MALNUTRITION TREATMENT AND PREVENTION: A CASE STUDY WITH CAROLINA FOR KIBERA

Jeff Walker2017 MPH-RD Candidate

Advisor: Peggy Bentley

OBJECTIVES

This case study was conducted through a two month internship with Carolina for Kibera (CFK). It was determined that the objectives of the project were:

1. To assess the program’s credibility by asking staff which policies and guidelines staff members followed during treatment.

2. To understand participants’ outcomes by examining quantitative data collected by CFK, interviews with staff, and focus groups with participant families.

3. To explore the programs’ benefits beyond clinical treatment by asking focus group participants and interview staff about household- and community-level changes.

4. To solidify and further the discussion about the future direction of CFK’s nutrition programs by collecting stakeholders ideas in one place.

DATA COLLECTION METHODOLOGY

To understand Lishe Bora’s programs quantitative and qualitative data was analyzed. Data was collected through:

Use of Lishe Bora’s patient records

Household visits

Participant observation

Focus groups with parents of current and past LisheBora participants

Interviews with stakeholders of CFK’s nutrition programs

INTRODUCTION TO KENYA Country of more than 48 million people1

44 different tribal and ethnic groups, most with local languages or dialects1

Major commercial, cultural, and political hub of East Africa

Political environment became favorable in nutrition in 20112

High levels of food insecurity and low to medium severity of stunting/wasting prevalence according to the World Health Organization (WHO)1

Photo Credit: The Commonwealth Secretariat, http://thecommonwealth.org/our-member-countries/kenya

INTRODUCTION TO KIBERA Informal settlement or slum of ~250,000 people3

Three largest tribes or ethnic groups are Luo, Luhya, and Kisii

Made up of thirteen villages located southwest of Nairobi’s Central Business District

46.5% employed in casual labor, with poor investment in transport, electricity, and sewage infrastructure4

Health care access more restricted, but still available through community clinics

Limited income and food costs often restrict diets to basic staples like ugali, sukuma wiki, chapati, beans, mandazi, and black tea

Stunting prevalence of 38-48%, categorized as high or very high severity by WHO5

KIBERA FACING EAST FROM THE RAIL LINE

THIRTEEN VILLAGES OF KIBERA

Photo Credit: Map Kibera Project , http://mapkiberaproject.yolasite.com/resources/villages_names.jpg

CAROLINA FOR KIBERA (CFK)Carolina for Kibera’s mission is “to develop local leaders, catalyze positive change and alleviate poverty in the Kibera slum of Nairobi.”6

Founded in 2001 by Rye Barcott, Tabitha Atieno, and Salim Mohamed

Committed to addressing malnutrition in Kibera

Rooted in participatory development; the community is heavily involved in identifying needs, program planning, and giving feedback

Three departments: Economics and Entrepreneurship, Health, and Social

Health Department operates many programs beyond Lishe Bora

CFK’S PEDIATRIC NUTRITION PROGRAMSClinical Programs

Lishe Bora Mtaani (Better Community Nutrition) is a Severe Acute Malnutrition (SAM) treatment program with early child development (ECD) components for children under five

Outpatient Therapeutic Program (OTP) for children with Moderate Acute Malnutrition (MAM)

Community Outreach Program

Multicomponent providing health ed, resources for healthy behavior, and community mobilization

GUIDELINES FOR LISHE BORA

WHO Guidelines

WHO Child Growth Standards (2006)7

WHO child growth standards and the identification of severe acute malnutrition in infants and children (2009)8

Guideline: Updates on the Management of Acute Malnutrition in Infants (2013)9

Kenyan Guidelines

Integrated Management of Acute Malnutrition (2009)10

Maternal, Infant, and Young Child Feeding Policy (2013)11

THE EVIDENCE-BASE OF LISHE BORA Intersection of nutrition and ECD is an important current topic among child development, education, medicine, public health, and nutrition researchers

Series in the Annals of the New York Academy of Sciences published in 2014 focuses on integrated nutrition and ECD interventions12

Integrated programs targeting undernourished children seemed especially beneficial13

Age range captures 1st and 2nd 1000 day windows14

Center-based programs in Malawi were improved outcomes especially for children who were orphaned, in poverty, or disabled15

QUANTITATIVE RESULTS

328 children enrolled and treated for SAM since opening in May 2013

Villages of Gatwekera, Kianda, and Soweto West have accounted for 86.9% of admissions

Three diagnoses for SAM include:Mid-Upper Arm Circumference (MUAC) of less than 11.5 cm – 68.6% of admissions Weight-for-height z-score of less than -3 – 26.8% Edema – 4.6%

289 children have been discharged, with 91.4% successfully cured

Same criteria were used to admit and discharge a child in 61.4%of cases

DISTRIBUTION OF CASE DURATION

2.18%

9.45%

49.82%

27.64%

4.73% 6.18%

1-5 Weeks

6-10 Weeks

11-15 Weeks

16-20 Weeks

21-25 Weeks

26+ Weeks

QUALITATIVE RESULTS5, 17-28

Benefits to the Child Beyond Anthropometrics

Increased activity levels, socialization, and physical abilities

Benefits to the Family

Nutrition and ECD information and resources provided

Improved financial stability during enrollment

Benefits to the Community

Increased difficulty in identifying children with malnutrition

Strong community partner in supporting and developing capacity

DISCUSSION OF CHALLENGES AND CONCERNS5, 17-28

Internal

Sustainability of the program

Declining enrollment

Lack of data for monitoring and evaluation

Limited communication between Community Health Workers (CHWs) and leaders at the program and department level

External

Household food environment

Lack of quality ECD centers and daycares

Lingering HIV stigma

DISCUSSION OF FUTURE DIRECTION5, 17-28

Collaboration with ECD centers and daycares in Kibera to provide nutrition education and services

CFK-owned and operated ECD center with admission limited to children discharged from malnutrition treatment programs

Promotion of Lishe Bora as a resource in the community and increased nutrition-focused household screening

Improvement of the monitoring and evaluation system to remain accountable to local stakeholders and improve CFK’s ability to prove impact and value in community

QUESTIONS?

REFERENCES1. Kenya National Bureau of Statistics et al. (2014). Kenya Demographic and Health Survey 2014, 14.

2. Scaling Up Nutrition Movement. (2017). Kenya - SUN. Retrieved November 27, 2017, from http://scalingupnutrition.org/sun-countries/kenya/

3. Desgroppes, A., & Taupin, S. (2009). Kibera: The Biggest Slum in Africa? Hal, 1–13. Retrieved from https://halshs.archives-ouvertes.fr/halshs-00751833/file/Amelie_Desgroppes_Sophie_Taupin_-_KIBERA.pdf

4. Kyobutungi, C., Ziraba, A. K., Ezeh, A., & Yé, Y. (n.d.). Population Health Metrics: The burden of disease profile of residents of Nairobi’s slums: Results from a Demographic Surveillance System. https://doi.org/10.1186/1478-7954-6-1

5. Obanyi, H. (2017). Sub-County Nutritionist Transcript. Kibera, Kenya.

6. Carolina for Kibera. (2017). CFK | Talent is universal, opportunity is not. Retrieved November 18, 2017, from http://cfk.unc.edu/

7. WHO Department of Nutrition for Health and Development. (2006). WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. https://doi.org/10.4067/S0370-41062009000400012

8. WHO child growth standards and the identification of severe acute malnutrition in infants and children. (n.d.). Retrieved from http://apps.who.int/iris/bitstream/10665/44129/1/9789241598163_eng.pdf?ua=1

9. World Health Organization. (2013). Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. World Health Organization, 1–123. https://doi.org/10.1007/s13398-014-0173-7.2

10. Kimani, F., & Sharif, O. (2009). National Guideline for Integrated Management of Acute Malnutrition. Clinton Foundation HIV/AIDS Initative, (June), 1–51.

REFERENCES11. Njiru, J., & Matiri, E. (2013). Maternal, Infant and Young child nutrition: National: National Operational Guidelines for health workers, 18–

160. Retrieved from http://pdf.usaid.gov/pdf_docs/PA00JTGD.pdf

12. Chan, M. (2014). Investing in early child development: An imperative for sustainable development. Annals of the New York Academy of Sciences, 1308(1). https://doi.org/10.1111/nyas.12376

13. Grantham-Mcgregor, S. M., Fernald, L. C. H., Kagawa, R. M. C., & Walker, S. (2014). Effects of integrated child development and nutrition interventions on child development and nutritional status. Annals of the New York Academy of Sciences, 1308(1), 11–32. https://doi.org/10.1111/nyas.12284

14. Gertler, P., Heckman, J., Pinto, R., Zanolini, A., Vermeersch, C., Walker, S., … Grantham-Mcgregor, S. (2014). Labor market returns to an early childhood stimulation intervention in Jamaica. Science. Retrieved from http://science.sciencemag.org/content/sci/344/6187/998.full.pdf

15. Black, M. M., & Rao, S. F. (2015). Integrating Nutrition and Child Development Interventions: Scientific Basis, Evidence of Impact, and Implementation Considerations 1–3. https://doi.org/10.3945/an.115.010348.852

16. Munthali, A. C., Mvula, P. M., & Silo, L. (2014). Early childhood development: the role of community based childcare centres in Malawi. SpringerPlus, 3(1), 305. https://doi.org/10.1186/2193-1801-3-305

17. Akoth, V. (2017). Lishe Bora ECD Teacher Transcript 1. Kibera, Kenya.

18. Areso, J. (2017). ECD Center Director Transcript. Kibera, Kenya.

REFERENCES

19. Kaburia, F. (2017). Tabitha Nutritionist Interview Transcript 2. Kibera, Kenya.

20. Lang’at, F. (2017). Tabitha Clinic Manager Transcript.

21. Madahana, M. (2017). Lishe Bora ECD Teacher Transcript 2. Kibera, Kenya.

22. Moturi, J. (2017). Tabitha Nutritionist Interview Transcript 1. Kibera, Kenya.

23. Muasa, M. (2017). CFK Head of Health Department Transcript.

24. Nekesa, J. (2017). Lishe Bora Data Clerk Transcript. Kibera, Kenya.

25. Omala, H. (2017). CFK Executive Director Transcript.

26. Opana, E. (2017). Lishe Bora Nutritionist Transcript. Kibera, Kenya.

27. Parents of Discharged Children 1. (2017).

28. Parents of Discharged Children 2. (2017).