a study on integrating nutrition into multisectoral
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A Study on Integrating Nutrition into Multisectoral Programming in
Somalia: Best Practices and Opportunities
Submitted to
National Office of Scaling-Up
Nutrition
Office of Prime Minister
Federal Government of
Somalia
Consultants
Dr. Leila Abdullahi
Dr. Florence Kyallo
Mr. Gilbert Rithaa
December 2020
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TABLE OF CONTENT
TABLE OF CONTENT ...................................................................................... i
LIST OF FIGURES ........................................................................................ ii
ACRONYMS AND ABBREVIATIONS .................................................................. iii
FORWARD .................................................................................................. v
ACKNOWLEDGEMENTS ................................................................................ vii
EXECUTIVE SUMMARY ................................................................................ viii
1 INTRODUCTION ..................................................................................... 1
1.1 Nutrition integration in Somalia .......................................................... 1
1.2 Rationale for study ........................................................................... 4
1.3 Goal ............................................................................................... 5
2 APPROACH AND METHODS ...................................................................... 6
2.1 Data collection ................................................................................. 6
2.2 Data analysis ................................................................................... 7
3 FIELD CHALLENGES ............................................................................... 8
4 KEY FINDINGS ...................................................................................... 9
4.1 Policy framework for nutrition integration in Somalia ............................ 10
4.2 Platforms for the integration of nutrition into multi-sectoral programming 11
4.2.1 Integrated nutrition interventions/activities in health ...................... 13
4.2.2 Integrated nutrition interventions/activities in agriculture and
livelihoods .......................................................................................... 14
4.2.3 Integrated nutrition interventions/activities in WASH ...................... 15
4.2.4 Integration of nutrition and education ........................................... 16
4.2.5 Integration of nutrition and social protection.................................. 16
4.2.6 Integration across several sectors: Health, WASH, agriculture, nutrition,
and social protection ............................................................................ 16
4.3 Enablers of nutrition Integration ....................................................... 17
4.3.1 Broad context:.......................................................................... 18
4.3.2 Understanding of the nature and magnitude of the undernutrition
problem in Somalia .............................................................................. 18
4.3.3 Interventions ............................................................................ 19
4.3.4 External support ....................................................................... 19
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4.3.5 Adoption system ....................................................................... 20
4.3.6 Health system characteristics ...................................................... 20
4.4 Bottlenecks to nutrition integration .................................................... 20
4.4.1 Broad context ........................................................................... 20
4.4.2 Intervention context .................................................................. 21
4.4.3 Adoption system: ...................................................................... 21
4.4.4 Systemic characteristics ............................................................. 22
4.5 Opportunities for nutrition integration ................................................ 23
4.6 Best practices ................................................................................ 24
5 CONCLUSION ...................................................................................... 26
6 RECOMMENDATIONS ............................................................................ 27
ANNEXES ................................................................................................. 30
ANNEX 1: SYSTEMATIC REVIEW................................................................ 30
ANNEX 2: KEY INFORMANT GUIDE ............................................................ 71
ANNEX 3: KEY INFORMANT ORGANIZATIONS .............................................. 74
LIST OF FIGURES
Figure 1: Framework for action to achieve optimum fetal and child nutrition and
development .............................................................................................. 3
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ACRONYMS AND ABBREVIATIONS
BNSP Basic Nutrition Service Package
BRCiS Building Resilient Communities in Somalia
CBFHWs Community Based Female Health Workers
CMAM Community Management of Malnutrition
COE Centre of Excellence
CSO Civil Society Organizations
ECD Early Childhood Development
EPHS Essential Package for Health Services
FAO Food and Agricultural Organization
FGS Federal Government of Somalia
FSNAU Food Security and Nutrition Analysis Unit
FS&N Food Security and Nutrition
GAM Global Acute Malnutrition
HMIS Health Management Information System
ICCM Integrated Community Case Management
IMAM Integrated Management of Malnutrition
IMCI Integrated Management of Childhood Illnesses
INGO International Non-Governmental Organization
IYCF Infant and Young Child Feeding
KII Key Informant Interview
MAM Moderate Acute Malnutrition
M&E Monitoring and Evaluation
MIYCF Maternal Infant and Young Child Feeding
MOH Ministry of Health
MOLSA Ministry of Labor and Social Affairs
MSP Multi-sectoral Platform
NDP National Develop Plan
NGO Non-Governmental Organization
NSU National Somalia University
PLW Pregnant and Lactating Woman
SAM Severe Acute Malnutrition
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SBCC Behavior Change Communication
SC Stabilization Centre
SDG Sustainable Development Goal
SUN Scaling Up Nutrition
SUN UN Scaling Up Nutrition-United Nations
SUN-FP Scaling Up Nutrition -Focal Person
UN United Nations
UNICEF United Nations Children Fund
WASH Water Hygiene and Sanitation
WHO World Health Organization
WFP World Food Program
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FORWARD
Optimal nutrition is fundamental to ending extreme poverty and to promote
resilient, democratic societies while advancing national prosperity. Achieving the
Sustainable Development Goal (SDG), goal 2.2 of reducing malnutrition in all its
forms necessitates a multi-sectoral approach to addressing the causes of
malnutrition. Malnutrition in Somalia is very high, with children and women
(especially at reproductive age), most affected. Efforts to combat malnutrition are
curtailed by frequent natural and man-made disasters, which make government and
partners shift focus increasing the investment on humanitarian interventions
prioritizing saving lives and not improving nutrition.
There is increasing consensus that effective nutrition interventions must reach
across sectors to address the multi-factorial determinants of malnutrition. Political
commitment and efforts to mainstream nutrition in all sectors are gaining
momentum. Somalia has made great investments in developing the policy
infrastructure that supports evidence-based multi-sectoral and sectoral nutrition
policies. In 2014, the Federal Republic of Somalia joined the SUN Movement. Several
line ministries are involved in nutrition, including the Ministry of Labor and Social
Services, Ministry of Agriculture, Ministry of Education, and Ministry of Health. The
line sectors of food security, water hygiene, and sanitation (WASH) and nutrition are
well articulated under Pillar seven of the National Development Plan (NDP) 2020-
2024. The NDP outlines strategies to strengthen several sectors that are key to
improving nutrition. Other policies include the Multi-sectoral nutrition strategy and
the Somalia Nutrition Strategy, among others.
Nutritionally vulnerable communities are usually also in need of WASH interventions,
social protection, improved schooling, women empowerment, and improved access
to food and health services. The findings of this study will help strengthen the
integration of nutrition into multi-sectoral programs in Somalia, by leveraging on the
strengths of each sector to combine efforts for improvement of nutrition outcomes.
Dr. Mohamed Abdi Farah
Special Adviser on Health and Nutrition National Coordinator for Scaling Up Nutrition
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Office of Prime Minister
Federal Government of Somalia
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ACKNOWLEDGEMENTS
This study was conducted under the guidance of SUN Coordination secretariat, Office
of the Prime Minister, Somalia led by Dr. Mohamed Abdi Farah and Dr. Mohamed Abdi
Hassan. The consultancy team consisted of Dr. Leila Abdullahi, Dr. Florence Kyallo,
and Gilbert Rithaa. The team is grateful to Clementina Ngina & Mohamed Abdimalik
for the contribution during the implementation of the study.
Special appreciation goes to all the field enumerators and to the participants of key
informant interviews for their valuable responses which have contributed to the
development of this report. The respondents were drawn from SUN Donor Network
(World Bank), BRCiS, SUN UN (UNICEF, WFP, and FAO), and SUN CSO (Action Against
Hunger, Save The Children, Norwegian Refugee Council, Concern Worldwide and
GREDOSOM).
Special thanks to UNICEF and WFP for their financial support to this study.
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EXECUTIVE SUMMARY
Introduction According to the Somalia Demographic Health Survey 2020, 28% of children below
five years are stunted, with regional disparity ranging from 12.3% in Somaliland to
38.9% in South West1. More than 40% of women and children are anemic. Over 26%
of women have iron deficiency anemia, while 34% of children and 11% of women are
vitamin A deficient2. The FSNAU-FEWSNET Post Gu report September 2020 reported
the prevalence of Global Acute Malnutrition (GAM) as Serious (10–14.9%). The
contributing factors to the high prevalence of acute malnutrition in Somalia include
high morbidity, low immunization, and vitamin-A supplementation, poor infant and
childcare practices, and food insecurity3. The non-affordability of a nutritious diet by
a majority of the population has serious consequences on the health and nutrition
status of children and women. A recent fill the nutrient gap analysis (FNG 2019)
showed the eight out of 10 households do not have access to a nutritious diet in
Somalia. The cost of a nutritious diet is four times higher than that of an energy-only
diet4. Malnutrition is both a cause and consequence of poverty. It is multi-causal
and multifaceted and eliminating it can only be through multi-sectoral efforts which
include the integration of nutrition-specific and nutrition-sensitive interventions with
other sectors. This study investigated the integration of nutrition with health,
agriculture, education, social protection, and water sanitation and hygiene (WASH).
Women empowerment was a cross-cutting issue. The study was conducted between
September and October 2020 using a mixed-methods approach comprising of a
systematic review and Key Informant Interviews (KIIs) with stakeholders in the
nutrition sector and other sectors in Somalia.
Rationale Integration of nutrition interventions aims to accelerate and scale-up efforts towards
the elimination of malnutrition as a problem of public health significance, focusing on
nutrition outcomes and commitments. There is increasing consensus that effective
nutrition interventions must reach across sectors to address the multi-factorial
1 SKDHS 2020 2 Ministry of Health FGS, FMS, Somaliland, UNICEF, Brandpro, Ground Work. Somalia
Micronutrient Survey 2019. Mogadishu, Somalia; 2020 3 FSNAU-FEWSNET, September 2020 4 Fill the nutrient gap analysis, cost of diet, SUN, office of Prime minister and WFP, Somalia, 2019
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determinants of malnutrition. In the past, many nutrition initiatives have been
vertical programs implemented through isolated delivery systems. However, there
has been a recent recognition that multi-factorial causation is best addressed with
multi-sectoral interventions including gender equality and empowerment of women,
being critical in achieving nutrition objectives. There is limited local evidence in
Somalia to inform local programming priorities within the multi-sectoral perspectives,
thus, there is a pressing need to ensure that nutrition programming provides value
for money, by optimizing available resources. This requires strong evidence on
successes and best practices that can be used to improve and strengthen multi-
sectoral programming in Somalia. To tackle the immediate and underlying
determinants of malnutrition, it is fundamental to continually generate, share, and
adopt evidence on best practices and successes in nutrition programming.
Purpose
The goal of the study was to generate evidence on integration models, best practices,
drivers, and opportunities for improvement to inform learning for multi-sectoral
programming for integrated nutrition interventions. Specifically, the study aimed:
i. To synthesize evidence on nutrition program integration models adopted
globally and their feasibility in the Somalia context.
ii. To synthesize and document evidence on best practices/successes in
integration of nutrition‐specific and nutrition-sensitive interventions in
Somalia.
iii. To identify internal and external drivers, bottlenecks, and opportunities
for effective integration of nutrition interventions in other sectors in
Somalia.
iv. To provide contextual or feasible recommendations for strengthening the
successful integration of nutrition-specific and sensitive interventions in
Somalia.
Methodology This study used a mixed-methods approach, involving the collection of both primary
and secondary data. Data was collected between 24th September 2020 and 22nd
October 2020, while secondary data was collected through a systematic review
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(Annex 1). A systematic literature search was conducted in both published and grey
resources, and integrated nutrition interventions into multi-sectoral
programmes were examined. The Preferred Reporting Items for Systematic Review
and Meta-Analysis Protocols (PRISMA-P) 2015 checklist was utilized. Primary data
was collected through Key Informant Interviews (KIIs) with selected respondents
representing various stakeholders in Somalia. The key informants were identified
through a consultative process through the Office of the Prime Minister
(OPM). Interviews were conducted virtually and face to face using a Key Informant
Interview Guide (Annex 2). The guide consisted of thematic and open-ended key
questions.
Key Findings
Integration of nutrition into multi-sectoral programming: current status in
Somalia and other fragile contexts.
Integration of nutrition and health: From the Key Informant Interviews, the
nutrition-specific interventions that were integrated with health included: counseling
of mothers on exclusive breastfeeding for the first six months of life; continued
breastfeeding for up to two years or beyond and timely, safe, adequate and
appropriate complementary feeding; growth monitoring and promotion; vitamin A
supplementation; and screening, treatment, and referral of severe acute malnutrition
(SAM) and moderate acute malnutrition (MAM), Zinc supplementation and treatment
of diarrhea and deworming. Other nutrition interventions identified under health
included Integrated Management of Childhood Illnesses (IMCI) /Integrated
Community Case Management (ICCM) and immunization. In the area, where food
security is an issue preventive supplementary feeding for both children and pregnant
and lactating mothers linking with the health system promotes the utilization of the
health system and supports to improve maternal and child health and nutrition.
The findings of the systematic review showed that integrated health and nutrition
programs resulted in improved Infant and Young Child Feeding Practices (IYCF). They
showed a significant increase in enhanced exclusive breastfeeding practices among
children 0- 6 months, by 27%; enhanced complimentary feeding practices by 5%; a
significant three-fold improvement in the initiation of breastfeeding within the first
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one hour; and a 53% protective effect on underweight among children older than 2
years. Other benefits included significant improvements in health care seeking
behaviors, including increased uptake of antenatal and postnatal care, facility
delivery, and vaccination, compared to the non-integrated program.
Integration of nutrition in agriculture and livelihoods: The nutrition
interventions/activities integrated with agriculture and livelihood interventions
included the delivery of nutrition education to households with a focus on dietary
practices, food preparation, food selection, the nutritional content of different foods,
and household food budgeting, with special tailoring of the education package based
on whether the target communities were pastoralist, fishing, and agricultural
communities. Social Behavior Change Communication was also used, especially to
address cultural practices and promote the consumption of nutritious meals and
dietary diversification. Long-term solutions to malnutrition require the transformation
of the food system along food supply chains, in food environments, and across
consumer behavior patterns to facilitate healthier diet choices.
Provision of productive farm inputs such as seeds was combined with technical
training on production, food handling, food safety, storage, processing of the various
food products (crop, livestock, and fish) as well as preservation techniques. FSL also
conducts training for community members on the consumption of locally available
nutritious foods that supports the nutritional status of U5 children and women.
Integration of nutrition and WASH: The WASH activities that were integrated with
nutrition included the provision of handwashing facilities and clean water; hygiene
awareness creation in the outpatient therapeutic programme (OTP) and
supplementary feeding programme (SFP) for outpatient treatment of SAM and MAM;
as well as in stabilization centers (SC) for the treatment of SAM with complications.
WASH programs also contribute to hygiene kits like soap, Aquitab, and more others
for Nutrition programs. Other activities that were routinely combined were Vitamin A
supplementation, nutrition education, and awareness, deworming and community
health and hygiene promotion, often during outreach.
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Integration of nutrition and education: The integrated nutrition activities in
education included school feeding programmes in which pupils received a nutritious
meal, as well as nutrition education in form of messages, with a focus on good eating
habits and healthy diets. Despite the access to adolescent girls in schools, no specific
interventions were targeting them, presenting a major gap considering the critical
stage of life and consequences of inadequate nutrition on health nutrition outcomes
in subsequent generations.
Integration of nutrition and social protection: Most social protection
programmes in Somalia were implemented with a humanitarian lens and not a
nutrition lens. Households with children with SAM or MAM were referred to cash
transfer programmes. On the other hand, the rural safety net- unconditional cash
transfer targeted women and mothers of children aged below 5 years. Provision of
child-friendly spaces for the nutritional screening of children and referral within child
protection centers was also mentioned. There was no evidence of impact on nutrition
outcomes. However, from the systematic review, one study on integrated nutrition
and cash transfer programmes reported significantly higher SAM recovery, lower
MAM relapse, and lower SAM relapse5 (Annex 1).
Integration across several sectors: Health, WASH, agriculture, nutrition,
and social protection
The systematic review conducted during the study period (Annex 1) showed that
multi-sectoral integration including hygiene, nutrition, clean delivery kits and
incentives, higher education level, and geographical contiguity to health facility were
associated with the increased use of maternal health services by pregnant women
and ultimate improvement of nutrition outcomes5. A good example is the
comprehensive package of assistance which included teachers' incentives, water,
sanitation, and hygiene (WASH), school meals among others, and was delivered
5 Fagerli, K., O'Connor, K., Kim, S., Kelley, M., Odhiambo, A., Faith, S., … Quick, R. (2017). Impact of
the integration of water treatment, hygiene, nutrition, and clean delivery interventions on maternal health service use. The American Journal of Tropical Medicine and Hygiene, 96(5), 1253–1260. https://doi.org/10.4269/ajtmh.16‐0709
xiii
through a partnership of more than one organization. The package targeted the same
schools in Gedo and Banadir.
Enablers of nutrition integration into multi-sectoral programming
The integration of nutrition into multi-sectoral interventions provides stronger
impacts on nutritional and non-nutritional outcomes as opposed to single
interventions. The main enablers of integration were classified as follows:
i. Broad context: This included political readiness, interest, support and
progress monitoring for resilience and development initiatives; availability of
highly educated personnel within the FGS; the universities in Somalia are also
training qualified nutrition professionals; access to a productive pool of young
people (less than30 years) who present the potential for unexplored knowledge
pathways; a vibrant media and private sector; increased goodwill and
willingness from communities.
ii. Policy environment: The Somalia government has made great strides in its
commitment to improving the nutritional status of the population, achieving
the SDGs and the World Health Assembly (WHA) global targets. The policy
environment in Somalia is conducive to the implementation of interventions
within nutrition and other related sectors at national and state levels. These
policies include the National Development Plan (NDP) 202-2024, the Somalia
Nutrition Strategy (SNS) 2020-2025, Somalia multi-sectoral nutrition strategy
and Common results framework for nutrition 2019-2014, Social mobilization
advocacy and communication strategy (SMAC)-2019-2021 and Somali
national micronutrient deficiency control strategy (2014–2016), Somalia
Social Protection Policy, Somalia Micronutrient deficiency control strategy,
among others.
iii. Knowledge sharing: The readily available data from the numerous studies
on the nutrition situation in Somalia, especially from FSNAU reports, provides
an opportunity for sectors to understand the nature and magnitude of the
undernutrition problem in Somalia and the indisputable role of complementary
sectors.
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iv. Interventions: There are notable clinical, organizational, and management
capacities in successful implementation sites, especially community
participation. The presence of Community Health Committees (CHCs) and
community champions is critical for ownership and sustainability of programme
interventions
v. External support: There is increased interest and goodwill by stakeholders,
and this is likely to result in more donors funding integrated programmes as
opposed to sectoral programmes. Consortia also present platforms for
discussions on joint funding, implementation, successes, and challenges of
integrated programmes, with the strong nutrition cluster being a source of
knowledge sharing.
vi. Adoption system: This includes compatibility of personal, professional, and
institutional goals, values and principles, collaborative support, engagement,
and involvement, learning, and career development opportunities, and support
for problem-solving.
Bottlenecks to nutrition integration The main bottlenecks to the integration of nutrition in multi-sectoral programming
include:
i. Broad context: Different line Ministries, sectors and clusters operate in
silos, with no discussions on integration. Lack of inter-sectoral coordination
and sectoral goals override nutrition goals. Limited understanding by most
stakeholders of the importance of nutrition integration into multi-sectors.
Other factors are linked to insecurity, which affects accessibility and reach
of needy beneficiaries; conflict of policies and the uncontrolled private food
markets including poor market regulation, leading to foods with little
nutrient value.
ii. Intervention context: There are clinical, organizational, and management
capacity gaps across the country and relevant government institutions. In
addition, funding is mainly sectoral, with no specific budget allocated to
implementation and monitoring of nutrition activities even when they are
mentioned in project documents. Inadequate data sharing and the
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humanitarian context of most interventions further undermine nutrition
integration. The concentration of partners in urban areas with little reach
in rural areas is also a challenge since rural areas have fewer potential
programmes for the integration of activities/services.
iii. Weak and inadequate resource, institutional and technical capacity to
implement and review multi-sectoral policy and strategy framework –
operationalization. There was also high staff turnover and attrition, limited
community and patient/caregiver involvement and empowerment, and
limited logistic capacity for bulky, expensive supplies. This presents missed
opportunities for learning and reflection on coordinated multi-sectoral
nutrition programming
iv. The clusters, sectors, and consortia work in silos with little or no
coordination with each other. Each focuses on achieving sectoral goals, yet
integration presents complementary benefits to all sectors. This leaves
some of the community needs unmet and sometimes leads to duplication
of activities.
v. Most projects are implemented as short term emergency projects as
opposed to long term developmental projects. Such projects receive
emergency funding, and the focus is on saving lives. Even where nutrition
could benefit, there was no integration at the project design level/phase.
vi. Multiple health information systems: Each sector has its Health information
system, which may be overburdening staff in an integrated programme
vii. Sociocultural practices that hinder the empowerment of women and their
participation in decision making in the household. These include widespread
and severe social and economic discrimination, gender-based violence, food
taboos for women and girls (especially pregnant and lactating women),
Female Genital Mutilation (FGM), early marriages, lack of birth spacing, and
high maternal mortality as highlighted in the Somalia Nutrition Strategy
2020-20256. The Strategy also identifies discriminatory Somalia customary
6 FGS, 2020. Somalia Nutrition Strategy 2020-2025
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law (Xeer) and religious law (sharia), as well as certain state legal systems
as being discriminatory against women.
viii. Limited investment in joint tracking, reflection, and learning on multi-
sectoral programming barriers, gaps, and best practices with a lens for
fragile context. There have been limited efforts in sustained nutrition
programming studies and learning for fragile contexts regionally and
globally, further hampering actors from drawing on winning interventions
and experiences.
ix. Lack of a standard guideline and curriculum on healthy diets, leading to
variations in nutrition training in institutions and messaging where nutrition
education is integrated.
x. Insecurity. Insecure regions are hardly reached by interventions and
services because of the high risk to staff.
Opportunities for nutrition integration Key opportunities for strengthening multi-sectoral nutrition integration include:
1. Stronger leadership and political will for nutrition integration from the
government. There has been enactment and progressive implementation of
the Somali National Development Plan (NDP) for 2019–2024, The Somali
Universal Health Coverage (UHC) Roadmap, (launched in September 2019)
where nutrition integration agenda and milestones are entrenched. The
nutrition budget across sectors has increased to over 3%.
2. Community involvement and goodwill are increasing, improving the conditions
for community consultations and the efforts to ensure that the most vulnerable
community members are reached.
3. Agriculture and livestock are identified in the NDP 2019-2024 among the major
contributors to the Somalia economy. Value addition of animal products also
presents an opportunity for the integration of nutrition to improve household
income and nutritional status. There is also the opportunity for modernization,
optimization, and value addition to agricultural products in the agricultural
regions of Somalia as outlined in the NDP.
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4. The presence of local NGOs provides an opportunity to reach poor households
and malnourished children in remote areas with multi-sectoral programming.
5. The most common nutrition-sensitive intervention with the widest coverage is
cash transfers, which can be used as an entry point for nutrition integration
into other sectors.
6. NGO consortia provide an opportunity for bringing together the different
sectors for joint planning, implementation, funding, monitoring of nutrition
integration. However, they are also perceived as barriers to integration given
that each consortium appears to ‘own’ and protect its activities.
7. The Somalia Partnership Forum (SPF) was identified in the NDP 2019-2024 as
a forum for inclusive political dialogue between the government of Somalia and
international partners at the highest level.
8. The academia provides an opportunity for the development and
implementation of a harmonized and integrated nutrition training curriculum
for Somalia.
Conclusions 1. Nutrition is integrated with various sectors including WASH, Health, social
protection, education, and agriculture, but nutrition indicators are not included
in the project designs and are therefore not monitored, and subsequently, data
on the impact on nutrition outcomes is lacking.
2. Funding for nutrition integration is limited and fragmented. Each sector
implements its activities and does not budget for implementation and
monitoring of integrated nutrition activities. In the absence of joint funding,
the nutritional needs of the community remain unmet.
3. The capacity for nutrition integration is low due to inadequate training for
different sector staff on nutrition integration.
4. Line ministries and agencies lack nutrition focal persons; therefore, nutrition
is not included in sectoral agenda.
5. Lack of coordination between clusters poses a challenge to nutrition integration
6. Sociocultural barriers exist in the implementation of nutrition-sensitive
interventions, especially those targeting women.
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7. Community participation is key to the integration of nutrition in multi-sectoral
programming, improves targeting of the most vulnerable, and increases
sustainability and ownership of interventions.
8. Food production or livelihood sector (Livestock, fishery, Agriculture) are not
well-reflected nutrition agenda.
Recommendations 1. The government should provide policy direction on nutrition integration, with
a clearly defined acceptable minimum for nutrition integration. While the
minimum nutrition integration package may vary from sector to sector,
promotion, and support for optimal IYCF and promotion and support for
optimal maternal nutrition and care should be included in all multi-sectoral
programming. In addition, all sectors should include clear nutrition objectives
and indicators in the programme design.
2. While treatment for malnourished, children is critical and immediate
interventions (MAM and SAM) are imminent, it is necessary to shift the focus
to longer-term preventive nutrition programmes integrating across various
sectors to build resilience and eventually build human capital through
harmonized capacity building and training of nutrition resource persons for
harmonized and standardized delivery of interventions
3. Identification and capacity building of a public institution into a Centre of
Excellence (CoE) for nutrition in Somalia. The CoE should be empowered to
provide leadership in addressing the multifaceted and multi-causal nutrition-
related challenges and gaps, showcase best practices while supporting training
and research for better nutrition service delivery across Multi-Stakeholder
Platforms (MSPs). The recommended institute is the University of Mogadishu.
4. The development of a harmonized nutrition curriculum and integration into the
education system in Primary, secondary and tertiary levels for capacity
building of programs on the MSP agenda.
5. Strengthening of Multi-sectoral integration at community and project level
should be considered from the design level, through increased and structured
community participation, with a focus on the first 1000 days of life including
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maternal nutrition. SUN-Somalia should take the lead in the development of a
joint action plan for nutrition integration by implementing partners, to guide
intervention priorities.
1
1 INTRODUCTION
1.1 Nutrition integration in Somalia
Optimal nutrition is fundamental to ending extreme poverty and to promote
resilient, democratic societies while advancing national prosperity. Malnutrition is
both a cause and consequence of poverty. It negatively affects all aspects of an
individual’s health and development and limits societies’ economic and social
development. It is also a multi-sectoral problem that requires concerted efforts from
all sectors to address it. Nutrition integration can be defined as the extent of adoption
and eventual assimilation of nutrition interventions into non-
nutrition programmes or interventions. Nutrition can be integrated into health,
agriculture, social protection, education, water, sanitation, and
hygiene programmes. Integration of nutrition-specific and sensitive interventions
seeks to address the triple burden of malnutrition characterized by the coexistence
of undernutrition as manifested by stunting, wasting, underweight, micronutrient
deficiencies, and overweight and obesity including diet-related non-communicable
diseases (DRNCD). All three forms of malnutrition occur within individuals,
households, and populations throughout the life course – pregnancy, lactation,
infancy, childhood, adolescence, adults, and older persons. Nutrition-specific
interventions and programmes address the immediate determinants of fetal and child
nutrition and development, while nutrition-sensitive interventions address the
underlying and basic causes of undernutrition which include poverty, scarcity of
access to adequate care resources, and to health, water, and sanitation services food
insecurity.
According to LANCET series 20137, 1 in five children suffer from chronic malnutrition
(stunted) and malnutrition is responsible for 45% of deaths of children aged below
five years. 32.4 million children are born Small for Gestational Age (SGA), 27% of
whom are in LMIC. At the same time, micronutrient deficiencies persist, especially
for Zinc, Vitamin A, iodine, iron, which affects child survival, growth, health, cognition,
development, and adult productivity. To achieve optimum fetal and child nutrition and
7 Black et al., 2013; Maternal and Child Nutrition 1
2
development, both nutrition-specific and nutrition-sensitive interventions need to be
implemented by different sectors and stakeholders working together (Figure 1). To
reduce the burden of malnutrition, the integration of nutrition into other sectors is
important. These sectors include health, agriculture and food security, social
protection, poverty reduction, gender, water sanitation and hygiene, environment
and climate change, private sectors, and trade/fiscal policies.
According to the Somalia Demographic Health Survey 2020, 28% of children below
five years in Somalia are stunted, with regional disparity ranging from 12.3% in
Somaliland to 38.9% in South West8. More than 40% of women and children are
anemic. Over 26% of women have iron deficiency anemia, while 34% of children and
11% of women are vitamin A deficient9. The FSNAU-FEWSNET Post Gu report
September 2020 reported the prevalence of Global Acute Malnutrition (GAM) as
Serious (10–14.9%)10. The contributing factors to the high prevalence of acute
malnutrition in Somalia include high morbidity, low immunization, and vitamin-A
supplementation, and poor infant and childcare practices, and food insecurity11.
Elevating and integrating nutrition interventions and services into
other programmes helps save lives, spur prosperity, and tackle one of the most
pervasive and enduring causes and consequences of extreme poverty. To achieve
optimum fetal and child nutrition and development, both nutrition-specific and
nutrition-sensitive interventions need to be implemented by different sectors and
stakeholders working together (Figure 1). To reduce the burden of malnutrition, the
integration of nutrition into other sectors is important. These sectors include health,
agriculture and food security, social protection, poverty reduction, gender, water
sanitation and hygiene, environment and climate change, private sectors, and
trade/fiscal policies.
8 SKDHS 2020 9 Ministry of Health FGS, FMS, Somaliland, UNICEF, Brandpro, Ground Work. Somalia
Micronutrient Survey 2019. Mogadishu, Somalia; 2020 10 FSNAU-FEWSNET, September 2020 11 FSNAU-FEWSNET, September 2020
3
Figure 1: Framework for action to achieve optimum fetal and child nutrition and development
Source: LANCET, 2013
Investing in nutrition-specific and nutrition-sensitive interventions is fundamental to
achieving our goals in improving global health, ending preventable child and maternal
death, promoting an AIDS-free generation, reaching vulnerable groups such as
children during an emergency, and strengthening food security. Integration also
seeks to accelerate improvements in nutrition by decreasing the prevalence of
maternal and child under-nutrition – particularly chronic and acute malnutrition and
micronutrient deficiencies in children under five and undernutrition and micronutrient
deficiencies in women of reproductive age (ages 15-49), with a specific focus on the
critical 1,000-day window from pregnancy to a child's second birthday. Science has
shown that the 1,000 days between pregnancy and a child's second birthday are the
most critical period to ensure optimum physical and cognitive development.
Integration of nutrition in sectors requires a robust learning agenda that supports
expanding research to address critical knowledge gaps; monitoring and rigorous
evaluation to inform program implementation and timely dissemination and
application of lessons learned.
4
1.2 Rationale for study
Integration of nutrition interventions aims to accelerate and scale-up of efforts
towards the elimination of malnutrition as a problem of public health significance,
focusing on nutrition outcomes and commitments. Improved nutritional status has
been linked to a decline in mortality, improved survival, and productivity12. In
addition, people practicing healthy behaviors, among them adequate intake of fruits
and vegetables have been shown to have 14 years' extra life expectancy. Adverse
nutritional events early in life affect the health of children, and influence their future
education and income, and may increase predisposition to chronic disease later in
life. There is increasing consensus that effective nutrition interventions must reach
across sectors to address the multi-factorial determinants of malnutrition. In the
past, many nutrition initiatives have been vertical programs implemented through
isolated delivery systems; however, there has been a recent recognition that multi-
factorial causation is best addressed with multi-sectoral interventions including
gender equality and empowerment of women being critical in achieving nutrition
objectives. Access to clean and safe water in Somalia has been identified as one of
the main challenges due to a combination of factors including arid climate, the
chemical concentration of water sources, and human-induced conflict, with existing
water sources being inadequate in terms of accessibility, quality, and quantity.
There is limited local evidence in Somalia to inform local programming priorities
within the multi-sectoral perspectives, thus, pressing need to ensure nutrition
programming provides value for money by optimizing on available resources. This
requires strong evidence on successes and best practices that can be used to improve
and strengthen multi-sectoral programming in Somalia. Currently, cross-sectoral
learning opportunities -through evidence-based studies and dissemination
workshops- are limited and or non-existent, within the nutrition sector and other line
sectors. To tackle the immediate and underlying determinants of malnutrition, it is
fundamental to continually generate, share, and adopt evidence on best practices
and successes in nutrition programming. This underpins the need for robust and
12 Ross et al., 2003. Effects of Malnutrition on Child Survival in China as Estimated by PROFILES, 2003
5
comprehensive learning platforms for nutrition-related studies to support learning
activities.
1.3 Goal
The goal of the study was to generate evidence on integration models, best practices,
drivers, and opportunities for improvement to inform learning for multi-sectoral
programming for integrated nutrition interventions. Specifically, the study aimed to:
i. To synthesize evidence on nutrition program integration models adopted
globally and their feasibility in the Somalia context
ii. To synthesize and document evidence on best practices/successes in
integration of nutrition‐specific and nutrition-sensitive interventions in Somalia
iii. To identify internal and external drivers, bottlenecks, and opportunities
for effective integration of nutrition interventions in other sectors in Somalia
iv. To provide contextual or feasible recommendations for strengthening the
successful integration of nutrition-specific and sensitive interventions in
Somalia
6
2 APPROACH AND METHODS
2.1 Data collection
Data was collected between 24th September 2020 and 22nd October 2020. This study
used a mixed-methods approach, involving the collection of both primary and
secondary data. Secondary data was collected using a systematic review, while
primary data was collected using Key Informant Interviews (KIIs).
The systematic literature search was conducted in both published and grey resources,
and integrated nutrition intervention into multi-sectoral programmes was examined.
The review included quantitative & qualitative studies describing efforts & approaches
to intervention (integration of services) of nature including randomized controlled
trials (RCTs) and controlled clinical trials (CCTs), or quasi-experimental, controlled
before and after studies (CBAs), case studies, policy reports, and guidelines. The
Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols
(PRISMA-P) 2015 checklist was utilized. Forty‐four studies were included in this
review, outlining the integration of nutrition‐specific interventions with various
existing programmes in global settings with applicability to fragile contexts. The full
report on the systematic review is available in Annex 1.
Primary data was collected through Key Informant Interviews (KIIs) with selected
respondents of various stakeholders in Somalia. The key informants were identified
through a consultative process facilitated by the Office of the Prime Minister (OPM).
The respondents were drawn from the following organizations: SUN Donor Network
(World Bank); BRCiS; SUN UN (UNICEF, WFP, and FAO) SUN CSO (Action Against
Hunger, Save The Children, Norwegian Refugee Council, Concern Worldwide and
GREDOSOM), and SUN Academia Network. Interviews were conducted virtually and
face to face using an interview guide (Appendix 2). The guide consisted of thematic
and open-ended key questions. Virtual interviews were conducted by the consultants
while face-to-face interviews were conducted by field staff in Somalia. All virtual
interviews were recorded with prior consent from the respondents. Interviewers also
recorded notes during the interviews. The list of organizations from whom
respondents were drawn is in Annex 3.
7
2.2 Data analysis
The systematic review and qualitative interview data were analyzed in a
complementary manner while triangulating methods and results. Qualitative data
from key informant interviews (KIIs) was analyzed into common themes, from which
inferences were made and conclusions were drawn.
Systematic review data were analyzed using standard summary statistics and
perform meta-analysis when more than 3 studies for each outcome meet the criteria
for the systematic review. Where the outcomes of interest were either dichotomous
or continuous; we calculated risk ratios and their corresponding 95% confidence
intervals and p-values for dichotomous outcomes, and mean differences and standard
deviations for continuous outcomes. Where outcomes are measured using different
scales, we calculated standardized mean differences (SMD). A random-effects model
was used with the assumption that the true effect size varied between studies.
Outcome measures that were qualitative in format i.e., patient satisfaction that
cannot be quantified, were discussed narratively (Annex 1).
Results have been presented in form of narratives, tables, and figures. Stakeholder's
inputs have been incorporated into the final report.
8
3 FIELD CHALLENGES
1. Because of the COVID-19 pandemic, the consultants were not able to travel to
Somalia and conduct face to face interviews. However, the OPM facilitated the
virtual interviews by linking the consultant with key informants from the various
organizations in Somalia.
2. The team sometimes faced challenges with internet connections, which affected
communication during virtual interviews.
9
4 KEY FINDINGS
The LANCET series 201313 identified two types of interventions whose scaling up will
address malnutrition in the word: nutrition-specific and nutrition-sensitive
interventions. Both types of interventions have the potential to be integrated into
multi-sectoral programming and with each other.
a. Nutrition-specific interventions and programmes
Nutrition-specific interventions and programmes address the immediate
determinants of fetal and child nutrition and development which include adequate
food and nutrient intake, feeding, caregiving and parenting practices, and low burden
of infectious diseases. The SUN identifies ten High Impact nutrition-specific
interventions which include:
• Promotion of exclusive breastfeeding in the first 6 months and continued
breastfeeding for up to 2 years
• Promotion of appropriate, adequate, and safe complementary feeding for children
aged 6-23 months
• Vitamin A supplementation for children aged 6-59 months
• Zinc supplementation for diarrhea management
• Deworming for children from 12-59 months
• Iron‐folic acid supplementation for pregnant women
• Food supplementation to children from 6-23 months and pregnant and lactating
women in the food insecure areas
• Food fortification of staple foods
• Salt iodization
• Multiple Micronutrient Supplementation (MNPs) for under5s
• Prevention and treatment of moderate acute under-nutrition in children under five
and pregnant and lactating women
• Prevention and treatment of severe acute malnutrition
• Dietary diversity among pregnant and lactating mothers
• Adolescent health and preconception nutrition
13 LANCET, 2013
10
b. Nutrition-sensitive interventions
Nutrition-sensitive interventions address the underlying and basic causes of
undernutrition (e.g., poverty, scarcity of access to adequate care resources; and to
health, water, and sanitation services food insecurity) through indirect but plausible
pathways. Nutrition-sensitive interventions can also serve as delivery platforms for
nutrition-specific interventions14. Complementary sectors to nutrition-sensitive
interventions include agriculture, health, social protection, early child development,
education, and water and sanitation. Notably, nutrition-sensitive intervention
programmes implemented within these sectors address the crucial underlying causes
of malnutrition, are usually large scale, reaching a majority of the vulnerable poor
and malnourished, and often as pathways for nutrition-specific interventions15. They
include:
• Agriculture and food security
• Social protection (social safety nets programs such as Cash and Voucher
Assistance (CVAs), Food Aid, NHIF)
• Early childhood development and education (ECDE) (This includes child
stimulation play and responsiveness)
• Maternal mental health
• Women’s empowerment
• Child protection
• Water, sanitation, and hygiene (WASH)
• Health and family planning services
• Schooling
4.1 Policy framework for nutrition integration in Somalia
Most organizations implementing nutrition interventions have and operate within
their policies and guidelines. However, the Federal Government of Somalia (FGS) has
demonstrated commitment and leadership in improving the nutritional status of the
citizenry through the development of a strong policy infrastructure that supports
14 LANCET, 2013a 15 Maternal and Child Nutrition 3. LANCET, 2013
11
nutrition interventions. The following key government documents have been
developed:
i. National Development Plan 202-2024
ii. Somalia Nutrition Strategy 2020-2025
iii. Somalia multi-sectoral nutrition strategy and common results framework
(2019-2014)
iv. Social Mobilization, Advocacy and Communication Strategy (SMAC)-2019-
2021
v. Somalia National Micronutrient Deficiency Control Strategy (2014–2016)
vi. New SFP strategy
vii. Food fortification strategy
viii. Micronutrient strategy
ix. Interim Country Strategic Plan 2019-2021
x. Livestock Sector Development Strategy
xi. Somalia guidelines for the management of acute malnutrition guidelines/CMAM
xii. Infant and young child nutrition strategy-draft not finalized
xiii. Basic nutrition service package
xiv. National Infant and Young Child Feeding Strategy for Somaliland 2012-2016
xv. Resilience and Recovery framework
4.2 Platforms for the integration of nutrition into multi-sectoral
programming
Integration of nutrition into other sectors can either take the form of building a joint
integrated project or incorporating specific nutrition objectives, activities, and
indicators into the project implemented by another sector.
The following criteria are used to identify the integration of nutrition in other sectors16
i. Targeting nutritionally vulnerable individuals and/or households
ii. Inclusion of explicit nutrition objective(s) and indicators in the program
design
16 Action Against Hunger, 2017. Wash and Nutrition. A practical guidebook on increasing nutritional
impact through the integration of WASH and nutrition programmes.
12
iii. Programming that considers gender aspects and explicitly
Empowers/engages women
iv. Promote strategies that enable households to diversify their diets and
livelihoods
v. Including nutrition education and social behavior change communication
strategies.
vi. Considering alternatives
Most of the respondents interviewed in this study spontaneously acknowledged the
importance of integrating nutrition into multi-sectoral programming, while
underscoring the lack of understanding of integration among partners, citing that
most programmes did not include integration in their designs.
Objective 8 of the Somalia Nutrition Strategy is to mainstream nutrition as a key
component of nutrition-sensitive sectors, with one of the targets being nutrition-
sensitive WASH, Health, Education, Social Protection policies, strategies, and
activities17
The following were identified as the potential platforms for the integration of
nutrition-specific and nutrition-sensitive interventions in Somalia.
i. Health: Nutrition is a key element of Primary Health Care (PHC)18. Integrating
nutrition within health systems helps reduce staggering healthcare spending and
save lives. Similarly integrating health and nutrition ensures accessibility and
increased uptake of both health and nutrition services.
ii. Agriculture: The LANCET series 201319 underscores the fact that targeted
agricultural programmes can affect nutrition through several pathways, in which
women’s social status, empowerment, control over resources, time allocation, and
health and nutritional status are key mediators. Agricultural production improves
household food availability and access from own production, is a source of income,
and affects food prices. In addition, the participation of women in agriculture
improves their access to, or control over resources and assets, and increase their
decision-making power within the household. However, women’s participation in
17 FGS 2020. Somalia Nutrition Strategy 2020-2025 18 Global Nutrition Report, 2020 19 Maternal and Child Nutrition 3. LANCET, 2013
13
agriculture can also have negative effects including limited time in childcare,
household management, and participation in income-generating activities. Their
health and nutritional status can also be affected due to excessive energy
expenditure and exposure to environmental hazards.
iii. Water Sanitation and Hygiene (WASH): Disease is one of the immediate
causes of malnutrition, often linked to an increased risk of death. Poor WASH
conditions are associated with a significant proportion of neonatal and postnatal
deaths, and diseases among children below five years, primarily in low- and
medium-income countries.
iv. Education: Malnutrition affects both the physical and cognitive development of
children. Early stunting is associated with less schooling, cognitive performance,
and low earnings in adulthood. On the other hand, interventions that target
nutrition and child development have beneficial effects on cognitive development
and academic achievement. Nutrition interventions can improve cognition even in
the absence of anthropometric benefits20. On the other hand, parental schooling,
especially the maternal level of schooling, has a significant effect on child nutrition
and development. The LANCET 2013 demonstrated that the risk of stunting is
significantly lower among mothers and fathers with at least some primary and
secondary schooling, with a higher significance with maternal schooling.
v. Social protection: Safety nets are linked to improved household food availability
and dietary quality. They have the potential to reduce poverty and increase the
use of health and education services. Specifically, cash transfers have been shown
to increase household expenditure on food and health as well as foster certain
aspects of women’s empowerment.
4.2.1 Integrated nutrition interventions/activities in health
Within health, nutrition-specific interventions can be integrated with health services,
including Integrated Management of Childhood Illnesses (IMCI)/ Integrated
Community Case Management (ICCM) and immunization. From the systematic
review, it was revealed that integrated programs enhanced complementary feeding
20 Black, Escamilla, and Rao, 2015. Integrating Nutrition and Child Development Interventions:
Scientific Basis, Evidence of Impact, and Implementation Considerations. Adv. In Nutrition
14
practices by 5% compared to the non-integrated programs. Specifically, the analysis
showed that the integration of nutrition into IMCI platforms resulted in significant
improvements in health care seeking behaviors, including increased uptake of
antenatal and postnatal care, facility delivery, and vaccination21.
The nutrition-specific interventions included counseling of mothers on breastfeeding
for up to two years and appropriate complementary feeding, growth monitoring,
supplementary nutrition, vitamin A supplementation (VAS), and screening,
management, and referral for malnutrition. Other interventions included nutrition
awareness creation through nutrition messages. Vitamin A supplementation along
with deworming was also carried out during national Immunization Days (NID) and
polio or measles campaigns. Integrated mobile health services were provided,
especially targeting pastoral communities. Management of Severe Acute Malnutrition
(SAM) and Moderate Acute Malnutrition (MAM) was conducted in nutrition centers as
well as health facilities Including MAM in pregnant and lactating women and
malnourished people leaving with TB/HIV.
The systematic analysis also demonstrated that integrated programs significantly
enhanced exclusive breastfeeding practices among children 0- 6 months by 27%
compared to the non-integrated program. Integration of nutrition in immunization
programmes showed significant three-fold improvement in the initiation of
breastfeeding within the first one hour, and protective effect on underweight among
children older than2 years by 53%. Lower SAM case fatality was also reported in
integrated SAM and MAM programmes, as well as lower SAM relapse.
However, the analysis did not find any protective effect of integration on stunting
among children aged 24–59 months and wasting among 0-23 months from the
integration of IMCI/iCCM programmes.
4.2.2 Integrated nutrition interventions/activities in agriculture and
livelihoods
The study found that nutrition activities/interventions were included in
agriculture/resilience programmes in Somalia.
21 Rehana, Bas, and Bhutta, 2018. Integrating nutrition into health systems: What the evidence
Advocates. Maternal and Child Nutrition
15
Delivery of nutrition education in all resilience interventions to prevent malnutrition
and improve dietary practices, food preparation, selection, nutritional benefits of
different, and budgeting. Integrated interventions among livestock farmers include
basic education on milk and meat consumption, handling, hygiene, safety, and
preservation. Among fishing communities, the integrated nutrition interventions
included education on safety in handling, preparation, and consumption.
Beneficiaries also received productive farming inputs, assets including seeds for
vegetables, as well as technical training on production processing and preservation
techniques. The aim was to increase the availability of micronutrient-rich foods at the
household level as well as dietary diversity. The resilience programme includes
behavior change communication to increase access to nutritious food.
4.2.3 Integrated nutrition interventions/activities in WASH
One of the initiatives of the Somalia Nutrition Strategy under objective 8 is to
integrate nutrition-sensitive WASH by promoting access to and utilization of
appropriate WASH practices. The target of these practices are caregivers and children
aged below 5 years.
Unsuitable or insufficient food intake and disease are the immediate causes of
undernutrition, both of which are directly or indirectly related to inadequate access
to water, sanitation, and hygiene (WASH). Poor care practices are also related to
poor hygiene and sanitation. WASH programmes provide a platform for the
integration of nutrition-sensitive and nutrition-specific interventions. The following
nutrition activities were offered within WASH programs: OTP and TSFP (Targeted
School Feeding Programme) programmes for outpatient treatment SAM and MAM as
well as stabilization centers for the treatment of SAM with complications. Packages
that include prevention of malnutrition include Vitamin A supplementation,
supplementary feeding programmes (MCHN and BSFP), nutrition education and
awareness, deworming, community health, and hygiene promotion. Other nutrition-
sensitive interventions include maternal and childcare practices and improving access
to health care.
16
4.2.4 Integration of nutrition and education
The school feeding programme was implemented in a few states in Somalia. The
integrated nutrition activities include nutrition education covering good eating habits
and healthy practices. WASH interventions and health messaging are also delivered
under the same platform. The children are also provided with a nutritious meal.
However, there were no specific interventions targeting adolescents, specifically girls.
The widespread evidence that maternal schooling is significantly associated with
reduced risk of stunting, strongly calls for interventions targeting girls, intending to
keep them longer in school and improve their nutritional status, thus laying the
foundation for healthy pregnancies and pregnancy outcomes. School feeding
programmes provide a platform for integration of health and nutrition for school-age
children particularly adolescent health, nutrition education, menstrual hygiene, and
micronutrient supplementation for adolescents.
4.2.5 Integration of nutrition and social protection
Social protection can be integrated into nutrition and vice versa. Our analysis found
one study on integrated nutrition and cash transfer programmes reported
significantly higher SAM recovery, lower MAM relapse, and lower SAM relapse.
In Somalia, households with children with SAM or MAM were referred to cash transfer
programmes. On the other hand, the rural safety net unconditional cash transfer
targeted women and mothers of less than five-year-olds. Targeting vulnerable
households enhances the households’ ability to provide care to young children and
other dependent family members. Productive safety net programmes whose target
is pregnant and lactating women, children below 5 years at OTP or TSFP aimed to
improve household food security, which is one of the underlying determinants of fetal
nutrition. Provision of child-friendly spaces for the screening of children and referral
within child protection centers was also mentioned.
4.2.6 Integration across several sectors: Health, WASH, agriculture,
nutrition, and social protection
Although nutrition integration within other sectors was reported to be low, a few
programmes were found to integrate nutrition within more than two sectors, notably
17
agriculture, social protection, and WASH. In one such programme, beneficiaries of
the agriculture and resilience intervention also received cash transfers targeting the
purchase of productive assets, as well as awareness creation on hygiene and
sanitation. WASH interventions integrated with health include the provision of water
purification chemicals, clean water, and latrines for health facilities. WASH services
were also delivered in health facilities, including the provision of clean water in
facilities with stabilization centers, where nutrition services were also provided. In
the IDP camps, nutrition services are provided along with clean water. Similarly,
integration of nutrition with education and WASH was also reported, where under the
school feeding programme (SFP). Beneficiaries of the school meals also receive
nutrition education, awareness on waste disposal, and the schools are provided with
clean water. The review showed that multi-sectoral integration including hygiene,
nutritional, clean delivery incentives, higher education level, and geographical
contiguity to a health facility was associated with the increased use of maternal health
services by pregnant women.
4.3 Enablers of nutrition Integration
There is growing evidence that the integration of nutrition-sensitive programs and
nutrition-specific interventions provides stronger impacts on nutritional and non-
nutritional outcomes as opposed to single interventions. The integration of nutrition
in more than one sector has the unique advantage of addressing the immediate,
underlying, and basic determinants of nutritional status. It brings multiple synergetic
effects, among them cost-effectiveness, sharing resources and personnel, joint
planning, and implementation, while maintaining sectoral limits. In addition, it
minimizes duplication of services, consolidates cumulative benefits to the
beneficiaries, fosters communication and knowledge sharing, and in the long term
eliminates the common practice of working in silos.
Combined interventions may be more efficient than separate interventions because
they are intended for the same population and make use of the same facilities,
transportation, and client contacts. In addition, for families, particularly for those
most at risk, combined interventions can also lead to increased access to services.
The following enablers of nutrition intervention were reported.
18
4.3.1 Broad context:
• Political readiness, interest, and support and progress monitoring for
resilience and development initiatives - Respondents cited the high-level
government leadership, especially the Office of the Prime Minister (OPM) and
the Ministry of Health (MOH), noting the SUN Movement Coordination office is
based at the OPM. Being non-sectoral accords the OPM the unbiased role of
bringing together all nutrition actors from all line ministers, donors, and NGOs.
• Policies that support nutrition integration - These include Nutrition
strategy, Livestock Sector Development Strategy, New SFP strategy, Food
fortification strategy Standards among others
• Human resource - The Federal Government of Somalia has a pool of highly
educated personnel who are spearheading policy development. In addition,
70% of the Somali population is less than 30 years. These young people can
be targeted for capacity building on nutrition education, BCC, and basic
technologies to promote nutrition integration. This provides an untapped
improved nutrition knowledge pathway
• Media - The Somalia Communications for Development Strategy (SCDS)
approach has been identified as ideal to promote optimal nutrition practices
since it addresses key behaviors along with intervening factors that facilitate
enabling environments for behavior and social change. The use of mass media
in the delivery of training programs and messages was successful during the
COVID-19 period.
• The vibrant highly innovative private sector - which plays a key role in
food security. There is thus a high potential for Private-public sector
partnership in the integration of nutrition-specific and sensitive interventions.
This is especially important to curb the sale of RUTF and RUSF in local markets,
as well as the marketing of formula feeds, both of which are widespread
4.3.2 Understanding of the nature and magnitude of the undernutrition
problem in Somalia
Respondents were knowledgeable on the causes and consequences of malnutrition
and the complementarity of sectors, illness and prevention and treatment pathways,
19
accurate information on the burden of disease, and political and social environment
to recognize the problem and initiate change. “There is no need of treating a severely
malnourished child and then discharging them to go to a home where there is no
clean water” a respondent from a local NGO. There is also a wide range of studies on
the nutrition situation in Somalia have been conducted, and these are a source of
valuable data for decision making in nutrition integration.
4.3.3 Interventions
There is evidence of continuous skill development in different sectors, decentralized
care increases exposure, access, utilization, and involvement. The Federal
Government of Somalia has a pool of highly educated personnel who are
spearheading policy development.
There are notable clinical, organizational, and management capacities in successful
sites. The presence of active Community Health Committees who in some cases
participate in participatory planning of nutrition interventions. Communities nutrition
champions and Community Based Female Health Workers (CBFHW) also serve as
advocacy agents promoting the uptake of nutrition and health services.
4.3.4 External support
Increased interest and goodwill stakeholders with more donors and partners
are funding or willing to fund nutrition integration. Most donors appreciate the
importance and need for integration, that impact is more likely where there is
integration.
Existence of consortia. Consortia that bring together several donors and serve as
a platform for pushing the nutrition integration agenda, especially funding and
implementation of nutrition-sensitive interventions.
Strong nutrition cluster: The nutrition cluster provides a knowledge-sharing
platform for other clusters
20
4.3.5 Adoption system
Integration can benefit from the compatibility of personal, professional, and
institutional goals, values, and principles; collaborative support, engagement, and
involvement; learning and career development opportunities; and support for
problem-solving
4.3.6 Health system characteristics
These include policy adaptation and translation; expanded, regulated, and aligned
partnerships; expanded health workforce; and decentralized care.
4.4 Bottlenecks to nutrition integration
4.4.1 Broad context
The different sectors and clusters operate in silos, with hardly any discussions on the
adoption of integration of nutrition within other and multi-sectors.
Lack of stakeholder coordination: The donors and consortia operate in silos, with
some sectors viewing the multi-sectoral approach as diverting sectoral focus.
Operation of clusters in silos and lack of inter-sectoral coordination leads to a lack of
joint planning for and implementation of integrated interventions because of the
diversity of designs. Integration is therefore neglected as each sector/organization
invests more in achieving sectoral/ organizational goals at the cost of nutrition
outcomes. There is also inadequate data collected locally to support nutrition
integration since most interventions lack baseline data for most interventions. Most
interventions in Somalia are delivered in the humanitarian context, with more focus
on saving lives and not improving nutrition outcomes.
Insecurity: Insecure regions are hardly reached by interventions and services
because of the high risk to staff.
Access to beneficiaries: Some beneficiaries are not accessible due to insecurity or
geographical local. In addition, Somalia has a high population of people in Somalia
are either displaced or are therefore constantly on transit. This poses a challenge as
they are hard to reach and often have high rates of malnutrition.
Conflict of policies (those in clusters, state, and FGS): The clusters have their
policies that have not been harmonized with those of the Federal Government of
21
Somalia. In addition, some resistance to acceptance of these policies has been
experienced in some states like Puntland and Somaliland, which may prefer to
develop state policy documents.
Uncontrolled local food market: The local food market is dominated by imported
food; whose quality is uncontrolled. This poses a challenge in the integration of
activities that leverage on local markets for access to food. Cash received by
households through cash transfers may end up being used to purchase poor quality
food of low nutritional value. Given the low local food production, efforts to improve
the nutritional status of the population may be compromised.
4.4.2 Intervention context
Clinical, organizational, and management capacity gaps in certain states. In addition,
interventions substituted by partners and limited community awareness and
involvement reinforcing mistrust. Funding restrictions also hinder integration efforts.
Funding is fragmented and specific to sectors, with nutrition being viewed as the
mandate one sector/cluster. In some cases, nutrition is mentioned in the project
document, but there are no indicators identified and budget allocated implementation
and monitoring nutrition activities. Additionally, most donors fund only basic nutrition
services (mainly the treatment of SAM and MAM) and not integrated/nutrition-
sensitive interventions/ services. When only one agency funds basic nutrition
activities, the needs of the community remain unmet.
The concentration of interventions and services in urban areas, with little done in
rural areas. There is a need to identify uncovered areas of Somalia (most partners
are concentrated in specific areas).
4.4.3 Adoption system:
There is perceived partner support favoring evading responsibility, lack of interest or
motivation or collaboration in care and learning, feeling of curtailed career
development, and high workload especially among healthcare workers.
Most projects are short term (less than a year). This period may not be adequate to
achieve nutritional impact.
22
Most organizations and agencies do not integrate nutrition at the design level. This
means that any nutrition activities that may be incorporated later during
implementation are not funded and also are not part of the monitoring and evaluation
plan. This leaves a gap in meeting the needs of communities. For example,
promotions of nutrition and health diet without the inclusion of WASH activities leaves
the community exposed to risks of diseases and infections, which waters down the
benefits of the nutrition intervention. Line ministries also lack nutrition focal persons,
especially in agriculture and other relevant sectors/ministries.
4.4.4 Systemic characteristics
Multiple health information systems; underfunded health budget; short-term
emergency funding; high staff turnover and attrition; limited logistic capacity for
bulky, expensive supplies; and limited community and patient/caregiver involvement
and empowerment.
Inadequate human resource and technical capacity within other sectors (education,
WASH, agriculture, social protection) is a gap in the integration of nutrition
interventions within those sectors.
The most commonly integrated nutrition activity was nutrition education and
awareness creation, mainly through nutrition messaging to promote good dietary
habits and healthy diets. However, the messaging is not standardized and may differ
from one implementer to another.
Somalia experiences recurrent shocks and emergencies: In the recent past, the
county has experienced floods, drought, locust’s invasion, and more recently the
global COVID-19 pandemic, accounting for a large proportion of donor expenditure
in Somalia.
Livelihood opportunities in Somalia are limited. As a consequence, communities have
limited options for diversification, which contributes to low income, food insecurity,
lack of food diversity, hygiene, and sanitation.
Sociocultural practices that hinder the empowerment of women and their
participation in decision making in the household and dictate that heads of
households (men) are in charge of all decision making at the household level. These
practices include widespread and severe social and economic discrimination, gender-
23
based violence, food taboos for women and girls (especially pregnant and lactating
women, Female Genital Mutilation (FGM), early marriages, lack of birth spacing and
have high maternal mortality as outlined in the Somali Nutrition Strategy 2020-
202522. The Strategy also identifies discriminatory Somalia customary law (Xeer) and
religious law (sharia), as well as certain state legal systems as being discriminatory
against women.
Limited investment in joint tracking, reflection, and learning on multi-sectoral
programming barriers, gaps, and best practices with a lens for fragile context. There
have been limited efforts in sustained nutrition programming studies and learning for
fragile contexts regionally and globally further hampering actors from drawing on
winning interventions and experiences.
4.5 Opportunities for nutrition integration
There is stronger leadership from the government, including the implementation of
the Somali National Development Plan for 2019–2024 and the Somali Universal
Health Coverage (UHC) Roadmap, (launched in September 2019). The Office of the
Prime Minister is also extensively engaging donors, NGOs, and all stakeholders in
Somalia under the SUN movement. In addition, the existence of evidence-based
multi-sectoral and sectoral nutrition policies and plans at the national level such as
NDP and FSNA. In addition, Nutrition is integrated into relevant sub-national policies
and strategies such as The Common Results Framework. Other policy documents
include the Food Fortification Strategy, Micronutrient strategy, Somalia multi-sectoral
nutrition strategy as well as the Somalia Nutrition strategy.
Community involvement and goodwill are increasing, improving the conditions for
community consultations and the efforts to ensure that the most vulnerable
community members, (such as minorities, people with disabilities, or widows) are
included in any cash transfer project. Community participation in the identification of
nutrition-sensitive interventions and the design of the integrated interventions
ensures ownership and sustainability of the project. District health teams have been
formed in some states which enhances community involvement in the planning of
22 FGS, 2020. Somalia Nutrition Strategy 2020-2025
24
integrated nutrition interventions to increase uptake, ownership, and sustainability
of the interventions. Examples are Puntland and Somaliland.
Food production is increasing in the agricultural regions. Agricultural land in Somalia
stands at 70%. Increased investment in integrated agriculture and livelihood
interventions can potentially improve household food availability and accessibility, as
well as increase incomes, thus addressing a key factor in the prevention of
malnutrition.
The presence of local NGOs provides an opportunity to reach poor households and
malnourished children in remote areas. Local NGOs have a wider reach than the
INGOs and international agencies and have the local infrastructure to reach the
remote vulnerable populations. In addition, there is increasing interest by
stakeholders in nutrition programming, including funding within clusters (GIZ,
Canada). There is also an opportunity for joint multi-sectoral needs assessment, thus
leading to integrated planning and responses. Some partners have continuous
training for their staff, a platform that can be leveraged to conduct multi-sectoral
training. The most common nutrition-sensitive intervention with the widest coverage
is Social protection, which can be used as an entry point for nutrition integration into
other sectors.
4.6 Best practices
Given the complementarity of nutrition-sensitive and nutrition-specific interventions,
a multiplier effect is achieved when integration is done at the sector level, especially
involving more than two sectors. An example is the integration of nutrition services,
promotion of sustainable diets, improving food system and food environment, health,
livelihoods support, village loans and savings associations, SBCC for development,
and community participation. Additional benefits would be realized by linking
vulnerable beneficiaries of health and nutrition services (for example immunization,
growth monitoring, treatment of SAM and MAM) to cash transfers. Integrated
packages should consist of livelihood support, depending on the type of livelihood.
For example, support the agro-sector would include the provision of farming inputs
such as vegetable seeds and tools, promoting short maturing crops, while providing
animal support for pastoralist communities. Integrating nutrition in all interventions:
25
For example, in emergency interventions, beneficiaries could receive training on food
preparation, selection, benefits, budgeting. Livestock interventions: milk and meat
hygiene, safety, preservation; fisheries: Nutrition education messages, safety in
handling, preparation. Integrated packages should be designed with a gender lens,
to include both males and females, as well as boys and girls.
26
5 CONCLUSION
1. Nutrition is integrated into various sectors including WASH, Health, social
protection, education, and agriculture, but nutrition indicators are not included
in the project designs and are therefore not monitored, and subsequently, data
on the impact on nutrition outcomes is lacking.
2. Funding for nutrition integration is limited and fragmented. Each sector
implements its activities and does not budget for implementation and
monitoring of integrated nutrition activities. In the absence of joint funding,
the needs of the community remain unmet.
3. The capacity for nutrition integration is low due to inadequate training for
different sector staff on nutrition integration.
4. Line ministries and agencies lack nutrition focal persons; therefore, nutrition
is not included in sectoral agenda.
5. Lack of coordination between clusters poses a challenge to nutrition integration
6. Sociocultural barriers exist in the implementation of nutrition-sensitive
interventions, especially those targeting women.
7. Community participation is key to the integration of nutrition in multi-sectoral
programming, improves targeting of the most vulnerable, and increases
sustainability and ownership of interventions.
27
6 RECOMMENDATIONS
Despite fragility and nutrition integration at the policy level, malnutrition and stunting
rates remain high in Somalia. The following recommendations will improve the impact
of integrated interventions on nutrition outcomes, both in the short and the long
term.
1. The government should provide policy direction on nutrition integration, with
a clearly defined acceptable minimum for nutrition integration. While the
minimum nutrition integration package may vary from sector to sector,
promotion, and support for optimal IYCF and promotion and support for
optimal maternal nutrition and care should be included in all multi-sectoral
programming. In addition, all sectors should include clear nutrition objectives
and indicators in the programme design.
2. While treatment for malnourished, children is critical and immediate
interventions (MAM and SAM) are imminent, it is necessary to shift the focus
to longer-term preventive nutrition programmes integrating across various
sectors to build resilience and eventually build human capital through
harmonized capacity building and training of nutrition resource persons for
harmonized and standardized delivery of interventions
3. Identification and capacity building of a public institution into a Centre of
Excellence (CoE) for nutrition in Somalia. The CoE should be empowered to
provide leadership in addressing the multifaceted and multi-causal nutrition-
related challenges and gaps, showcase best practices while supporting training
and research for better nutrition service delivery across Multi-Stakeholder
Platforms (MSPs). The recommended institute is the University of Mogadishu.
4. The development of a harmonized nutrition curriculum and integration into the
education system in primary, secondary and tertiary levels for capacity
building of programs on the MSP agenda.
5. Strengthening of Multi-sectoral integration at community and project level
should be considered from the design level, through increased and structured
community participation, with a focus on the first 1000 days of life including
maternal nutrition. SUN-Somalia should take the lead in the development of a
28
joint action plan for nutrition integration by implementing partners, to guide
intervention priorities.
6. Development of a Multi-Sectoral Platform (MSP) to bring together high-level
donor involvement in nutrition integration. This will break the pattern of silos
and encourage collaboration among donors. The platform will be used for
collaborative planning, implementation, and monitoring of resources and
implementation of integrated interventions.
7. Development of an integrated national health and nutrition information
management system to help gather, compile, and analyze health and
nutrition data to help manage health and nutrition and
reduce healthcare costs.
8. All implementing partners should develop action plans for nutrition integration.
This should be aligned to ensure the complementarity of resources and efforts.
9. To break the intergenerational cycle of malnutrition, there is a need for
interventions that target adolescent girls. Adolescence is a period of rapid
growth that is accompanied by increased nutrient demand. The nutritional
problems common in adolescence include stunting, iron deficiency and anemia,
vitamin A deficiency, among others. The health and nutritional status of
adolescent girls determines the quality of the next generation. Malnourished
girls graduate into malnourished mothers, who give birth to low-birth-weight
babies. Low birth weight babies grow as a malnourished child, probably
stunted, into a malnourished teenager, and then into a malnourished mother,
and the cycle continues. Adolescence provides a unique opportunity to foster
a healthy transition from childhood into adulthood.
10. Improving coordination and enhancing partnership among relevant ministries
(nutrition, health, agriculture, Labor, water), humanitarian organizations, and
other relevant stakeholders to ensure the integration of health and nutrition
goals in all WASH projects from the start.
11. Deliberate effort to invest in interventions that empower women, reproductive
health including a reduction in FGM which has a long-term effect on women's
health, in turn, children's health, birth weight, safe pregnancy, and delivery
and ultimately nutritional status.
29
12. There is a need for additional human resources to guide nutrition integration.
Nutrition focal persons should be engaged in all sectors including agriculture,
education, social protection, health, and WASH sectors. These will spearhead
the strengthening of integration of nutrition services into the sectors.
13. Integrated nutrition interventions should include a clear nutrition indicator with
outcomes such as improved dietary diversity, reduced GAM/wasting, increased
immunization coverage, reduced stunting, and wasting, reduced academia.
14. Increased funding for nutrition-sensitive interventions
15. Development of national guidelines for healthy diets for the Somali population.
16. Engagement with the private sector.
30
ANNEXES
ANNEX 1: SYSTEMATIC REVIEW
Best practices and opportunities for integrating nutrition Specific and
Sensitive Interventions for Fragile Contexts: A systematic review.
Abstract
Undernutrition in all its forms contributes to approximately 45% (3.1 million) of
preventable deaths in children under 5 each year. Effect following undernutrition i.e.
physical growth & cognitive development etc. can be prevented by acting during the
so-called ‘window of opportunity’ of the first 1,000 days. The first 1000 days is
deemed important as it corresponds to the entire period of intra-uterine development
plus the first 2 years of life of the child. There is considerable evidence of positive
nutrition outcomes resulting from integrating nutrition‐specific interventions into
nutrition specific program. However, current knowledge on establishing and
sustaining effective integration of nutrition intervention in fragile context is limited.
The objective of this review is to map the existing types of integration platforms and
review the evidence on integrated nutrition interventions/ program impacts on
specific nutrition outcomes.
In the study, we systematically searched the literature on integrated nutrition
intervention into multi-sectoral programme in PUBMED, Google’s Scholar, the
Cochrane Library, World Health Organisation (WHO), United Nations Children's Fund
(UNICEF), World Bank and trial registers from their inception until Oct 30, 2020 for
up-to-date published and grey resources. We screened records, extracted data, and
assessed risk of bias in duplicates. We rated the certainty of evidence according to
Cochrane methods and the GRADE approach. This study is registered with PROSPERO
(CRD42020209730).
Forty‐four studies were included in this review, outlining the integration of nutrition‐
specific interventions with various existing programme. Some of the existing
integration platform included integrated community case management and
Integrated Management of Childhood Illness, Child Health Days, immunization, early
31
child development, and cash transfers. Limited quantitative data were suggestive of
some positive impact on nutrition and non‐nutrition outcomes with no adverse effects
on primary programme delivery. From the 44 included studies we observed that there
were a number of model of integration which varies according to the context and
demands of the particular setting in which integration occurs. Overall, existing
evidence for nutrition sensitive and specific interventions remains limited by number,
quality and variability in design of studies. It’s worthwhile to note, prioritization of
interventions is strongly dependent on the context key criteria like relevance, political
support, effectiveness, feasibility, expected contribution to health system
strengthening, local capacities, ease of integration and targeting for sustainability,
cost effectiveness and financial availability.
Keywords
integration, nutrition outcome, nutrition specific, nutrition sensitive, multi-sectoral
programme
32
Contents
Abstract ................................................................................................... 30
Background .............................................................................................. 34
Broad Objective ...................................................................................... 36
Specific objectives: ................................................................................. 36
Methods: ................................................................................................. 36
Inclusion criteria ..................................................................................... 36
Types of studies .................................................................................. 36
Types of participants ............................................................................ 36
Study setting ...................................................................................... 37
Interventions ...................................................................................... 37
Comparison group ................................................................................ 38
Types of outcome measures .................................................................. 38
Exclusion criteria: ................................................................................ 39
Search methods for identification of studies ................................................ 39
Data collection and analysis ..................................................................... 40
Data extraction and management ............................................................. 40
Risk of bias (quality) assessment .............................................................. 40
Subgroup analysis: ................................................................................. 40
Assessment of heterogeneity .................................................................... 41
Data synthesis ....................................................................................... 41
Quality Assessments: .............................................................................. 41
Ethics approval: ..................................................................................... 41
Results .................................................................................................... 42
Results of the search ............................................................................... 42
Study description and geographical location. ............................................... 43
Nutrition integration platform ................................................................... 43
Risk of bias: .......................................................................................... 52
Impact of integration models or approaches on nutrition outcomes ................. 52
Best practices, drivers and bottlenecks to integration ................................... 57
Discussion ................................................................................................ 62
Recommendations ..................................................................................... 63
33
Appendices............................................................................................... 65
PRISMA guideline ................................................................................... 65
Pubmed search ...................................................................................... 68
Risk of bias assessment ........................................................................... 68
34
Background
Underweight, stunting and wasting are among internationally recognized key
indicators that are used to measure nutritional imbalance resulting in undernutrition.
Undernutrition is a major cause of disease and death in impoverished communities
i.e. fragile settings where sub-optimal growth is responsible for an estimated 2.2
million deaths annually in children under five years of age23. In 2018, stunting and
wasting affected 149 million and 49 million children, respectively, increasing their
susceptibility to mortality from infectious disease24. Stunting during childhood can
have irreversible, long-term effects, such as decreased adult productivity, depressed
cognitive function, and increased risk for obesity and low-birth-weight offspring25.
Under-nutrition has often been viewed as a problem of limited food availability and
solutions for addressing under-nutrition with main focus to increase food production.
However, such a vertical approach ignores a wide range of contributing factors which
nutrition interventions need to address in order to achieve tangible results. According
to the World Health Organization (WHO), integrated health services, also called the
‘horizontal’ approach, represent “the process of bringing together common functions
within and between organizations to solve common problems, developing a
commitment to shared vision and goals and using common technologies and
resources to achieve these goals.26 For example, access to safe drinking-water,
sanitation and hygiene (WASH) services is a fundamental element of healthy
communities and has an important positive impact on nutrition. To have a meaningful
WASH & Nutrition integration requires a good understanding of complex causes and
determinants of undernutrition.
For the purposes of this document, integration of multi-sectoral approach i.e. food
security and livelihood, education, WASH etc. into nutrition intervention is defined
broadly as including one or more nutrition specific interventions within a nutrition
23 Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C and J Rivera Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371(9608): 243-260. 24 World Health Organization. WHO Global Database on Child Growth and Malnutrition. 2019, WHO: Geneva. 25 Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L and HS Sachdev Maternal and child
undernutrition: consequences for adult health and human capital. Lancet 2008; 371(9609): 340-357. 26 World Health Organization Study Group on Integration of Health Care Delivery: Integration of health care delivery. WHO, Geneva, Switzerland 1996.
35
sensitive intervention or programmatic effort. In this context: nutrition-sensitive
interventions are interventions addressing the underlying determinants of fetal and
child nutrition and development: food security, adequate care giving resources at the
individual, household and community levels, access to health services and a safe and
hygienic environment and incorporate specific nutrition goals and actions. Nutrition-
specific interventions are interventions addressing the immediate determinants of
fetal and child nutrition and development: adequate food and nutrient intake,
feeding, care giving and parenting practices, access to clean sanitation environment
etc.
Aiming for a long term, sustainable and at scale impact on under-nutrition calls for
adopting a multi-sectoral approach and acting in an integrated way on all causal
context-specific factors leading to under-nutrition. Multi-sectoral program and
nutrition integration has to promote multi-level response strategies, linking curative,
preventive and longer term structural actions and acting jointly on existing immediate
and underlying causes of under-nutrition. Globally, policy makers and implementers
need to put in rigorous effort to explore innovative means to reduce the existing high
burden of malnutrition.27 One of the strategies is to strengthen integration of nutrition
interventions into existing programmes. Currently there have been significant
interest with minimal evidence in integration of nutrition sensitive interventions like
agriculture, social safety nets, early child development, classroom education and
WASH.28,29 Our study proposes to map and synthesis evidence on existing integration
platforms with a nutrition lens with an intention to enhance specific nutrition
outcomes.
27 Horton, Richard & Lo, Selina. (2013). Nutrition: A quintessential sustainable development goal. Lancet. 382. 10.1016/S0140-6736(13)61100-9. 28 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N; Maternal and Child Nutrition Study Group. The politics of reducing malnutrition: building commitment and accelerating progress. Lancet. 2013;382(9891):552-569. doi:10.1016/S0140-6736(13)60842-9 29 Ruel MT, Alderman H; Maternal and Child Nutrition Study Group. Nutrition-sensitive interventions
and programmes: how can they help to accelerate progress in improving maternal and child nutrition? [published correction appears in Lancet. 2013 Aug 10;382(9891):506]. Lancet. 2013;382(9891):536-551. doi:10.1016/S0140-6736(13)60843-0
36
Broad Objective
To synthesize evidence on integration of nutrition-specific and -sensitive
interventions in the global context and its applicability in fragile context.
Specific objectives:
a) Map the existing sector and multi-sectoral nutrition integration platforms.
b) Synthesize evidence on best practices for sector and multi-sectoral nutrition
integration platforms/programs (both nutrition‐specific and sensitive
interventions).
c) Review evidence on impact of integrated programs on specific nutrition
outcomes (such as maternal and child nutrition).
d) Identify internal and external drivers of program integrations in different
contexts.
e) Identify bottle necks to successful sector and multi-sectoral nutrition
intervention integration.
f) Document opportunities and suggestions to effective program integration of
nutrition interventions for Somalia context.
g)
Methods:
This study followed the Preferred Reporting Items for Systematic Review and Meta-
Analysis Protocols (PRISMA-P) 2015 checklist as indicated in appendix 1.
Inclusion criteria
Types of studies
We included quantitative & qualitative studies describing efforts & approaches to an
intervention (integration of services) of a nature including randomized controlled
trials (RCTs) and controlled clinical trials (CCTs), or quasi-experimental, controlled
before and after studies (CBAs), case studies, policy reports and guidelines.
Types of participants
We considered studies/ programme that reported on integration of nutrition sensitive
and specific interventions directed at populations with an intention to improve
nutrition outcome. The unit of analysis for this review are the programme rather than
37
the individual receiving the intervention. A programme integration is be defined as
program that incorporate nutrition specific and sensitive interventions with specific
nutrition goals and actions and explicit indicators.
Study setting
Global settings with applicability to fragile context. Based on the Fund for Peace the
Fragile States Index (FSI) 2020 list, the fragile countries 2020 includes Yemen, Syria,
Somalia, South Sudan, Afghanistan, Iraq, Central African Republic, Democratic
Republic of the Congo, Sudan & Mali.30
Interventions
Integrated management approach, with a focus on holistic and comprehensive
nutrition-specific and -sensitive interventions compared to a control. Nutrition specific
and sensitive services of particular interest include but not limited to;
a) Nutrition-specific interventions and programmes
• Promotion of exclusive breastfeeding in the first 6 months
• Promotion of appropriate, adequate and safe complementary feeding for
children aged 6-23 months
• Vitamin A supplementation for children aged 6-59 months
• Zinc supplementation for diarrhea management
• Deworming for children from 12-59 months
• Iron‐folic acid supplementation for pregnant women
• Food fortification of staple foods
• Salt iodization
• Multiple Micronutrient Supplementation (MNPs) for under5s
• Prevention and treatment of moderate acute under-nutrition
• Prevention and treatment of severe acute malnutrition
• Dietary diversity among pregnant and lactating mothers
30 The Fund for Peace. Fragile States Index (FSI) 2020 Fragility in the World 2020.
https://fragilestatesindex.org/.
38
• Adolescent health and preconception nutrition
Nutrition-specific interventions aim to address the more immediate causes of
undernutrition, such as inadequate dietary intake and poor health.
b) Nutrition-sensitive interventions
• Agriculture and food security
• Social protection (social safety nets programs such as CVAs, Food
Donations/Aids, NHIF, CT)
• Early childhood development and education (ECDE) (This will include child
stimulation play and responsiveness, Nutrition)
• Maternal mental health
• Women’s empowerment
• Child protection
• Water and sanitation (WASH)
• Health and family planning services
• Schooling
Nutrition-sensitive interventions address the underlying and basic causes of
undernutrition (e.g. poverty, food insecurity, education, women’s empowerment, and
social status) through indirect but plausible pathways. Nutrition-sensitive
interventions can also serve as delivery platforms for nutrition-specific
interventions31.
Comparison group
None
Types of outcome measures
1. Integrated programme characteristics to include:
• The programme start year, location(s) & duration;
• Level of programme integration at which implemented I.e. primary care,
secondary care, tertiary care, and quaternary care (teaching and referral
hospitals), public / private sector;
31Anne Bush and Jane Keylock, NutritionWorks . Strengthening Integration of Nutrition within Health
Sector Programmes An Evidence-based Planning Resource. European Commission.
39
• Whether the integration covers specific groups e.g. adults’ vs children,
pregnant and lactating women, under-fives, adolescents etc...
• Types of services /intervention integrated.
• What were the components of the integration process? i.e. was it joint
programme where clients were seen for example on the same day, or
was it just referral pathways between the services.
2. Programme integration: We will assess how the approach to integration was
developed and designed i.e.
• How the integration of nutrition sensitive and specific interventions was
executed;
• Challenges and barriers linked to the programme integration;
• Facilitators of programme integration.
3. Programme results
-What is the impact of integration broadly categorized as;
a) Impact on target group nutrition outcome
b) Impact on other key client-centred outcomes E.g. Number of client
visits required, client satisfaction
c) Impact on nutrition and health of households
Exclusion criteria: We excluded studies evaluating the impact of stand-alone
programmes on nutrition outcomes.
Search methods for identification of studies
We developed a comprehensive search strategy using the framework described in
appendix 2, for websites, peer-reviewed studies and grey literature with no time
and language limits, and the following databases will be included at a minimum:
PUBMED, Google’s Scholar database and the Cochrane Library. We searched the
websites of the World Health Organisation (WHO), United Nations Children's Fund
(UNICEF), World Bank and trial registers such as the International Clinical Trials
Registry Platform (ICTRP) for trials. Furthermore, we screened the reference lists of
all the included studies and related systematic reviews for other potentially eligible
primary studies.
40
Data collection and analysis
Two authors independently screen through titles and abstracts of the retrieved
records to identify potentially eligible studies. The full texts of the potentially eligible
studies will also be assessed using the pre-specified eligibility criteria. The two
authors compared lists of included studies and resolved discrepancies by discussion
and consensus. Disagreements was resolved through discussion and a third author
was contacted when the authors failed to reach consensus.
Data extraction and management
A data collection form was designed and used independently by two review authors
to extract data from the included studies. The following information was extracted
from each included study; study setting (region/site and country), type of study,
study participants, types and description of the intervention and study outcomes, as
described above.
Risk of bias (quality) assessment
The Cochrane Collaboration’s risk of bias tool was used for cluster and individual
randomized controlled trials32 and for non-randomized studies, the risk of bias in non-
randomized studies of interventions (ROBINS-I) tool was used.33 We did not assess
the risk of bias of guidelines/policies.
Subgroup analysis:
The following considerations was taken during subgroup analysis of review data: level
/ sector of the programme at which integration performed, types of services
integrated i.e. nutrition specific and sensitive service delivery, the intervention
approaches/strategies used.
32 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898. 33 Sterne J, Hernán M, McAleenan A, Reeves B, Higgins J. Chapter 25: Assessing risk of bias in a non-randomized study | Cochrane Training. Cochrane Handb Syst Rev Interv version 60 . 2019. https://training.cochrane.org/handbook/current/chapter-25.
41
Assessment of heterogeneity
For quantitative studies of similar interventions reporting similar outcomes, statistical
heterogeneity was examined using the chi-squared test for homogeneity (with
significance defined at 10% alpha level). Statistical heterogeneity was quantified
using the I2statistic. For qualitative studies or qualitative outcomes, heterogeneity
was discussed in the text only.
Data synthesis
We described data using standard summary statistics and perform meta-analysis
when more than 3 studies for each outcome meet the criteria for the systematic
review. Where the outcomes of interest were either dichotomous or continuous; we
calculated risk ratios and their corresponding 95% confidence intervals and p-values
for dichotomous outcomes, and mean differences and standard deviations for
continuous outcomes. Where outcomes are measured using different scales, we
calculated standardised mean differences (SMD). A random effects model was used
with the assumption that the true effect size varied between studies. For the outcome
measure that were qualitative in format i.e. patient satisfaction that cannot be
quantified, we discussed it narratively.
Quality Assessments:
A single author graded the certainty of evidence, with verification of all judgements
by a second author. The overall quality of evidence was conducted using a modified
GRADE approach.
Ethics approval:
This is a rapid review of existing literature and it does not require ethics approval.
42
Results
Results of the search
We identified 13,138 records from the electronic databases and grey sources. After
excluding 476 duplicates, we screened 12,662 records, and found that 12,602 records
were not relevant to our review question. We reviewed the remaining 60 potentially
eligible full-text articles for inclusion and excluded 16 of them with reasons listed in
Figure 1. Forty-four studies met the inclusion criteria and were described in Table
1 below. The search process and selection of studies is presented in the Prisma flow
diagram Figure 1 below.
Figure 2: Prisma flow chart
43
Study description and geographical location.
We included 44 papers that met the inclusion criteria. Studies ranged from individual
randomized control trials, Cluster RCT, cohort, cross-sectional studies, to qualitative
studies. The studies were representative from wide range of countries in four
continents i.e. Asia (India, Bangladesh, Philippines, Vietnam, Pakistan); Africa
(Congo, Sierra Leone, Ethiopia, Zambia, Madagascar, Malawi, Ghana, Niger, South
Africa, Uganda, Tanzania, Kenya); North America (Dominican Republic); South
America (Guatemala).
Nutrition integration platform
We reviewed and mapped 44 included studies according to the primary programmes
into which nutrition‐specific interventions were integrated. These primary
programmes, or “integration platforms,” included integrating nutrition into following
existing program:
a) Integrated Management of Childhood Illness and integrated community case
management (IMCI/iCCM),
b) Integrating management of severe and moderate acute malnutrition
(SAM/MAM) into health services,
c) Integrating nutrition into Child Health Days (CHD) and integrating nutrition
into immunization,
d) Integrating nutrition into social programmes, including ECD and cash transfers.
e) Other programmes;” i.e. programmes that integrated nutrition‐specific
interventions, including promotion of breastfeeding and appropriate
complementary feeding, feeding practices, growth monitoring, supplementary
nutrition, vitamin A supplementation, home fortification, screening and
management for malnutrition into existing community health facilities.
44
Table 1: Characteristics of included studies
Study ID Country Study design Integration
program
Nutrition Interventions Included
Arifeen et al., 200934 Bangladesh Cluster RCT Nutrition into
IMCI/iCCM
Counselling of mothers on breastfeeding
and appropriate complementary feeding,
local feeding practices, growth
monitoring, supplementary nutrition,
vitamin A supplementation, and
screening, management and referral for
malnutrition.
Armstrong et al.,
200435
Tanzania Cross-sectional study
Bhandari et al., 201236 India Cluster RCT
Bryce et al., 200537 Tanzania Non-RCT
El Arifeen et al., 200438 Bangladesh Cluster RCT
Friedman & Wolfheim,
201439
Multi-countries Mixed studies
Masanja et al., 200540 Tanzania Cross-sectional study
34 Arifeen, S. E., Hoque, D. E., Akter, T., Rahman, M., Hoque, M. E., Begum, K., & Ahmed, S. (2009). Effect of the integrated management of childhood illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: A cluster randomised trial. The Lancet, 374(9687), 393–403. https://doi.org/10.1016/S0140‐6736(09)60828‐X 35 Armstrong, S. J., Bryce, J., de Savigny, D., Lambrechts, T., Mbuya, C., Mgalula, L., & Wilczynska, K. (2004). The effect of integrated management of childhood illness on observed quality of care of under‐fives in rural Tanzania. Health Policy and Planning, 19(1), 1–10. 36 Bhandari, N., Mazumder, S., Taneja, S., Sommerfelt, H., & Strand, T. A. (2012). Effect of implementation of integrated management of neonatal and childhood Illness (IMNCI) programme on neonatal and infant mortality: Cluster randomised controlled trial. BMJ, 344, e1634.
https://doi.org/10.1136/bmj.e1634 37 Bryce, J., Gouws, E., Adam, T., Black, R. E., Schellenberg, J. A., Manzi, F., … Habicht, J.‐P. (2005). Improving quality and efficiency of
facility‐based child health care through integrated management of childhood illness in Tanzania. Health Policy and Planning, 20(suppl_1), i69–
i76. https:// doi.org/10.1093/heapol/czi053 38 El Arifeen, S., Blum, L. S., Hoque, D. E., Chowdhury, E. K., Khan, R., Black, R. E., & Bryce, J. (2004). Integrated management of childhood illness (IMCI) in Bangladesh: Early findings from a cluster‐randomised study. The Lancet, 364(9445), 1595–1602.
https://doi.org/10.1016/S0140‐ 6736(04)17312‐1 39 Friedman, L., & WoLFheim, C. (2014). Linking nutrition & (integrated) Community Case management. A review of operational experiences. London: Children's Investment Fund Foundation, Save the Children, ACF. 40 Masanja, H., Schellenberg, J. A., De Savigny, D., Mshinda, H., & Victora, C. G. (2005). Impact of Integrated Management of Childhood Illness on inequalities in child health in rural Tanzania. Health Policy and Planning, 20(suppl_1), i77–i84. https://doi.org/10.1093/heapol/ czi054
45
Study ID Country Study design Integration
program
Nutrition Interventions Included
Mazumder et al.,
201441
India Cluster RCT
Miller et al., 201442 Ethiopia Cross-sectional study
Rasanathan et al.,
201443
Sub-Saharan
countries
Cross-sectional study
Schellenberg et al.,
200444
Tanzania Cross-sectional study
Taneja et al., 201545 India Cluster RCT
Aguayo et al., 201346 India Cross-sectional study
41 Mazumder, S., Taneja, S., Bahl, R., Mohan, P., Strand, T. A., Sommerfelt, H., … Martines, J. (2014). Effect of implementation of integrated management of neonatal and childhood illness programme on treatment seeking practices for morbidities in infants: Cluster randomised trial. BMJ, 349, g4988. https://doi.org/10.1136/bmj.g4988 42 Miller, N. P., Amouzou, A., Tafesse, M., Hazel, E., Legesse, H., Degefie, T., & Bryce, J. (2014). Integrated community case management of childhood illness in Ethiopia: Implementation strength and quality of care. The American Journal of Tropical Medicine and Hygiene, 91(2),
424–434. https://doi.org/10.4269/ajtmh.13‐0751 43 Rasanathan, K., Muñiz, M., Bakshi, S., Kumar, M., Solano, A., Kariuki, W., & Young, M. (2014). Community case management of childhood illness in sub‐Saharan Africa—Findings from a cross‐sectional survey on policy and implementation. Journal of Global Health, 4(2). 44 Schellenberg, J. R. A., Adam, T., Mshinda, H., Masanja, H., Kabadi, G., Mukasa, O., & Wilczynska, K. (2004). Effectiveness and cost of
facility‐based integrated management of childhood illness (IMCI) in Tanzania. The Lancet, 364(9445), 1583–1594. https://doi.org/
10.1016/S0140‐6736(04)17311‐X 45 Taneja, S., Bahl, S., Mazumder, S., Martines, J., Bhandari, N., & Bhan, M. K. (2015). Impact on inequities in health indicators: Effect of implementing the integrated management of neonatal and childhood illness programme in Haryana, India. Journal of Global Health, 5(1). https://doi.org/10.7189/jogh.05.010401 46 Aguayo, V. M., Agarwal, V., Agnani, M., Agrawal, D. D., Bhambhal, S., Rawat, A. K., & Singh, K. (2013). Integrated program achieves good survival but moderate recovery rates among children with severe acute malnutrition in India. The American Journal of Clinical Nutrition, 98(5), 1335–1342. https://doi.org/10.3945/ajcn.112.054080
46
Study ID Country Study design Integration
program
Nutrition Interventions Included
Amadi et al., 201647 Zambia Cohort study SAM/MAM into
Health Services
Community and facility-based
management of SAM and MAM. Brits et al., 201748 South Africa Cohort study
Deconinck et al.,
201649
Niger Qualitative study
Kouam et al., 201450 Bangladesh Qualitative study
Puett et al., 201551 Bangladesh Qualitative study
Puett et al., 201352 Bangladesh Mixed study
Sadler et al., 201153 Bangladesh Cross-sectional study
47 Amadi, B., Imikendu, M., Sakala, M., Banda, R., & Kelly, P. (2016). Integration of HIV care into community management of acute childhood
malnutrition permits good outcomes: Retrospective analysis of three years of a programme in Lusaka. PLoS One, 11(3), e0149218. https:// doi.org/10.1371/journal.pone.0149218 48 Brits, H., Joubert, G., Eyman, K., De Vink, R., Lesaoana, K., Makhetha, S., & Moeketsi, K. (2017). An assessment of the integrated nutrition programme for malnourished children aged six months to five years at primary healthcare facilities in Mangaung, Free State, South Africa. South African Family Practice, 59(6), 214–218. https://doi.org/ 10.1080/20786190.2017.1340252 49 Deconinck, H., Hallarou, M. E., Pesonen, A., Gérard, J. C., Criel, B., Donnen, P., & Macq, J. (2016). Understanding factors that influence the integration of acute malnutrition interventions into the national health system in Niger. Health Policy and Planning, 31(10), 1364–1373.
https://doi. org/10.1093/heapol/czw073 50 Kouam, C. E., Delisle, H., Ebbing, H. J., Israël, A. D., Salpéteur, C., Aïssa, M. A., & Ridde, V. (2014). Perspectives for integration into the local health system of community‐based management of acute malnutrition in children under 5 years: A qualitative study in Bangladesh.
Nutrition Journal, 13(1), 22. https://doi.org/10.1186/1475‐2891‐13‐22 51 Puett, C., Alderman, H., Sadler, K., & Coates, J. (2015). ‘Sometimes they fail to keep their faith in us’: Community health worker perceptions of structural barriers to quality of care and community utilisation of services in Bangladesh. Maternal & Child Nutrition, 11(4), 1011–1022. https://doi.org/10.1111/mcn.12072 52 Puett, C., Coates, J., Alderman, H., & Sadler, K. (2013). Quality of care for severe acute malnutrition delivered by community health
workers in southern Bangladesh. Maternal & Child Nutrition, 9(1), 130–142. https://doi.org/10.1111/j.1740‐8709.2012.00409.x 53 Sadler, K., Puett, C., Mothabbir, G., & Myatt, M. (2011). Community case management of severe acute malnutrition in southern Bangladesh. Boston: Tufts University.
47
Study ID Country Study design Integration
program
Nutrition Interventions Included
Tadesse et al., 201754 Ethiopia Cohort study
Doherty et al., 201055 Ethiopia,
Madagascar,
Tanzania,
Uganda,
Zambia,
Zimbabwe
Cross-sectional study Nutrition into
Child Health
Days
Vitamin A supplementation and nutrition
screening.
Palmer et al., 201356 Multi-countries Cross-sectional study
Anand et al., 201257
28 sub-Saharan
African
countries
Cross-sectional study Nutrition into
Immunization
Vitamin A supplementation, early and
exclusive breastfeeding, infant and
young child feeding practices and growth
monitoring. Baqui et al., 200858 India Quasi-experimental
54 Tadesse, E., Worku, A., Berhane, Y., & Ekström, E. C. (2017). An integrated community‐based outpatient therapeutic feeding programme
for severe acute malnutrition in rural Southern Ethiopia: Recovery, fatality, and nutritional status after discharge. Maternal & Child Nutrition. 55 Doherty, T., Chopra, M., Tomlinson, M., Oliphant, N., Nsibande, D., & Mason, J. (2010). Moving from vertical to integrated child health programmes: Experiences from a multi‐country assessment of the Child Health Days approach in Africa. Tropical Medicine & International
Health, 15(3), 296–305. https://doi.org/10.1111/j.1365‐ 3156.2009.02454.x 56 Palmer, A. C., Diaz, T., Noordam, A. C., & Dalmiya, N. (2013). Evolution of the child health day strategy for the integrated delivery of child health and nutrition services. Food and Nutrition Bulletin, 34(4), 412–419. https://doi.org/10.1177/156482651303400406 57 Anand, A., Luman, E. T., & O'Connor, P. M. (2012). Building on success— Potential to improve coverage of multiple health interventions through integrated delivery with routine childhood vaccination. Journal of Infectious Diseases, 205(suppl_1), S28–S39. https://doi.org/10.1093/infdis/ jir794 58 Baqui, A., Williams, E. K., Rosecrans, A. M., Agrawal, P. K., Ahmed, S., Darmstadt, G. L., & Ahuja, R. C. (2008). Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India. Bulletin of the World Health Organization, 86(10), 796–804A. https://doi.org/ 10.2471/BLT.07.042226
48
Study ID Country Study design Integration
program
Nutrition Interventions Included
Ching et al., 200059 Philippines and
Vietnam
Cross-sectional study
Hodges et al., 201560 Sierra Leone Quasi-experimental
Klemm et al., 199661 Philippines Cross-sectional study
Ropero-Álvarez et al.,
201262
Multi-countries Cross-sectional study
Fernandez‐Rao et al.,
201463
India RCT Nutrition into
ECD
Home/preschool fortification with
multiple micronutrient powder,
responsive stimulation, early nutrition Gowani et al., 201464 Pakistan RCT
59 Ching, P., Birmingham, M., Goodman, T., Sutter, R., & Loevinsohn, B. (2000). Childhood mortality impact and costs of integrating vitamin A supplementation into immunization campaigns. American Journal of Public Health, 90(10), 1526–1529. 60 Hodges, M. H., Sesay, F. F., Kamara, H. I., Nyorkor, E. D., Bah, M., Koroma, A. S., & Katcher, H. I. (2015). Integrating vitamin A supplementation at 6 months into the expanded program of immunization in Sierra Leone. Maternal and Child Health Journal, 19(9), 1985–
1992. https://doi.org/ 10.1007/s10995‐015‐1706‐1 61 Klemm, R. D., Villate, E. E., Tuazon‐Lopez, C., & Ramos, A. C. (1996). Coverage and impact of adding vitamin a capsule (VAC) distribution
to annual national immunisation day in the Philippines. Manila: Philippines Department of Health and Helen Keller International. 62 Ropero‐Álvarez, A. M., Kurtis, H. J., Danovaro‐Holliday, M. C., Ruiz‐Matus, C., & Tambini, G. (2012). Vaccination week in the Americas: An
opportunity to integrate other health services with immunization. Journal of Infectious Diseases, 205(suppl_1), S120–S125. https://doi.org/ 10.1093/infdis/jir773 63 Fernandez‐Rao, S., Hurley, K. M., Nair, K. M., Balakrishna, N., Radhakrishna, K. V., Ravinder, P., … Black, M. M. (2014). Integrating
nutrition and early child‐development interventions among infants and preschoolers in rural India. Annals of the New York Academy of
Sciences, 1308(1), 218–231. https://doi.org/10.1111/nyas.12278 64 Gowani, S., Yousafzai, A. K., Armstrong, R., & Bhutta, Z. A. (2014). Cost effectiveness of responsive stimulation and nutrition interventions on early child development outcomes in Pakistan. Annals of the New York Academy of Sciences, 1308(1), 149–161. https://doi.org/10.1111/ nyas.12367
49
Study ID Country Study design Integration
program
Nutrition Interventions Included
Yousafzai et al., 201465 India RCT interventions, monitoring of child
nutrition and growth promotion.
Grellety et al., 201766 Congo RCT Nutrition into
Cash Transfer
Programs
Treatment of SAM according to the
national protocol and counselling with or
without a cash supplement of US$40
monthly for 6 months.
Berti et al., 201067 Ethiopia,
Ghana, Malawi
& Tanzania
Cross-sectional
survey
Nutrition into
Other Programs
Infant and young child feeding practices
and micronutrient supplementation.
Fagerli et al., 201768 Kenya Cross-sectional study
Grossmann et al.,
201569
Guatamala Before and after
study
65 Yousafzai, A. K., Rasheed, M. A., Rizvi, A., Armstrong, R., & Bhutta, Z. A. (2014). Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: A cluster‐randomised
factorial effectiveness trial. The Lancet, 384(9950), 1282–1293. https:// doi.org/10.1016/S0140‐6736(14)60455‐4 66 Grellety, E., Babakazo, P., Bangana, A., Mwamba, G., Lezama, I., Zagre, N. M., & Ategbo, E.‐A. (2017). Effects of unconditional cash
transfers on the outcome of treatment for severe acute malnutrition (SAM): A cluster‐randomised trial in the Democratic Republic of the
Congo. BMC Medicine, 15(1), 87. https://doi.org/10.1186/s12916‐017‐ 0848‐y 67 Berti, P. R., Mildon, A., Siekmans, K., Main, B., & MacDonald, C. (2010). An adequacy evaluation of a 10‐year, four‐country nutrition and
health programme. International Journal of Epidemiology, 39(2), 613–629. https://doi.org/10.1093/ije/dyp389 68 Fagerli, K., O'Connor, K., Kim, S., Kelley, M., Odhiambo, A., Faith, S., … Quick, R. (2017). Impact of the integration of water treatment, hygiene, nutrition, and clean delivery interventions on maternal health service use. The American Journal of Tropical Medicine and Hygiene,
96(5), 1253–1260. https://doi.org/10.4269/ajtmh.16‐0709 69 Grossmann, V. M., Turner, B. S., Snyder, D., Stewart, R. D., Bowen, T., Cifuentes, A. A., & Cliff, C. (2015). Zinc and vitamin supplementation in an under‐5 indigenous population of Guatemala: Influence of lay health promoters in decreasing incidence of diarrhea.
Journal of Transcultural Nursing, 26(4), 402–408. https://doi.org/10.1177/ 1043659614524786
50
Study ID Country Study design Integration
program
Nutrition Interventions Included
Guyon et al., 200970 Madagascar Before and after
study
Nguyen et al., 201771 Bangladesh Cluster-RCT
Parikh et al., 201072 Dominican
Republic
Cross-sectional study
Saiyed & Seshadri,
200073
India Cross-sectional study
Singh et al., 201774 India Quasi experimental
Sivanesan et al.,
201675
India Cross-sectional study
70 Guyon, A. B., Quinn, V. J., Hainsworth, M., Ravonimanantsoa, P., Ravelojoana, V., Rambeloson, Z., & Martin, L. (2009). Implementing an integrated nutrition package at large scale in Madagascar: The essential nutrition actions framework. Food and Nutrition Bulletin, 30(3), 233–244. https://doi.org/10.1177/156482650903000304 71 Nguyen, P. H., Kim, S. S., Sanghvi, T., Mahmud, Z., Tran, L. M., Shabnam, S., … Frongillo, E. A. (2017). Integrating nutrition interventions into an existing maternal, neonatal, and child health program increased maternal dietary diversity, micronutrient intake, and exclusive
breastfeeding practices in Bangladesh: Results of a cluster‐randomized program evaluation. The Journal of Nutrition, 147(12), 2326–2337.
https://doi.org/ 10.3945/jn.117.257303 72 Parikh, K., Marein‐Efron, G., Huang, S., O'Hare, G., Finalle, R., & Shah, S. S. (2010). Nutritional status of children after a food‐supplementation program integrated with routine health care through mobile clinics in migrant communities in the Dominican Republic. The
American Journal of Tropical Medicine and Hygiene, 83(3), 559–564. https://doi.org/ 10.4269/ajtmh.2010.09‐0485 73 Saiyed, F., & Seshadri, S. (2000). Impact of the integrated package of nutrition and health services. Indian Journal of Pediatrics, 67(5), 322–328. https://doi.org/10.1007/BF02820677 74 Singh, V., Ahmed, S., Dreyfuss, M. L., Kiran, U., Chaudhery, D. N., Srivastava, V. K., & Santosham, M. (2017). Non‐governmental
organization facilitation of a community‐based nutrition and health program: Effect on program exposure and associated infant feeding
practices in rural India. PLoS One, 12(9), e0183316. https://doi.org/10.1371/ journal.pone.0183316 75 Sivanesan, S., Kumar, A., Kulkarni, M. M., Kamath, A., & Shetty, A. (2016). Utilization of integrated child development services (ICDS) scheme by child beneficiaries in Coastal Karnataka India. Indian Journal of Community Health, 28(2), 132–138.
51
Study ID Country Study design Integration
program
Nutrition Interventions Included
Tandon, 198976 India Cross-sectional study
Head Jeniffer 199977 Ethiopia Cross-sectional study
76 Tandon, B. (1989). Nutritional interventions through primary health care: Impact of the ICDS projects in India. Bulletin of the World Health Organization, 67(1), 77–80 77 Head, Jennifer & Pachón, H & Tadesse, Wasihun & Tesfamariam, M & Freeman, MC. (2019). Integration of water, sanitation, hygiene and nutrition programming is associated with lower prevalence of child stunting and fever in Oromia, Ethiopia. African Journal of Food Agriculture Nutrition and Development. 19. 14971-14993. 10.18697/ajfand.87.17785.
52
Risk of bias:
Of the 14 randomized control study, most of the included studies were at ranging
from high to moderate risk of bias for randomization due to inadequate sequence
generation and allocation concealment, as well as the lack of blinding of the
participants and personnel and blinding of the outcome assessor. Blinding could not
be achieved due to the nature of the intervention. For the remaining 30 observational
studies the risk of bias was equally moderate as most of the domains on the risk of
bias assessment were elaborated to be with some flaws. Detailed risk of bias for both
randomized and observation studies are elaborated in appendix 3a & b respectively.
Impact of integration models or approaches on nutrition outcomes
Integrated nutrition intervention and IMCI/iCCM programmes
a) Integrated nutrition intervention and IMCI/iCCM programmes on complementary
feeding: Three studies 78,79,80 pooled analysis of nutrition‐specific outcomes
suggests that the effect of integrated program enhanced the complimentary
feeding practices by 5% compared to the non-integrated program. However, there
was no statistically significant difference in the effect of integration on
complimentary feeding practices among the group Fig 2. Complimentary feeding
practices targeted children aged 6–9 months receiving breast milk and
complementary feeding. The nutrition specific outcome included counselling of
mothers on breastfeeding and appropriate complementary feeding, local feeding
practices, growth monitoring, supplementary nutrition, vitamin A
supplementation, and screening, management and referral for malnutrition.
Figure 3: Effect of Integrated program on complementary feeding nutrition outcome
78 Schellenberg 2014, pg 18 79 Mazumder 2014, pg 18 80 Arifeen 2009, pg 17
53
b) Integrated nutrition intervention and IMCI/iCCM programmes on exclusive
breastfeeding: Three studies 81,82,83 pooled analysis of nutrition‐specific outcomes
suggests that the effect of integrated program enhanced the exclusive
breastfeeding practices among children younger than 6 months by 27% compared
to the non-integrated program and the effect showed a statistically significant
difference among the integrated group Fig 3. The nutrition specific outcome
included counselling of mothers on breastfeeding and appropriate complementary
feeding, local feeding practices, growth monitoring, supplementary nutrition,
vitamin A supplementation, and screening, management and referral for
malnutrition.
Figure 4: Effect of Integrated program on exclusive breastfeeding nutrition outcome
c) Integrated nutrition intervention and IMCI/iCCM programmes on stunting: Two
studies 84,85 pooled analysis of nutrition‐specific outcomes suggests that integrated
program had no protective effect in stunting among children aged 24–59 months
compared to the non-integrated program and the effect showed a no statistically
significant difference among the groups Fig 4. The nutrition specific outcome
included counselling of mothers on breastfeeding and appropriate complementary
feeding, local feeding practices, growth monitoring, supplementary nutrition,
vitamin A supplementation, and screening, management and referral for
malnutrition.
81 Schellenberg 2014, pg 18 82 Mazumder 2014, pg 18 83 Arifeen 2009, pg 17 84 Schellenberg 2014, pg 18 85 Mazumder 2014, pg 18
54
Figure 5: Effect of Integrated program on stunting
d) Integrated nutrition intervention and IMCI/iCCM programmes on wasting: Two
studies 86,87 pooled analysis of nutrition‐specific outcomes suggests that integrated
program had no protective effect in wasting among children aged 0–23 months
(<−2 WHZ) compared to the non-integrated program and the effect showed a
statistically significant difference among the groups Fig 5. The nutrition specific
outcome included counselling of mothers on breastfeeding and appropriate
complementary feeding, local feeding practices, growth monitoring,
supplementary nutrition, vitamin A supplementation, and screening, management
and referral for malnutrition.
Figure 6: Effect of Integrated program on wasting
Integrated nutrition intervention and immunisation programmes
a) Integrated nutrition intervention and immunisation programmes on initiated
breastfeeding within first hour: Two studies 88,89 pooled analysis of nutrition‐
specific outcomes suggests that the effect of integrated program enhanced the
early breastfeeding initiation practices within 1 hour of delivery by 3 times
compared to the non-integrated program and the effect showed a statistically
significant difference among the integrated group Fig 6. The nutrition specific
86 Schellenberg 2014, pg 18 87 Mazumder 2014, pg 18 88 Hodges 2015, pg 21 89 Bangui 2008, pg 21
55
outcome included Vitamin A supplementation, early and exclusive breastfeeding,
infant and young child feeding practices and growth monitoring.
Figure 7: Effect of Integrated program on breastfeeding initiation
b) Integrated nutrition intervention and immunisation programmes on underweight:
Two studies 90,91 pooled analysis of nutrition‐specific outcomes suggests that the
effect of integrated program was protective toward underweight of children more
than2 years by 53% compared to the non-integrated program and the effect
showed a statistically significant difference among the integrated group Fig 7.
The nutrition specific outcome included Vitamin A supplementation, early and
exclusive breastfeeding, infant and young child feeding practices and growth
monitoring.
Figure 8: Effect of Integrated program on underweight
Two platforms (CHD and ECD programmes) did not have sufficient data for
quantitative analysis of outcomes. Table 1 summarizes the estimates for the pooled
outcomes reported as we could not conduct a meta‐analysis for any of the nutrition‐
specific or non‐nutrition outcomes where studies were one‐time cross‐sectional
surveys and did not provide data for comparison.
90 Klemm1996, pg 21 91 Hodges 2015, pg 21
56
For integrated SAM/MAM programmes, recovery from SAM was reported to range
from 18% in a facility‐based management programme in India to 23% in the primary
care health care system in Ethiopia, 50% in South Africa, 65% in the community
component in India, and 70% in Zambia92,93,94,95. In the integrated Zambia
programme, recovery from MAM was demonstrated to be around 80%, and the study
reported an impact on SAM case fatality rates 96. A single study on integrated nutrition
and cash transfer programmes 97 reported higher SAM recovery, lower MAM relapse,
and lower SAM relapse in the integrated group compared with the control group.
Change in weight, weight for age z score, weight for height z score, and body mass
index z score were also significantly better in the intervention group compared with
the control group. The study reported to have no difference in change in
height/length, height/age, or mid‐upper arm circumference between intervention and
control groups.
There were other integrated nutrition and other programmes that could not be
categorized in the above platforms and integrated nutrition‐specific interventions.
The programmes includes promotion of breastfeeding and appropriate
complementary feeding, feeding practices, growth monitoring, supplementary
nutrition, vitamin A supplementation, home fortification, screening and management
for malnutrition into existing community health setups, and maternal, newborn, and
child health centres and clinics). The studies were one-time cross-sectional surveys
hence we could not pool any of the outcomes.
Narratively, among nutrition‐specific outcomes, the India programme showed
significantly improved early initiation of breastfeeding and exclusive breastfeeding 98,
and programmes for Kenya and Bangladesh suggested significantly higher
intervention coverage for vitamin A supplementation, paediatric iron folic acid
supplementation, and supplementary nutrition99,100. The Kenya programme also
92 Aguayo 2013, pg 19 93 Amadi 2016, pg 19 94 Brits 2017, pg 19 95 Tadesse 2017, pg 20 96 Amadi 2016, pg 19 97 Grellety 2017, pg 23 98 Singh 2017, pg 24 99 Fagerli 2017, pg 23 100 Nguyen 2017, pg 24
57
reported significant increase in the exclusive breastfeeding rates from baseline to end
line, as well as improved antenatal visits, health facility delivery, and postnatal visits
101.
Best practices, drivers and bottlenecks to integration
A growing body of evidence supports the notion that integration of nutrition sensitive
programs and nutrition specific interventions provide stronger impacts on nutritional
and non-nutritional outcomes than either intervention alone. Combined interventions
may be more efficient than separate interventions, because they are intended for the
same population and make use of the same facilities, transportation, and client
contacts. In addition, for families, particularly for those most at risk, combined
interventions can also lead to increased access to services. In the included studies
table two below summarises the findings and opportunities or barriers that were
observed in eight studies during integration of nutrition interventions to various
program. Thematically some of the key drivers/ opportunities that facilitated, and
barriers that hindered, integration can be summarized as table 2 below.
Key drivers/opportunities that facilitated the integration were:
• Broad context: political readiness, interest, and support and progress
monitoring for resilience and development initiatives
• Nature of the problem: knowledge of causes and consequences of illness and
prevention and treatment pathways, accurate information on the burden of
disease, and political and social environment to recognize the problem and
initiate change
• Intervention: skill development; decentralised care increasing exposure,
access, utilization and involvement; quality of care showing effectiveness and
increasing awareness and user satisfaction; and clinical, organizational and
management capacities in successful sites
• Adoption system: compatibility with personal, professional and institutional
goals, values and principles; collaborative support, engagement and
involvement; learning and career development opportunities; and support for
problem solving
101 Fagerli 2017, pg 23
58
• Health system characteristics: policy adaptation and translation; expanded,
regulated and aligned partnerships; expanded health workforce; and
decentralised care
Key barriers that hindered the integration were:
• Broad context: demographic pressure and multi-sectoral approach diverting a
sectoral focus • Nature of the problem: missing evidence
• Intervention: clinical, organizational and management capacity gaps in certain
sites, interventions substituted by partners and limited community awareness
and involvement reinforcing mistrust
• Adoption system: partner support favouring evading responsibility; lack of
interest or motivation or collaboration in care and learning, feeling of curtailed
career development, and high workload
• Health system characteristics: multiple health information systems;
underfunded health budget; short-term emergency funding; high staff
turnover and attrition; limited logistic capacity for bulky, expensive supplies;
and limited community and patient/ care giver involvement and empowerment
59
Table 2: bottle neck and opportunities associated with best practices on integration model.
Study ID Integration
program
Key findings/ Recommendations Barriers and opportunities for
improvement
Armstrong et al.,
2004102
There were few differences between
IMCI and comparison districts in the
level of health system
support for child health services at
facility level.
Opportunities: IMCI, in the presence of a
decentralized health system with practical
health system planning tools, is feasible for
implementation in resource poor countries
and can lead to rapid gains in the quality of
case-management.
Bhandari et al.,
2012103
Implementation of the IMNCI resulted in
substantial improvement in infant
survival and in neonatal survival in those
born at home.
Opportunities: High quality training,
ensuring adequate supervision, timely
supplies, and task based incentives
to community health workers was critical for
the observed effect.
Aguayo et al.,
2013104
SAM/MAM into
Health Services
The survival rates in the integrated
model for the management of SAM (IM-
SAM) program were very high
Opportunities: Existing health systems can
be strengthened with feasible adjustments
i.e. integrated model that comprises facility-
and community-based therapeutic care
Amadi et al.,
2016105
Comprehensive community malnutrition
programme, incorporating HIV care, can
achieve low mortality
Opportunities: Community-based screening
may seem like a resource-intensive approach
but the result is justified
102 Armstrong 2004, pg 17 103 Bhandari 2012, pg 17 104 Aguayo 2013, pg 19 105 Amadi 2016, pg 19
60
Study ID Integration
program
Key findings/ Recommendations Barriers and opportunities for
improvement
Brits et al., 2017106 Half of the children improved from
severe malnutrition to underweight or
exited at target weight
Barriers observed include; obstacles in
implementing the guidelines correctly and
lack of monitoring of the integrated program.
Deconinck et al.,
2016107
Key hindering factors identified were not
fully understanding severity, causes and
consequences
of the problem
Barriers: lack of information on burden of
acute malnutrition, recognition of the public
health priority, leadership for policy
adaptations and implementation, technical
and financial resources, effectiveness of
the intervention and capabilities and
motivation of health actors.
Baqui et al.,
2008108
Most of the reduction in mortality was in
the group who were visited within the
first 3 days of birth
Opportunities: Reaching newborn babies at
the community level is crucial in settings
where the availability and utilization of
facility-based care is low.
Systems must also be put in place to ensure
that these workers visit neonates at home
during the first hours and days after birth and
provide a link to competent
health services
Barriers: Workers’ competency in the new
neonatal component of the programme, their
workload and inadequate management and
supervision were possible barriers to higher
coverage.
106 Brits 2017, pg 19 107 Deconinck 2016, pg 19 108 Baqui 2008, pg 21
61
Study ID Integration
program
Key findings/ Recommendations Barriers and opportunities for
improvement
Fagerli et al.,
2017109
The study shows multi-sectoral
integration including hygiene,
nutritional, clean delivery incentives,
higher education level, and geographical
contiguity to health facility were
associated with increased use of
maternal health services by pregnant
women.
Barriers: low education level, distance from
health facilities, and poor socioeconomic
status.
109 Fagerli 2017, pg 23
62
Discussion
Nutrition-specific interventions aim to address the more immediate causes of
undernutrition, such as inadequate dietary intake and poor health. These could have
a dramatic impact on reducing malnutrition. Nutrition-specific interventions alone will
not eliminate undernutrition; however, in combination with nutrition-sensitive
interventions, there is enormous potential to enhance the effectiveness of nutrition
investments worldwide. Nutrition-sensitive interventions address the underlying and
basic causes of undernutrition (e.g. poverty, food insecurity, education, women’s
empowerment, and social status) through indirect but plausible pathways.
Interventions such as agriculture, livelihoods, social safety nets, women’s
empowerment, education, and early child development, all contribute indirectly to
improving nutrition outcomes. Nutrition-sensitive interventions can also serve as
delivery platforms for nutrition-specific interventions. Harmonisation of interventions
and messages across community platforms of different sectors is crucial for
coherence.
Combined interventions may be more efficient than separate interventions, because
they are intended for the same population and make use of the same facilities,
transportation, and client contacts. However, in order for integrated nutrition to be
embedded to multi-sectoral program successfully, a variety of opportunities and
challenges must be addressed. From an intervention perspective, the key to
successful integration was evidence-based strategy; from a program perspective, it
was leadership, capacities and resources; from an adoption system perspective, it
was knowledge, capabilities, motivation and opportunities to provide quality
interventions; and from the broader context perspective, it was political interest and
recognized need. Key challenges that need to be addressed include workload of staff
and supervisors, communication and coordination among different integrated
programmes and among staff in different sectors, and an acknowledgement at the
national and community levels that comprehensive address both nutrition and non-
nutrition outcome.
There is currently a great interest and need to document the true costs and benefits
of integrating interventions for young children across relevant sectors and building
on existing community resources. However, at present, there is paucity of data on
63
this important element of integrated programming and most importantly in fragile
context. Hence a need for a robust evidence to address the need.
Most importantly, the prioritisation of interventions in any context should be based
on a robust situational analysis supported by strong evidence. Despite strong
associations and plausible impact pathways, the existing evidence base for some
nutrition interventions, especially nutrition sensitive approaches, remains limited by
number, quality and variability in design of studies. Prioritisation of interventions is
also strongly dependent on the following criteria: relevance, political support,
effectiveness, feasibility, expected contribution to health system strengthening, local
capacities, ease of integration and targeting for sustainability, cost effectiveness, and
dependent on available financing and presence of a funding gap.
Investments in the generation of robust and relevant evidence to inform
implementation, strengthen accountability and guide the evolution of policies to
ensure optimal nutrition impact should be considered an essential design component.
Ensuring the incorporation of both high impact nutrition specific interventions and
essential nutrition sensitive intervention areas in the multi-sector must be understood
as a key component of any broader national commitment and multi-sectoral strategic
framework for eradicating malnutrition through a rights-based approach.
Conclusion
Combined interventions may be more efficient in integration of nutrition intervention
into multi-sectoral program. For example, a comprehensive package not limited to;
hygiene, nutritional services, clean delivery incentives, awareness and education, and
distance to services motivated an increase in the use of services. Over and above,
community-level nutrition integration actions show the breadth and variety of
nutrition-related positive outcomes across the studies.
Recommendations
There is scarce data around integrated nutrition programmes in fragile context. Either
way in other context shows mixed evidence and information gaps. The evidence does
suggest, however, that there is much potential for integrating nutrition interventions
into related programmes to ensure adequate, efficient service delivery, and impact
on nutrition outcome. We recommend that context-specific learning of integrating
malnutrition may expand to include causal modelling and scenario testing to inform
64
strategy designs. The method may also be applied to monitor progress of integrating
nutrition by the multi-sectoral nutrition plan to guide change.
65
Appendices
6.1 Appendix 1: PRISMA guideline
Section/topic # Checklist item Reported on
page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 39
ABSTRACT
Structured
summary
2 Provide a structured summary including, as applicable: background;
objectives; data sources; study eligibility criteria, participants, and
interventions; study appraisal and synthesis methods; results; limitations;
conclusions and implications of key findings; systematic review registration
number.
39/40
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 42/43
Objectives 4 Provide an explicit statement of questions being addressed with reference to
participants, interventions, comparisons, outcomes, and study design
(PICOS).
43
METHODS
Protocol and
registration
5 Indicate if a review protocol exists, if and where it can be accessed (e.g.,
Web address), and, if available, provide registration information including
registration number.
CRD42020209730
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report
characteristics (e.g., years considered, language, publication status) used as
criteria for eligibility, giving rationale.
44/46
Information sources 7 Describe all information sources (e.g., databases with dates of coverage,
contact with study authors to identify additional studies) in the search and
46
66
date last searched.
Search 8 Present full electronic search strategy for at least one database, including
any limits used, such that it could be repeated.
Appendix 2
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in
systematic review, and, if applicable, included in the meta-analysis).
46
Data collection
process
10 Describe method of data extraction from reports (e.g., piloted forms,
independently, in duplicate) and any processes for obtaining and confirming
data from investigators.
46
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding
sources) and any assumptions and simplifications made.
46
Risk of bias in
individual studies
12 Describe methods used for assessing risk of bias of individual studies
(including specification of whether this was done at the study or outcome
level), and how this information is to be used in any data synthesis.
46/47
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 47
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if
done, including measures of consistency (e.g., I2) for each meta-analysis.
47
Risk of bias across
studies
15 Specify any assessment of risk of bias that may affect the cumulative
evidence (e.g., publication bias, selective reporting within studies).
47
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup
analyses, meta-regression), if done, indicating which were pre-specified.
47
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in
the review, with reasons for exclusions at each stage, ideally with a flow
diagram.
48
Study
characteristics
18 For each study, present characteristics for which data were extracted (e.g.,
study size, PICOS, follow-up period) and provide the citations.
Table 1; 50
Risk of bias within
studies
19 Present data on risk of bias of each study and, if available, any outcome level
assessment (see item 12).
57
67
Results of individual
studies
20 For all outcomes considered (benefits or harms), present, for each study:
(a) simple summary data for each intervention group (b) effect estimates
and confidence intervals, ideally with a forest plot.
48/65
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals
and measures of consistency.
48/65
Risk of bias across
studies
22 Present results of any assessment of risk of bias across studies (see Item
15).
57
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup
analyses, meta-regression [see Item 16]).
n/a
DISCUSSION
Summary of
evidence
24 Summarize the main findings including the strength of evidence for each
main outcome; consider their relevance to key groups (e.g., healthcare
providers, users, and policy makers).
66/67
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at
review-level (e.g., incomplete retrieval of identified research, reporting
bias).
n/a
Conclusions 26 Provide a general interpretation of the results in the context of other
evidence, and implications for future research.
66
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support
(e.g., supply of data); role of funders for the systematic review.
67
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic
Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
68
Appendix 2: Pubmed search
Search Strategy
Subject Search Terms
Integration integrat* care OR "integration of care" OR integrat*
services OR "integration of services" OR integrat*
programmes OR integrat* programs OR “integration of
programmes” OR “integration of programs” OR integrat*
service delivery OR “integration of service delivery” OR
integrat* services OR “integration of services” OR integrat*
delivery OR integrat* management OR “integration of
management”
OR
coordinat* care OR "coordination of care" OR coordinat*
services OR "coordination of services" OR coordinat*
programmes OR coordinat* programs OR “coordination of
programmes” OR “coordination of programs” OR coordinat*
service delivery OR “coordination of service delivery” OR co
ordinat* services OR “coordination of services” OR
coordinat* delivery OR coordinat*
management OR “coordination of management” OR co-
ordinat* care OR "co-ordination of care" OR co-ordinat*
services OR "co-ordination of
services" OR co-ordinat* programmes OR co-ordinat*
programs OR “co-ordination of programmes” OR “co-
ordination of programs” OR co-ordinat* service delivery OR
“co-ordination of service delivery” OR co-ordinat* services
OR “co-ordination of services” OR co-ordinat* delivery OR
coordinat* management OR “co-ordination of
management”
OR
horizontal care OR vertical care OR horizontal services OR
vertical services OR horizontal programmes OR horizontal
programs OR vertical programmes OR vertical programs
OR horizontal service delivery OR vertical service delivery
OR horizontal services OR vertical services OR horizontal
delivery OR vertical management OR vertical management
Interventions
'nutrition intervention' OR 'nutrition specific program' OR
'nutrition sensitive program' OR 'nutrition specific
intervention' OR 'nutrition sensitive intervention'
69
Nutrition outcomes "nutritional status" OR "nutritional outcomes" OR
malnutrition OR "diet* diversity" OR micronutrient* OR
growth OR anthropometr*,
6.2 Appendix 3: Risk of bias assessment
Appendix 3a: Risk of bias graph for RCTs studies: review authors' judgements about
each risk of bias item presented as percentages across all included studies.
0 20 40 60 80 100
Selection bias
Performance bias
Detection bias
Attrition bias
Reporting bias
Other bias
Low risk Moderate Unclear
0 10 20 30 40 50 60 70 80 90 100
1. Was the study's target population a close representationof the national population ?
2. Was the sampling frame a true or close representation ofthe target population?
3. Was some form of random selection used to select thesample?
4. Was the likelihood of nonresponse bias minimal?
5. Were data collected directly from the subjects (asopposed to a proxy)?
6. Was an acceptable case definition used in the study?
7. Was the study instrument that measured the parameterof interest shown to have validity and reliability?
8. Was the same mode of data collection used for allsubjects?
9. Was the length of the shortest period for the parameterof interest appropriate?
10. Were the numerator(s) and denominator(s) for theparameter of interest appropriate?
Low risk Moderate risk Unclear
70
Appendix 3b: Risk of bias graph for observational studies: review authors'
judgements about each risk of bias item presented as percentages across all included
studies
71
ANNEX 2: KEY INFORMANT GUIDE
Integrating nutrition into multisectoral programming: best practices
globally and opportunities in the Somalia context
Key informant interview Guide
Identification Information
Name of Person Interviewed:
____________________Title______________________________
Institution/Organization: ________________________ Date of Interview:
___________________
Person conducting the interview:
___________________________________________________
Introduction
- Introduce yourself and provide a brief and concise study introduction
(capturing rationale, objectives and value-add of the study results)- Study
Purpose: the study aims learn and document evidence, best practices,
drivers, bottlenecks and opportunities for successful and sustainable
integration of nutrition specific and sensitive interventions in Somalia. In this
study, we define Nutrition-specific interventions refer to interventions that
address the immediate determinants of foetal and child nutrition and
development. These include Vitamin A and zinc supplementation, exclusive
breastfeeding, dietary diversity promotion and food fortification. Nutrition-
sensitive interventions influence the underlying determinants of nutrition such
as water, sanitation and hygiene; child protection; schooling; early child
development; maternal mental health; agriculture and food security; health
and family planning services; social safety nets; and women’s empowerment.
- Self-introduction
Hello, my name is _______. I am representing the SUN Movement Somalia.
The Government of Somalia plans to scale up nutrition interventions through
integration of nutrition into other sectors and existing programmes. In this
regard, I would like to ask you some questions regarding the integration of
72
nutrition sensitive and nutrition specific interventions. The interview will take
45minutes to 1 hour and your participation is entirely voluntary. There is no
penalty for not participating. Your views and ideas will be included our report,
but we will not use your name.
Can we proceed with the interview?
Yes_____________________No__________________
Instruction
- Note to interviewers: familiarize yourself with interviewee position and tile
before the interview and address them accordingly
- Proceed to start interview and take key notes for validation by the interviewee.
Guiding Questions
1. There has been an increasing attention to integration of nutrition sensitive and
sensitive programming practices globally. In Somalia, what are the existing
nutrition integration platforms (packages of interventions or models) in
Somalia and other fragile contexts? To what extent are they feasible for
Somalia context?
2. To what extent has the integration been successful in impacting nutrition
outcomes in the country? In what aspects has the nutrition outcomes been
impacted by the nutrition integration practices? What are the gaps to be
addressed?
3. From an implementer’s perspective, what are the best practices for effective
integration of nutrition specific and sensitive interventions in Somalia and other
fragile contexts?
4. From experience and with a lens of nutrition outcomes, what are the main
bottlenecks and drivers of effective nutrition integration in Somalia and similar
settings at both governance and implementation level? As you respond,
73
highlight possible best alternatives (opportunities) to addressing identified
bottlenecks to positively impact nutrition outcomes?
a) Drives or enables of effective nutrition integrations
b) Bottlenecks to effective nutrition integration
c) Opportunities to strengthening nutrition integration and impacting
nutrition outcomes
5. In reference to Somalia and learning from other fragile countries, what are
packages of integrated nutrition services would best optimize nutritional
outcomes? What features or program design elements would be best to
consider or adopt in the integrated nutrition services?
6. Perhaps I may have left out a key aspect of integrating nutrition specific and
sensitive interventions that Somalia and its partners can learn from? Are there
any observations, learnings or contributions that you feel are important to
capture in this learning report for Somalia nutrition actors, especially at
implementation level?
Thank you for your time and valuable responses.
74
ANNEX 3: KEY INFORMANT ORGANIZATIONS
1. World Bank
2. BRCiS
3. UNICEF-Somalia
4. WFP-Somalia
5. FAO-Somalia
6. Action Against Hunger
7. Save the Children
8. Norwegian Refugee Council
9. Concern Worldwide
5. GREDOSOM
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