The underlying causes of malnutrition in old Fangak payam, Central Upper Nile, Southern Sudan


Executive Summary
After 3 years of intervention in Old Fangak payam, Central Upper Nile, Southern Sudan, Action Against Hunger (ACF-USA) was facing 2 main difficulties: on one hand increasing rates of malnutrition over the years in spite of external interventions in the fields of nutrition, food security and health; and on the other hand the low attendance to the feeding programmes despite the alarming nutritional situation. Therefore, ACF-USA decided to implement a survey on the underlying causes of malnutrition among the children under-5 years in order to have a better understanding of the nutritional situation and to improve the appropriateness of the programmes to tackle malnutrition.

The survey has been based on UNICEF approach: the Nutritional Causal Analysis (NCA). T his approach identifies 3 levels of factors leading to malnutrition: the direct causes, which are inadequate food intake and disease; the underlying causes, which refer to 3 spheres: food security at the household level, public health and hygiene, and social and care environment; and the basic causes, which correspond to the structural factors, at the society level. The survey focused on the underlying causes of malnutrition.

The main tools used to collect information were the focus group discussions and individual interviews with key informants and caretakers. The implementation of the survey took place between November 2003 and January 2004. The team faced difficulties in accessing the population because of the displacement constraints in this area -- all movements are done by foot, some villages are very distant or isolated because of swamps -- and seasonal population movements due to water shortage. I n spite of the constraints, the team succeeded in collecting the needed information.

In parallel, ACF-USA has also carried out an exhaustive survey in the same area aiming at estimating the prevailing nutritional status of the under-5 population, determining the coverage of the health education and nutritional surveillance programme implemented in mid-2003, and determining the coverage of the feeding programs. The findings of this survey has been useful for the understanding of the situation in Old Fangak, in providing more accurate population figures, new estimation of the nutritional situation among children aged 12-59 months (exhaustive screening using MUAC and height), and information on the practices related to water.

Following the analysis of the collected data, the main findings are:

  • Disease is a prevailing factor leading to malnutrition in this area;

  • The high prevalence of disease cases is due to hostile environment, lack of safe drinking water, poor personal and environmental hygiene, poor health seeking and limited health services;

  • The food intake of the under-5 is also questioned, since weaning practices are inappropriate, children only benefit from 2 meals a day and diet is imbalanced;

  • A large part of the underlying causes of malnutrition are related to inadequate childcare practices: breastfeeding, weaning, feeding, hygiene, and health seeking;

  • The lack of support from kinship is an aggravating factor affecting the availability of the mothers and the food security situation at the household level.

  • Food availability at the household level is not a major concern however a prolonged milk and cereals shortage can rapidly deteriorate the nutritional status.

  • While these factors affect similarly all children, including children aged more than 5 years, children aged 6-29 months appear as the most vulnerable since they particularly suffer from inadequate breastfeeding and weaning.

The survey on the underlying causes of malnutrition has not provided the full explanation of the increasing malnutrition rates over the past years, either the identification of seasonal variations. Malnutrition rates fluctuate on an unexpected basis without obvious links with "hunger gap" or post-harvest period. Therefore it is difficult to conclude on the seasonal or chronic feature of the malnutrition in this area.

The exhaustive screening carried out in December 2003/January 2004 has displayed a significant improvement of the nutritional situation - 22% of the children aged 1 to 5 years are at risk of malnutrition using MUAC and height, as compared to 47.9 % in March 2003. T his improvement has to be confirmed with a new anthropometric survey to be conducted in the coming month. I n addition, the exhaustive survey has displayed population figures considerably below the official ones, meaning that the coverage of ACF-USA feeding centres was probably better than stated.

Taking into consideration the results of these surveys and in order to better tackle malnutrition in Old Fangak, ACF-USA particularly recommends:

Recommendations for ACF-USA to participate in reducing malnutrition in Old Fangak:

To continue and improve the nutritional surveillance:

  • Nutrition surveys: to ensure the implementation of anthropometric surveys ideally twice a year, before and after the rainy season, in order to compare the results to previous years and to have a clear picture of the evolution of the nutrition situation. The quality of the nutrition surveys needs to be ensured through a very close supervision of the local personnel recruited and trained for this specific purpose.

  • Nutritional surveillance through ACF-USA health surveyors: to reinforce community capacity to have a reliable nutritional surveillance system. ACF-USA will particularly enhance this through a better monitoring of the health surveyors (with more regular presence of professional health and nutrition personnel in the field) and the reinforcement of the sustainability of the system (motivation of the health surveyors, involvement of the Community Nutritional Committees).

  • Pilot of growth monitoring: since there is no proper growth monitoring in Old Fangak for the time being, ACF-USA proposes to implement a pilot. The health surveyors already operating in the field could follow specific children on a regular basis, using height (scaled stick) and age (referring to local calendar). ACF-USA Health Education Department needs to go thoroughly into the methodological and practical issues, particularly the sample size, frequency, capacity of male/female health surveyors to do it for literacy reasons, etc.

To continue promoting adequate breastfeeding and to improve the promotion of adequate weaning:

  • Health education sessions: ACF-USA Health Education Department proposes to continue promoting breastfeeding through education sessions with the support of existing posters. ACF-USA also intends to add messages on weaning: on the appropriate timing (from the age of 6 months) and on weaning foods (consistency and diversification).

  • Training on breastfeeding and weaning: as breastfeeding and weaning are important issues, ACF-USA Health Education Department envisages a specific training for the health surveyors in charge of the health education sessions as well as for the women's groups. It is assumed that women will be more sensitive to weaning issues than men and that mothers will be therefore more receptive if the message comes from women. As most of the health surveyors are male, it seems relevant to reinforce the dissemination of the messages on weaning through the women's groups. A first training should be organised before the rainy season, probably in Old Fangak boma. According to the results of this experience, the training will be repeated in the other bomas of Old Fangak payam.

To promote balanced diet:

  • Training/Education sessions on breastfeeding and weaning: the training and messages on weaning foods will be a good opportunity to promote diversification of the diet, including with the use of locally available foods that are not consumed at the time being, like pumpkin leaves and some wild foods.

  • Training on gardening techniques: in order to sustain the gardening initiative implemented in 2003/04, ACF-USA proposes to ensure training sessions on gardening techniques like seeds savings.

  • Distribution of diversified seeds: ACF-USA intends to distribute diversified seeds (possibly okra, simsim, groundnuts and cowpeas) in Old Fangak area before the next planting season.

To promote balanced diet:

  • ACF-USA intends to meet with SCF-UK, who is in charge of the education programmes in Old Fangak payam, in order to discuss possible plans regarding school feeding in this area.

  • According to the discussions, and if SCF-UK does not intend to implement school feeding, ACF-USA will engage discussions with WFP in order to support a school feeding programme in the 4 bomas of Old Fangak. The implementation and monitoring issues will then be discussed with the local partners.

To continue and to strengthen health education:

  • To continue disseminating messages on the following topics: explanation on faecal transmission routes, need for building latrines or covering faeces, washing hands and face regularly, fetching water in the safer water points (in spite of the distance), systematically treating water, protecting water and foods, early referral of the children to the health centres when they are sick.

  • To ensure a better dissemination of the health education messages through:
    • Reinforcement of the monitoring of the health surveyors with more regular presence of professional health and nutrition personnel in the field, in order to ensure they meet their objectives, i.e. house-to-house visits to randomly selected households and health education sessions.

    • Improvement of the presentation skills of the health surveyors (participatory teaching practices) and increased use of culturally acceptable visual aids.

    • Determination of other tools to facilitate the dissemination of the messages.

    • Intensive refresher training.

    • Extension of the audience with additional health education sessions in identified public places like churches, marketer water points.

    • Reinforcement of the sustainability of the health educators network (motivation of the health surveyors, involvement of the Community Nutritional Committees).

    • Increasing involvement of the health units (PHCC/PHCU): collaboration of ACF-USA and COSV on the definition of health education sessions/messages and monitoring; ACF-USA support to the CHW with training and visual aids.

    • Increasing involvement of the schools: collaboration of ACF-USA and teachers on the definition of health education sessions/messages and monitoring; ACF-USA support to the teachers with training and visual aids.

To ensure that people have the means to ensure proper hygiene:

  • To envisage a better access to soap: to envisage the possibility to locally make soap.

  • To envisage better storage capacities for food and water: ACF-USA intends to make a needs assessment and according to the results to implement a distribution of non-food items (buckets, etc).

To assess the possibility to ensure safer water sources:

  • In-depth assessment of the needs

  • Review of the different possibilities to ensure safe sources of water: digging wells, boreholes, filtering system, rainwater collection, etc.

  • Proposition of intervention.

To save women's time with the promotion of a collective mill: the findings of the survey on the underlying causes of malnutrition have highlighted that the heavy workload of the women prevent them from dedicating time to their children. T his can affect the food intake of the children as well as the health seeking practices. The main time consuming activities of the women are grinding grains, cooking and fetching water. I n order to save women's time, ACF-USA suggests promoting a collective mill, which should allow reducing the time spent in grinding. For this purpose, ACF-USA proposes:

  • To gather information on existing experiences and successful stories of mill promotion (Tearfund).

  • If relevant, to envisage a pilot project of collective mill in Old Fangak town.

To envisage the support to health structures to detect and treat malnutrition: taking into account ACF-USA last estimation of population figures and the improvement of the nutritional situation, ACF-USA does not envisage any supplementary feeding programme but intends to focus on preventing mortality through the treatment of severe acute malnutrition. Therefore:

  • ACF-USA proposes to discuss with COSV about the capacities of the PHCC in treating severe cases of malnutrition.

  • According to the results of the discussion and if needed, ACF-USA could provide technical advice and support to set up a home treatment programme, with the first phase of the treatment in the PHCC inpatients. ACF-USA support could be envisaged through the training of the CHW and the supervision of the nutrition activities.

Other recommendations to tackle malnutrition in Old Fangak:

To improve the quality of the health services:

  • Decentralised services: as the CHW in the PHCU can only treat basic diseases and as people cannot always afford to go to Old Fangak PHCC due to the distance and difficulty to move (swamps), it is recommended that the PHCC nurse ensures regular visits to the 3 PHCUs (in Chotbora, Wangleil and Pulpam) in order to provide people with more appropriate diagnosis and treatment. T his initiative could require additional professional health personnel.

  • Improved skills in the PHCU: additional training and closer monitoring of the CHW, particularly those working in the PHCU, should allow a better quality of the provided medical services.

  • Maternal and Child Health care (MCH): for the time being COSV is implementing pre-natal consultations in the PHCC and supports a T BAs network. No information has been collected on post-natal care. MCH definitely needs to be reinforced in order to have a better follow up of the mothers and new-borns (particularly for immunization) and to collect information on the birth weight. MCH could also be the initial step for a proper growth monitoring, which is non-existent at the present time.

To support diet diversification through farming training: diet diversification is an important issue to participate in the reduction of the malnutrition in Old Fangak. ACF-USA has promoted and still promotes diversification through distribution of diversified seeds and training sessions. Additional technical support/training from specialised agencies, particularly FAO, would reinforce the impact of the diversified seeds distribution.

To increase the number of safe water points, particularly in Pulpam: previous experiences of UN Water Bureau have failed in drilling boreholes in Pulpam because of the inadequacy of the drilling machine. ACF-USA recommends that the experience be renewed with a more performing machine.

General recommendations:

The findings of the survey on the underlying causes of malnutrition in Old Fangak payam have displayed a large range of factors interacting and leading to malnutrition. These factors are related to different fields: nutrition, health, health and hygiene education, water and sanitation, and food security. Therefore the response to malnutrition has to be multisectoral, with the complementary analysis and intervention of agencies/organisations specialised in the above-mentioned fields. ACF-USA strongly recommends a good collaboration and coordination of these agencies/organisations to successfully tackle malnutrition. I n particular:

  • For any feeding programme to be implemented in Upper Nile ACF-USA recommends a closer collaboration with the health structures of the area.

  • To ensure that all agencies working in the same area collect standardised information on the context (food security, epidemic outbreak) and their own activities (feeding/health centres attendance, morbidity, mortality, distributions, etc), and share it with the other agencies on a regular basis, e.g. every month.

To follow the food security situation: as a possible aggravating factor of malnutrition, the food security situation needs to be followed-up in order to identify a possible food shortage and to plan actions to prevent it, like distributions of seeds, tools, fishing equipment or food rations. The main sources of information are the sentinel sites (like USAID Famine Early Warning System (FEWS net) and WFP Early Warning System) as well as the teams in the ground.

To strengthen the food security capacities of the population:

  • To promote animal health programmes in order to preserve the existing herds and to increase the contribution of the livestock to the food security at the household level (as an economic asset and as a food source - milking products and meat).

  • To improve capacities of the community in being food self-sufficient: examples: training on farming and fishing techniques to increase yields, food preservation, seeds saving, marketing, etc. These are long-term initiatives.

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