download - World Vision's Nutrition Centre of Expertise

ENU
EMERGENCY NUTRITION UPDATE
In the Spotlight
Mental Health and
Psychosocial Support
in Emergency Nutrition
Programmes
April – September 2012 ISSUE 14
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
Photo by Muhammad Ali/World Vision
1

ENU SPOTLIGHT
Mental Health and
Psychosocial Support
(MHPSS)
Incorporating MHPSS Considerations within Nutrition
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.
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).
Lack of
nutritious food
Malnutrition
Severe food
shortage
Poor health
Insufficient
care/stimulation
Psychosocial
deprivation
Submitted by Megan
McGrath, Mental Health
and Psychosocial Support
Coordinator, Humanitarian
and Emergency Affairs, World
Vision Australia
Developmental delays/mental health problems
Source: WHO, Mental health and psychosocial well-being among children in severe food shortage, 2007.
2

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 nonstunted
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; 175:554–558
Inter-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 growthstunted
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
3

Incorporating
MHPSS
Considerations
within Nutrition
Programmes
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 childcaregive
interactions are important
in order to facilitate children’s
emotional, social and language
development.
Educate caregivers on the
importance of emotional
communication.
Physical Stimulation:
Children need a physically
stimulating environment in order
to develop their psychomotor
and language skills and to enhance
cognitive development.
Express warmth and affection to the
child in a manner consistent with
cultural norms
Encourage verbal and non-verbal
communication between the child
and caregiver
Respond to the needs of the child
Show appreciation for what the child
manages to do
Ensure that the environment
provides adequate sensory
experiences for the child
Provide play materials
Encourage caregivers to look into the child’s eyes and smile
at him or her, especially during breastfeeding. Express physical
affection to the child
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 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).
Provide verbal praise for the child’s accomplishments. Also, show
non-verbal signs of appreciation and approval (e.g. clapping,
smiling).
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.
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
Provide opportunities to practice
skills
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.
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.
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.
4

Women- and Infant-Friendly
Spaces (WAIFS) in Pakistan
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.
Challenges
Although WAIFS are transitional supports, contributing to the short- to mediumterm
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 forward
After 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
WAIFS
Women- 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.
5

NEWS FROM THE FIELD
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
Integrating Mental Health
and Psychosocial Support
into the Sahel Nutrition
and Refugee Crisis
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.
6

CMAM Update for FY12 (October 1, 2011–September 30, 2012)
Country
Chad
S. Sudan
Kenya
Ethiopia
Somalia
Niger
WCRC
Burundi
Mali
Pakistan
Sierra Leone
Mauritania*
Tonj South,
Tonj North and
Gogrial West
10 2
2 regions –
Punjab, Sindh
1 health
district
13 22 1 17 16 4
4
Project
areas / ADPs
covered
New projects
in Tonj East and
Gogrial East
OTP= 61
OTP=45
OTP=41
OTP=12
OTP= 16
OTP=45
OTP=15
SFP=60
OTP=6
SFP=31
SFP=21
NA NA
SFP=1
OTP=24 OTP=13
SFP= 167
SFP=37
SFPPLW=22
SC=86
SFPPLW=63
SC=1
SFPPLW=30
SFPPLW=4
Total number
of sites
SC=2
SFPPLW=142
SC=5
SFP=551
SC=4
SC=10
SC=7
OTP=10311
OTP= 1091
OTP= 6919
OTP=233
OTP=1637
OTP=442
OTP=7788
OTP=4057
SFP=25167
OTP=248***
SFP=7334
SFP=4978
OTP=2338
SC=86 SFP=551
Number
admitted
SFP=1019
SFP=4224
SFP=NA
SFP=29018
OTP=2176
OTP= 4393
SFP=11895
SFPPLW=5929
SFP= 9187
SFPPLW=17649
SC=7
SFPPLW=3718
SFPPLW=291
SC=2
SC=132
SC=NA
SC=113
SC=1306
SC=168
SC=562
SFPPLW=2346
SC=557
No RUTF stock
available March
to July
Oct1, 2011
to Sept 30,
2012
OTP=83.1%
SFP=95.4%
OTP=95.9%
SFP=98.9%
OTP=96%
SFPPLW=98.9%
SC=97.3%
OTP=89.6%
SFP=92.3%
OTP=82.8% 31.9%***
SFPPLW=99.2%
SC=87.6%
OTP=93.7%
SFP=97.2%
OTP=98.4%
OTP=93.4%
SC=89.7%
OTP=82.9%
SFP=86.8%
SFPPLW=82.4%
OTP=75.9%
SFP=89.8%
Recovered OTP=56.5%**
SFPPLW=83.7%
SC=78.6%
OTP=0%
OTP=0.6%
OTP=1.3%
OTP=0.6%
OTP=2.2%
SFP=0%
SFP=0%
OTP=

Research Updates
Cost-Effectiveness of CMAM by
Community Health Workers in
Southern Bangladesh
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 communitybased
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.
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.
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?
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
Severe acute malnutrition(SAM) (nonoedematous)
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.
8

Tools, Guidelines and Recommendations
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%20
DecisionTool%20July%202012%20
with%20Cover.pdf
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/
New SMART
website launched in
English, French and Spanish
SMART (Standardized Monitoring and Assessment of Relief and Transitions) is an interagency
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/
9

Research and Global Participation
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
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.
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
Global Health & WASH
Nutrition Centre of Expertise
WE ARE ALWAYS
LOOKING
for 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/
activities
Best part of your job/working in
emergencies
When you’re not working, what
do you enjoy doing?
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.
10