Assessment of the effectiveness of a small quantity lipid-based nutrient supplement on reducing anaemia and stunting in refugee populations in the Horn of Africa: Secondary data analysis.

Stunting and micronutrient malnutrition are persistent public health problems in refugee populations. UNHCR and its partner organisations implement blanket supplementary feeding programmes using a range of special nutritional products as one approach to address these issues. The evidence base for the efficacy and effectiveness of a small quantity lipid-based nutrient supplement, Nutributter®, in reducing stunting and anaemia is limited. Secondary data analysis was used to assess the effectiveness of Nutributter® distribution on anaemia and stunting in children aged 6-23 months (programme target group) and 6-59 months (the standard age group sampled in routine nutrition surveys). Analysis was conducted using routine pre and post-intervention cross-sectional nutrition survey data collected between 2008-2011 in five refugee camps in Kenya and Djibouti. Changes in total anaemia (Haemoglobin<110g/L), anaemia categories (mild, moderate and severe), and stunting (height-for-age z-score <-2) were explored using available data on the Nutributter® programme and contextual factors. A significant reduction in the prevalence of anaemia in children aged 6-23 months and 6-59 months was seen in four of five, and in all five camps, respectively (p<0.05). Reductions ranged from 12.4 to 23.0, and 18.3 to 29.3 percentage points in each age group. Improvements were largely due to reductions in moderate and severe anaemia and occurred where the prevalence of acute malnutrition was stable or increasing. No change in stunting was observed in four of five camps. The replicability of findings across five sites strongly suggests that Nutributter® distribution was associated with a reduction in anaemia, but not stunting, among refugee children in the Horn of Africa. Benefits were not restricted to the 6-23 month target group targeted by the nutrition programme. However, even following this intervention anaemia remained a serious public health problem and additional work to define and evaluate an effective intervention package is warranted.

Operational guidance on the use of special nutritional products in refugee populations.

BACKGROUND: Stunting, acute malnutrition, and micronutrient malnutrition are persistent public health problems in refugee populations worldwide. In recent years there has been an increase in the availability and use of special nutritional products in emergency and development contexts to help address inadequate nutrient intakes from low-diversity diets. The availability of new special nutritional products, and the decision by the United Nations High Commissioner for Refugees (UNHCR) to use blanket supplementary feeding programs to prevent stunting and anemia, raised new challenges for designing, monitoring, and evaluating nutritional programs. OBJECTIVE: To develop an Operational Guidance on the use of special nutritional products for the prevention of micronutrient malnutrition, stunting, and acute malnutrition in refugee populations. Methods. A literature review and a series of consultations with technical experts, operational organizations, and field staff were performed over a period of 2 years. The Operational Guidance was finalized and released in December 2011. RESULTS: The Operational Guidance describes six stages for defining nutritionalproblems and identifying possible solutions; assessing and managing risks; testing acceptability and adherence, program design and implementation; and monitoring and evaluation. Key performance indicators are defined and a working nomenclature for new special nutritional products is described. CONCLUSIONS: The UNHCR Operational Guidance has filled an important gap in helping field staff deal with the opportunities and challenges of preventing undernutrition through the use of new products in blanket supplementary feeding programs. The need for further integration of guidance on selective feeding programs is discussed.

United Nations High Commissioner for Refugees feeding program performance in Kenya and Tanzania: a retrospective analysis of routine Health Information System data.

BACKGROUND: The United Nations High Commissioner for Refugees (UNHCR) Health Information System is a primary source of routine nutrition program data and provides a comprehensive assessment of UNHCR selective feeding programs in more than 90 refugee camps in 18 countries worldwide. OBJECTIVE: To evaluate the coverage and effectiveness of UNHCR supplementary and therapeutic feeding programs for malnourished children under 5 years of age in Kenya and Tanzania refugee camps. METHODS: Analysis of Kenya and Tanzania refugee camp population, growth monitoring and nutrition program data from the UNHCR Health Information System. RESULTS: UNHCR-supported implementing partners in Kenya and Tanzania admitted nearly 45,000 malnourished refugee children in selective feeding programs between January 2006 and May 2009. Average recovery rates of 77.1% and 84.6% in the therapeutic and supplementary programs, respectively, mortality rates of less than 1%, and average readmission below 5% suggest that feeding programs had a beneficial effect on enrolled children. CONCLUSIONS: Increasing admission and enrollment in supplementary feeding programs was successful in preventing cases of severe malnutrition in some camps. Further attention to these camps would be likely to yield sizeable benefits in terms of absolute reductions in malnutrition prevalence and mortality rates.

Assessing the impact of micronutrient intervention programs implemented under special circumstances--meeting report.

INTRODUCTION AND OBJECTIVE: The World Food Programme and the Office of the United Nations High Commissioner for Refugees organized a meeting of experts to discuss evaluation of micronutrient interventions under special circumstances, such as emergency and refugee situations. RESULTS: Multimicronutrient interventions for groups with higher needs may include home fortification products for young children or supplements for pregnant and lactating women. The choice of preparation should be guided by target group needs, evidence of efficacy of a product or its compounds, acceptability, and cost-effectiveness. Different designs can be used to assess whether an intervention has the desired impact. First, program implementation and adherence must be ascertained. Then, impact on micronutrient status can be assessed, but design options are often limited by logistic challenges, available budget, security issues, and ethical and practical issues regarding nonintervention or placebo groups. Under these conditions, a plausibility design using pre- and postintervention cross-sectional surveys, a prospective cohort study, or a step-wedge design, which enrolls groups as they start receiving the intervention, should be considered. Post hoc comparison of groups with different adherence levels may also be useful. Hemoglobin is often selected as an impact indicator because it is easily measured and tends to respond to change in micronutrient status, especially iron. However, it is not a very specific indicator of micronutrient status, because it is also influenced by inflammation, parasitic infestation, physiological status (age, pregnancy), altitude, and disorders such as thalassemia and sickle cell disease. CONCLUSION: Given the constraints described above, replicability of impact in different contexts is key to the validation of micronutrient interventions.