A Relational Approach to the Drivers of Child Acute Malnutrition.

BACKGROUND: This article presents a new analytical approach to acute malnutrition causal analysis that is different from the orthodox approach in 2 respects. First, it engages with basic causes, that is, beyond the usual focus on individuals and households. Second, it uses a relational view in the causal analysis. The orthodox approach identifies the malnourished and their individual and household characteristics. In contrast, a relational approach explores the ways in which the relationships between people, their livelihoods, and the environment, mediated by systems and institutions, create the underlying drivers associated with acute malnutrition for some, while simultaneously creating better conditions for others. METHODS: The article draws on 2 case study communities in West Darfur, Sudan, first considering the Darfur context and the inequitable policies and weakened institutions that have led to ethnic polarization, multilayered conflict, and humanitarian crises. The article explores how this context has played out differently in each community, contrasting their livelihood specializations, conflict-related losses, and livelihood diversification over time. FINDINGS: This analysis shows how the relative vulnerability of some people versus others is strongly influenced by their social, economic, and political relationships, as reflected in their shifting power relations and uneven control over livelihood resources. CONCLUSIONS: Shifting the focus to the basic drivers, especially the institutional structures, processes, and relationships, will deepen the causal analysis of child acute malnutrition, make it more meaningful, and provide a new direction for engagement, learning, and action to address the deepening problem of child acute malnutrition.

Plain language titleA Relational Approach to the Drivers of Acute MalnutritionPlain language summaryThis article introduces a new approach to understanding the causes of child acute malnutrition that differs from the traditional methods in 2 key ways. First, it goes beyond focusing solely on individuals and households by examining the underlying and basic causes. Secondly, it adopts a relational perspective in analyzing the causes. The traditional approach to studying the causes of acute malnutrition identifies malnourished individuals and examines their personal and household characteristics. In contrast, the relational approach looks at how the connections between people, their livelihoods, and the environment, influenced by systems and institutions, contribute to the development of acute malnutrition while also creating better conditions for some others. To illustrate this approach, the article presents findings from 2 communities in West Darfur, Sudan. It examines the Darfur context, including the policy and institutional context that has contributed to ethnic polarization and multiple conflicts and led to humanitarian crises. The article compares these 2 communities, focusing on their livelihood specializations, losses related to conflict, and changes in livelihood strategies over time. The article argues that by concentrating on the basic drivers of acute malnutrition, particularly the institutional structures, processes, and relationships, we can gain a deeper understanding of the issue. This approach can make the analysis of child acute malnutrition more meaningful and provide new insights for addressing this pressing problem.

The Livestock for Health Study: A Field Trial on Livestock Interventions to Prevent Acute Malnutrition Among Women and Children in Pastoralist Communities in Northern Kenya.

BACKGROUND: Livestock-dependent communities in Africa's drylands disproportionately experience acute malnutrition, especially during drought seasons. We detail the design and implementation of the Livestock for Health (L4H) study aimed at determining the effect of providing livestock feed and nutritional counselling to prevent seasonal spikes of acute malnutrition. METHODS: The L4H study employed a 3-arm cluster randomized controlled trial to compare households in pastoralist settings in northern Kenya receiving livestock feeds during critical dry periods, with or without nutritional counseling, with control households. Over 4 dry seasons, 2019 to 2021, the study collected data on household milk production, consumption patterns, mothers'/children's nutritional status, household socioeconomic status, herd dynamics, and human and animal health status every 6 weeks. RESULTS: L4H recruited 1734 households, with 639, 585, and 510 households assigned to intervention arms 1 and 2 and control arm 3, respectively. From these households, 1734 women and 1748 children younger than 3 years were recruited. In total, 19 419 household visits were completed, obtaining anthropometric measures 9 times on average for each child and mother. Eighty-one households (5%) were lost from the study due to the mother's death, child's death, migration, and withdrawal for other reasons. DISCUSSION: L4H's success in a challenging environment was possible due to strong community engagement, formative studies to inform trial design, collaboration with local authorities, and effective interdisciplinary collaboration. Subsequent manuscripts will report the study findings. TRIAL REGISTRATION: The study was registered October 29, 2020, and is online at ClinicalTrials.gov (ID: NCT04608656).

Community Clustering of Food Insecurity and Malnutrition Associated With Systemic Drivers in Chad.

BACKGROUND: Chad suffers from protracted hunger, facing high food insecurity (Integrated Food Security Phase Classification 3 and above), and acute malnutrition levels that surpass the emergency threshold (15% global acute malnutrition) yearly. The Food Security Sector, with European Union support, leads an inclusive effort to increase synergy between humanitarian, development, and peace-building actors to understand and address drivers of hunger. OBJECTIVE: To understand the spatial distribution of child wasting and household food insecurity and systemic drivers (conflict, livelihoods, vegetation, cultural norms) as well as better understand the relationship between child wasting and household food insecurity in Kanem and Bahr el Ghazal (BeG) region, Chad, with the goal of improving nexus programming and targeting. METHODS: A cross-sectional randomized cluster survey was conducted in August 2021 in Kanem and BeG across 86 villages, reaching 7002 households and 6136 children. Data were collected on child anthropometry, household food security, and livelihoods. Using mixed methods, primary data were triangulated with secondary geospatial data on vegetation index and conflicts as well as qualitative interviews with local actors. Analysis was conducted using comparison tests, linear and logistic crude, and adjusted models, as well as looking at the design effect as a measure of clustering of outcomes at the community level. RESULTS: The geospatial distribution of hunger indicators shows child wasting and food insecurity are highly clustered. However, communities with a high prevalence of child wasting were not those with the highest levels of food insecurity, indicating different pathways. Clustering of food insecurity and child wasting is due to basic drivers of conflict, health, and seasonal access to natural resources. CONCLUSIONS: The high levels of food insecurity and child wasting are each concentrated in specific survey clusters and are not necessarily connected. They result from different causal pathways at the community level linked to the systemic drivers of the rule of access to natural resources, environmental seasonality, and livelihoods. This suggests a greater need for an integrated humanitarian, development, and peace-building interventions to address the persistent high prevalence of food insecurity and child wasting. It also suggests that these community-level and systemic drivers require greater consideration from the start in research design and data collection.

Plain language titleUnderstanding Linkages Between Household Food Insecurity, Child Malnutrition, and Their Respective Clustered Drivers in ChadPlain language summaryChad experiences emergency levels of household food insecurity and child malnutrition. To address this issue, the United Nations Food and Agricultural Organization has undertaken a collaborative effort to enhance cooperation among humanitarian, development, and peace-building actors. The objective of this study was to examine how child malnutrition, food insecurity, and their drivers cluster across communities in Kanem and Bahr El Ghazal to improve response planning and targeting. The study collected data in August 2021 on malnutrition, food security, livelihoods, vegetation, and conflict and carried out interviews with local informants. In total, the research covers 86 villages, 7,002 households, and 6,136 children. The research shows that the 2 measures of hunger, child malnutrition and food insecurity, are highly clustered, affecting some communities more than others. However, villages with a high prevalence of child acute malnutrition did not have the highest levels of food insecurity, suggesting different community-level drivers. The clustering of food insecurity and malnutrition at the village level was linked to the diversity of livelihoods, the experience of conflict, health, and seasonal limitations in accessing natural resources. These findings are crucial for informing the targeting and design of integrated humanitarian, development, and peace programs. Taking a systemic approach and fostering strong coordination across interventions to address the drivers of food insecurity and malnutrition holds great potential for tackling hunger in Chad.

The impact of livestock interventions on nutritional outcomes of children younger than 5 years old and women in Africa: a systematic review and meta-analysis.

Background: Nutrition-sensitive livestock interventions have the potential to improve the nutrition of communities that are dependent on livestock for their livelihoods by increasing the availability and access to animal-source foods. These interventions can also boost household income, improving purchasing power for other foods, as well as enhance determinants of health. However, there is a lack of synthesized empirical evidence of the impact and effect of livestock interventions on diets and human nutritional status in Africa. Objective: To review evidence of the effectiveness of nutrition-sensitive livestock interventions in improving diets and nutritional status in children younger than 5 years old and in pregnant and lactating women. Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of published studies reporting on the effect of livestock interventions on maternal and child nutrition in Africa. Data were extracted, synthesized, and summarized qualitatively. Key outcomes were presented in summary tables alongside a narrative summary. Estimation of pooled effects was undertaken for experimental studies with nutritional outcomes of consumption of animal-source foods (ASFs) and minimum dietary diversity (MDD). Fixed effects regression models and pooled effect sizes were computed and reported as odds ratios (ORs) together with their 95% confidence intervals (CI). Results: After the screening, 29 research papers were included in the review, and of these, only 4 were included in the meta-analysis. We found that nutrition-sensitive livestock interventions have a significant positive impact on the consumption of ASFs for children < 5 years (OR = 5.39; 95% CI: 4.43-6.56) and on the likelihood of meeting minimum dietary diversity (OR = 1.89; 95% CI: 1.51-2.37). Additionally, the impact of livestock interventions on stunting, wasting, and being underweight varied depending on the type of intervention and duration of the program/intervention implementation. Therefore, because of this heterogeneity in reporting metrics, the pooled estimates could not be computed. Conclusion: Nutrition-sensitive livestock interventions showed a positive effect in increasing the consumption of ASFs, leading to improved dietary diversity. However, the quality of the evidence is low, and therefore, more randomized controlled studies with consistent and similar reporting metrics are needed to increase the evidence base on how nutrition-sensitive livestock interventions affect child growth outcomes.