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

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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.

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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