift from
a project-driven approach to a systems response
that addresses the underlying causes of famine.
 Interventions Should Target The
Different Layers Of Causes
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 Interventions and assessments at different
levels should be aligned
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 Examples of FNS indicators at different
levels
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 Examples of FNS data sources to assess the
FNS situation at different levels
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 Examples of FNS intervention at
different levels
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 Evolution of responses to Food insecurity
(Ethiopian Experience)
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 Social Protection
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 The change Model Food and Nutrition Policy

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 Long Term Strategies
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Poverty Economic
Reduction Growth

Improved Social
Increased Child Sector
productivity Nutrition Investments
Enhanced
Human
Resource
 Implementation #1
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 Strategies to reduce malnutrition should

I. Be implemented at different levels
 Households
 Community
 Regional
 National
 International
 Implementation #2
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II. Combine different approaches

 Bottom up – Triple A Cycle

 Top-down

 Supplementation programs
 Fortification
 Food relief programs
 Implementation #3
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III. Involve those communities who were

directly affected in
 Needs assessment

 Planning

 Implementation

 Monitoring and evaluation

*This fosters :Self reliance and Mobilization of

local resources
 Implementation #4
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IV. Be fully integrated

 Strategies that tackle only immediate causes
of malnutrition need to be:
 Repeated often to have sustainable effect

 Enhanced by activities which address the

underlying or basic cause of malnutrition

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