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Over 16 million children under the age of 3 are afflicted by severe acute malnutrition, a condition that increases their chance of dying nine-fold. SAM, as the condition is known, manifests as a child who is severely underweight for her height and who exhibits edema, a swelling of the feet and sometimes limbs, arms, and face. Children afflicted by SAM have trouble developing both physically and cognitively. They are also more susceptible to other childhood illnesses, like diarrhea and pneumonia.
So how can we prevent the onset of SAM?
That’s a tricky question to answer. UNICEF describes SAM prevention as such:
Ending acute malnutrition is a complex social and political challenge. Prevention and long term solutions involve dismantling unequal power structures, improving equitable access to health services and nutritious foods, promoting breastfeeding and optimal infant and young child feeding practices, improving water and sanitation, and planning for cyclic food shortages and emergencies.
Prevention isn’t as simple as a giving a vaccine or sleeping under a mosquito net. It requires action from a range of people, like caregivers of children to community health workers to economic policymakers. We know that what children eat, their hygiene, their birth weight, and a variety of other factors are associated with their risk of SAM, but we have no clear evidence on which prevention interventions work. It can feel paralyzing to take on such a daunting challenge.
Last year, the Airbel Center was tasked by the Children’s Investment Fund Foundation (CIFF) to explore different approaches to prevention. Current prevention efforts range from breastfeeding exclusively to multi-pronged approaches that include a dizzying number of interventions like home gardens, cash transfers, and feeding practices all together. The former approach risks not addressing enough factors while the latter risks inefficiency.
Since the evidence base alone doesn’t provide sufficient direction, the Airbel team went in search of inspiration from families most at risk of SAM in Liberia and Tanzania. Here’s a recap of what stood out to us:
Women everywhere could recite best practices for children’s health
We found women everywhere who could rattle off “exclusive breastfeeding for 6 months, having good hygiene, and ‘loving your child as yourself.’ ” This doesn’t mean the messages are relevant. For example, along the Liberia-Guinea border, women’s farming plots are in the forest and the terrain is rough. Women leave their babies at home when they go into the fields. They face the same challenges in breastfeeding as women everywhere but they don’t have the option to pump their breast milk. As a result, women may know the benefit of exclusive breastfeeding but face financial pressure to cultivate their gardens instead.
The takeaway: Unless we recognize and design for the economic pressures that families at risk of SAM face, our messages won’t be relevant.
Caregivers are investing in growing healthy children but their investments aren’t always sound
“How do white people grow their children so big?” we were asked by 2 women in villages 5 hours apart. We encountered some families who fed their babies rice milk when they couldn’t breastfeed. Others sacrificed to feed children coconut water. In one particularly humble village, parents who fed their children potato greens — a great source of nutrition — felt shame: potato greens are considered a last resort food of poor people.
The takeaway: If we don’t provide the next best options for best practices, caregivers may expend their limited resources on poor investments.
Vulnerable households have little economic cushion to try new things
The families we encountered in Liberia and Tanzania are smallholder, subsistence farmers, meaning that they consume much of what they grow and have little ability to save their crop until market prices are favorable. What surprised me is how much of these farmer’s hard-won crop is lost during storage in their homes or in open sheds. This loss is due to rodents, insect infestation, and/or fungal contamination. For grains (sorghum, millet, maize, rice) and legumes (cowpeas, peanuts), famers can lose 15–33% of their crop to poor storage. To make matters worse, the fungal infestation from crops that weren’t dried well before storage can grow fungus that produce mycotoxins harmful to children’s health.
The takeaway: Reducing post-harvest loss is one approach to increasing household income that would allow households to be more financially stable and absorb more risk.
Using these observations combined with input from experts in food security and nutrition and with the support of CIFF, Airbel is designing a prototype that builds on 3 components:
- Positive Practices: Identify and promote existing practices in communities, like hand washing and diversifying the foods children eat, that are associated with SAM prevention then introduce new ones to fill gaps and provide households with options.
- Post-Harvest Loss: Offer an alternative to current storage practices that better protects against losses of crops from rodents, insects, and fungus; and that may generate revenue.
- Cash: Provide unconditional cash to pregnant women and caregivers of children under 3 years to facilitate the uptake of new behaviors, like eating (rather than selling) eggs or buying soap. As well as, coupling cash transfers with behaviorally messages around caregiver identities and/or motivations.
We’ll be running a prototype in southern Niger to better shape these 3 components alongside our Niger-based colleagues and the communities we will be serving. The prototype will be run in 3 communities that will each receive a different treatment:
- Community A — Unconditional Cash Transfers
- Community B — Positive Practices (behavioral intervention) + Unconditional Cash
- Community C — Post-Harvest Loss (communal warehouse) + Positive Practices + Unconditional Cash
Over the next few days, we’ll detail how we plan to design each prototype, and we want your feedback! Leave a comment below or email us at firstname.lastname@example.org.