This part presents a number of potential actions whose aims range from saving lives to supporting the diversification of people's livelihood mechanisms. These actions are considered against the key screening criteria that were presented in Part IV. The potential actions are assessed for their relevance in addressing specific nutrition and food security problems and their feasibility in different emergency contexts. The discussion then explains how combining or sequencing interventions can increase their effectiveness in protecting and promoting good nutrition in the long term. A combination of food production and/or diversification, health, water and sanitation interventions, together with nutrition education, is ideal for achieving improved nutritional well-being. Examples of indicators for monitoring the process and impact of actions are also included.
The potential actions are grouped under the following broad themes:
A little girl eating a millet kuskus
FAO/5054/M. Bracher
Enabling people to produce at least some of their own food is an essential component of any strategy to address food insecurity in acute and chronic crisis situations. However, a combination of support to life-saving and to livelihood-protecting/enhancing activities may be needed for some time following an acute emergency.
Relevance
Wherever and whenever possible, food distribution should be combined with actions designed to improve self-reliant access to food. If an assessment has highlighted food insecurity as a contributory factor to malnutrition, and there are conditions suitable for agriculture and livestock husbandry, it is relevant to support food production and diversification. The activity should be appropriate to the context, introduce incremental change and reflect identified seasonal food shortfalls and nutrient gaps. Actions can aim to increase food diversity through field crop production, horticulture, rearing of poultry or small livestock, cultivation of fruit and nut trees, aquaculture/fishing, small-scale irrigation and the utilization of wild foods.
Box 28: Filling nutrient gaps by increasing food diversity
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Feasibility
These actions are feasible only where there are reasonable expectations of stability and security. Interventions to promote improved and diversified food production do not imply that other types of emergency support can be completely phased out, especially food aid. General food rations are not calculated to cover the food energy needs that are needed for the physical labour involved in agricultural work.
The following paragraphs outline the aspects that should be considered when assessing the feasibility of interventions aimed at improving food production and diversification.
Access to adequate land and water availability. Access to a sufficient area of land of sufficient quality to produce a family's food requirements can be problematic owing to a number of factors. Resource-poor and single-headed households, IDPs and resettled refugees are more likely to face difficulties. Negotiations need to be conducted with local authorities and host populations to determine possible modalities for providing land for affected populations. The measures should take into account existing population pressure, and landownership and tenure patterns. The resulting arrangements may be formal or informal, each of which has different implications for the choice of intervention. Potential areas for agricultural production need to be assessed in terms of the security situation, the threat of crop theft, the distance between living areas and agricultural land, and the availability of water. Often, these factors mean that only small areas can be cultivated, so home gardening, homestead fruit tree production (e.g. of rapidly maturing trees such as banana, papaya and guava), poultry or small livestock programmes may be more appropriate than staple crop production. (See Box 29 for examples of gardening activities for displaced people.) Rainfall distribution will influence the feasibility of upland agriculture. However, more intensive vegetable production may be possible around water points, small dams, low-lying permanently damp areas or the margins or wetlands.
Box 29: Cultivation of gardens in crisis situations
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In Malawi, refugees from Mozambique who had access to small plots of land and grew vegetables were less likely to suffer from pellagra than those who did not have such access. In Sierra Leone, people displaced from rural areas to Freetown started vegetable gardening as a means of generating income and diversifying their diets. Women living in conflict areas were supported in vegetable gardening (through seeds, cuttings and tools). They cultivated communal plots of land and worked in groups as protection against individual attacks and rape. They grew mainly roots and tubers such as sweet potatoes, because these were less easily raided than other crops. In the United Republic of Tanzania, between 1995 and 1997, refugees from Rwanda and Burundi grew many different kinds of staple crops and vegetables and raised livestock inside and around the camps, even though food production was officially prohibited by the Tanzanian Government. Refugees found ways of leasing land from local farmers, for example, by paying them in kind. In Swaziland, during the 2001-2002 food crisis UNICEF supported communities establishing community/school farms and gardens to grow drought-resistant crops and provide an ongoing supply of food to schools, as well as a base for extension advice and seedlings for the gardens at neighbourhood care points supporting orphans and vulnerable children (OVCs). |
Existing natural resource-based livelihood activities. The interventions selected should be adapted to local conditions. Information on the agro-ecological conditions, existing agricultural, fishing and forestry activities, and the production cycle and constraints (pests and diseases) should be available from secondary information, key informants and the situation assessment. It is also necessary to consider the pre-existing cultural practices and preferences of the incoming population group, but this may be difficult if people have been displaced into a very different agro-ecological zone (e.g. a shift from predominantly cassava-adapted areas to cereal-producing ones).
Availability and division of labour. An understanding of the division of labour and labour requirements for different livelihood activities should be incorporated into the choice and planning of interventions. Affected populations often have higher proportions of women, the elderly and children. If virgin land is allocated for agriculture, women may not have access to male labour for clearing, and other arrangements need to be considered (e.g. food-for-work mechanisms, tractor hire, etc.). Women may not have the necessary experience or agronomic knowledge for certain crops. Labour requirements and peak labour periods vary for different agricultural and non-agricultural activities. Comparing the labour requirements of different interventions with daily and seasonal activity calendars for men and women can help identify interventions that will not add to women's existing workloads. A high prevalence of HIV/AIDS may increase labour stress. Potential interventions should therefore be oriented towards non-labour-intensive activities (e.g. cassava production, poultry keeping), improved labour productivity through water harvesting and soil conservation interventions, and the spreading of existing labour peaks.
The location of agricultural activities should also be considered with respect to labour constraints (e.g. home gardens versus upland fields). It may be easier and more appropriate to target women through identifying the types of land that they have access to, and the crops, livestock and natural resources that are normally under their control. Women may be more likely to participate in interventions that can be implemented at locations around the homestead, or close to water points, as such activities can be combined with their other responsibilities.
Woman from the fishing cooperative smoking fish on a Chorkhor oven, constructed with Telefood funds
FAO/22536/CESPA-Mali
Storage, processing and marketing considerations. When screening potential interventions, the storage, processing and marketing characteristics and trade-offs of the particular crop should be considered. Root and tuber crops may be preferable, because they can be stored in the ground and are less susceptible to looting. However, cassava (for example) requires specific processing techniques to eliminate toxicity. Oilseed production could contribute to raising the energy density of infant weaning foods, and can improve the palatability of family meals; however, there is a need to have knowledge about household- or local-level processing techniques, or to provide suitable technology. Vegetable production is useful for both diversifying household food consumption and generating cash income. However, access to markets and/or knowledge about conservation (e.g. solar drying) is necessary to cope with potential production gluts. Some processing activities may be more appropriate at the area level than the household level. Processing interventions should also consider the needs of households that face labour constraints or have housebound members, for example, HIV/AIDS-affected households.
Input requirements. One of the most widespread rehabilitation interventions is the distribution of seeds, hand tools and, where appropriate, pesticides, fertilizers and animal health inputs. However, to make use of these inputs, households must also have enough food (e.g. from a general ration). Without the protection of a general ration, households may be forced to eat the seed, sell the agricultural inputs to buy food, or work on other people's farms or on food-for-work schemes at the expense of cultivating their own fields. Interventions that depend on the continuation of external inputs are unlikely to be sustainable. Input supply should be tied to a revolving or payback mechanism, and the provision of support to local small-scale traders who can continue to market inputs in the longer term. In areas with high HIV/AIDS prevalence it may be appropriate to promote low-input agricultural systems to minimize the expenditure for households that are already under economic stress.
If seed distribution is being considered, it is important to understand the existing practices and mechanisms for seed multiplication, conservation and distribution, and how these can be supported and strengthened. Examples of this could be the use of "quality declared" rather than "certified" seed, and supporting local purchase and marketing mechanisms through seed fairs or seed voucher systems.
Inputs for other livelihood activities might include the establishment of mother tree nurseries, the provision of fishing equipment, the restocking of small livestock, and access to craft materials, beehives, etc. Box 30 gives examples of different types of support to fishers, but these have no explicit link to nutrition.
Box 30: Diversified livelihoods contributing to diversified income and food production
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In Somalia, the International Committee of the Red Cross (ICRC) implemented an intervention to address both the immediate and the longer-term food insecurity of vulnerable groups in the Middle Juba Region. In October 2002, the Somali Red Crescent Society (SRCS)/ICRC distributed food for seed protection to 2 500 families. The food consisted of 30 kg of maize, 10 kg of beans and 5 kg of oil. At the same time, maize, cowpea and sesame seeds were distributed. As part of a longer-term food security initiative, 4 000 families received fishing kits consisting of twine (for the local manufacture of nets), hooks and monofilament (for lines). Each kit was accompanied by 10 kg of salt for conserving the fish for later consumption by the household and for sale. ICRC will follow this distribution with an extensive training programme aimed at ensuring good fishing methods, fish conservation and marketing. The intervention has been welcomed as timely and highly appropriate. In Mozambique, in response to the 2000 floods, support to the artisan fishing communities had the following objectives:
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Source: FSAU Somalia. 2002. Monthly nutrition update, October 2002; FAO OSRO/MOZ/004/ITA, 2001.
Effectiveness
Interventions aimed at increasing and diversifying agricultural production can be highly effective in contributing to sustained improvements to household food and income sources. This depends on the availability of and access to the basic means of production, favourable climatic conditions, political and military stability, and markets.
The integration of agricultural extension and nutrition education activities will help to ensure that improvements in household food security are translated into nutritional well-being for all members of the family. This is especially important when unfamiliar crops are being promoted.
The distribution of agricultural inputs provides an ideal opportunity for agriculture and nutrition education on the nutritional values of crops, the benefits of producing and consuming a wide variety of foods, and the specific nutritional needs of individuals in the family. Education is more effective when associated with inputs that increase the demand for available information. Gardening can also stimulate the creation of marketing associations, cooperatives and shops. Box 31 describes some examples of how improved food production can translate into improved consumption or benefits for vulnerable households.
Box 31: Linking improving food production to improved consumption
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Monitoring
Children in an orphanage eating a meal from a communal bowl
FAO/23432/M. Bleich
Relevance
For population groups that are dependent on market purchases/exchange for their main source of essential food and non-food items, improving economic access to food is particularly relevant in situations where:
non-agricultural and urban-based livelihood activities and income sources have been affected by the loss or destruction of productive assets or working capital (e.g. sewing machines, bicycles, tools or equipment for craftwork, market stalls, stock);
households have been dependent on a regular income from formal employment, but the salaried family member has migrated at an earlier stage of the crisis or has become unemployed, or payments have become irregular;
normal sources of employment have been cut off, or increased competition (e.g. casual daily labour) has forced wage rates down;
families' purchasing power has diminished through rapid increases or sharp fluctuations in the prices of basic goods and services.
In crisis situations physical access to markets may have been disrupted because transport, road infrastructure and market facilities have been damaged, destroyed or mined. Itinerant trading networks can also be affected by the impact of HIV/AIDS, as the high mobility of traders may put them at greater risk of infection.
Feasibility
Petty trading of food and non-food commodities is one of the most common income-generating activities in African countries, and is often practised by women and youths. These activities can restart quickly, especially in situations where food rations are sold to obtain other essential food and non-food items. Small start-up grants or a daily credit system could be established to support activities such as the sale of snack or processed foods or the trading of used clothing.
Transporting food
WFP
Box 32: Examples of actions to promote access to food
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Actions aimed at increasing employment and income opportunities
Market interventions (maintaining a stable supply of products)
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The sourcing of new or alternative employment opportunities requires:
Successful income-generating activities require:
The following factors should be taken into account when considering the feasibility of a particular intervention:
In unstable situations, it may be more appropriate to concentrate on training in skill areas that are "mobile" and can be applied or practised after a population has returned to its home area (e.g. business-related skills, management).
Interventions should take into account the needs of physically vulnerable groups, and consider supporting home-based enterprises or enterprises that do not require physical labour (e.g. electrical repairs).
Many income-generating activities rely on the availability of raw materials for craft production (mats, baskets), or access to industrial or recycled materials for the production of household utensils, etc. This could lead to the unsustainable utilization of natural resources.
Effectiveness
The development of income-generating activities can increase income levels and purchasing power. However, these do not necessarily translate into improved nutritional well-being. Income generation activities need to be targeted and complemented by other actions, such as the following:
The income that is earned and controlled by women is more likely to be used for family welfare, and so support for training and establishing small businesses should be appropriate to women's needs.
Social marketing and communication techniques can be used to link increased purchasing power with appropriate nutritional knowledge to support informed decision-making. An example of this could be protecting existing positive nutrition practices (e.g. breastfeeding) that may be under threat in new situations. Another example is to promote positive behavioural changes, for example diversifying diets in urban areas.
Support to the rehabilitation of market infrastructure and market functioning can be more effective when:
market facilities are designed to provide water, sanitation, rubbish collection and local meeting/recreation facilities;
the construction or rehabilitation of market facilities is used as an opportunity to improve the location and access roads and to establish or revitalize a market management committee;
small-scale traders are supported as the vital link between producers and large-scale merchants.
Box 33: Stimulating market recovery
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The floods that hit the Mozambican town of Chokwe in 2000 caused widespread destruction. Those families that had members with salaried occupations, or kinship networks in unaffected areas were able to recover more quickly. In response to demand and purchasing power, informal trading activities resumed rapidly, using porters and canoes where road communications were cut. The use of cash payments to support the reconstruction of houses (as opposed to assistance in kind) was appropriate in places where market activities re-established themselves quickly. This approach supported market functioning, and allowed participants to chose the type of materials used. |
Source: Adapted from DEC, 2001.
Monitoring
Fresh fruit and vegetables in market
FAO/5089/M. Bracher
Relevance
In many acute crisis situations, storage issues may not be a priority problem. Households may not be involved in agricultural production, or agricultural surpluses are sold immediately, for example, to meet non-food needs or to avoid the risk of looting. However, in the acute stage of a crisis it is important to provide information and raise awareness about the best methods to store general ration commodities at the household level, particularly blended foods that may contain oil.
After prolonged periods of social and economic upheaval, the local knowledge and skills related to storage technology may have been lost and need to be rediscovered. When unfamiliar crops (e.g. sweet potatoes) or crop varieties with different storage characteristics (e.g. "dent" maize varieties, which have softer kernels than "flint" varieties) are introduced, there is a need to provide farmers with relevant information and access to appropriate storage technology.
During periods of gradual change, improved storage facilities and techniques can help to address problems related to post-harvest losses, wide inter-annual fluctuations in production levels, low food availability during hungry periods, seasonal price fluctuations and the destruction of storage structures through conflict, flood or hurricane damage.
Feasibility
Technical interventions should be based on an analysis of the causes of food losses. Local methods, practices and material for storing different food commodities should be identified, and the positive aspects of these strengthened. Consideration should also be given to crop-specific practices for certain crops, whether men or women are responsible for the storage of specific crops or for specific stages in storage processes (e.g. the production or treatment of foods to be stored), and how seed storage is dealt with.
The level (field, household, village) of storage should be appropriate to the context. The feasibility of village-level stores needs to be carefully assessed in terms of cultural beliefs, management requirements, costs and the strength of local organization.
In order to implement storage interventions successfully, materials, capital (or small grants if necessary) and labour should be available.
Box 34: Examples of storage interventions
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Effectiveness
Not only can storage interventions be effective in increasing the availability and stability of food supplies, but they can also contribute to improved environmental hygiene around the home through reducing insects, rodents, etc. There may be direct improvements to health status through reducing the risks of mycotoxin contamination caused by moulds. However, storage interventions need to be cost-effective; it may be cheaper to sell surpluses and purchase later on, rather than invest in improved storage structures.
Activities to improve storage should be integrated with agricultural extension programmes. Training can be provided in the management of local structures, the safe use of chemicals, the identification of fungal contamination, and alternative safe uses for spoiled grains (e.g. animal feed), etc.
Monitoring
Processing, conservation and preparation
Relevance
All foods need to be processed into a more digestible or palatable form (grain to flour) and/or conserved to prolong shelf-life. Examples include processed roots and tubers, smoked and dried fish, fermented milk, and dried fruits or vegetables (wild and cultivated). Not only does processing extend the availability of these foods and increase dietary diversity, but it can also add value when the products are marketed. Interventions in this area are relevant if:
new foods that require novel treatment have been introduced, either through a general ration or through people's displacement or resettlement in different farming systems;
household processing equipment has been left behind or stolen, or is unsuitable for new foods;
women spend a high proportion of their time processing food (e.g. pounding maize), which could better be spent on child care or other productive activities (e.g. by providing labour-saving technology, village grinding mills);
vitamin A deficiency is present at certain times of the year, and could be addressed through the preservation of dark-green leafy vegetables or dark orange fruits and vegetables;
surpluses or gluts of crops are followed by periods of scarcity;
a lack of cooking fuel creates difficulties in cooking ration commodities such as beans.
Feasibility
The following factors should be considered when assessing the feasibility of interventions:
women's time and the gender-differentiated use of the proposed technology, including the possibility of its being taken over by men if it proves successful;
the cultural acceptability of the technology;
the availability of sufficient materials for constructing the technology;
the cost (capital and recurrent) of the new technology;
the level of use (e.g. household, village);
the availability of products needed for processing (e.g. salt, fuelwood);
seasonal aspects (e.g. drying is more difficult in the rainy season).
Box 35: Examples of processing, conservation and preparation interventions
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Effectiveness
These types of interventions can improve the use of food products and reduce seasonal fluctuations in micronutrient availability. Some interventions may lead to a reduction in women's labour requirement through the mechanized processing of cereals, or through more efficient or alternative cooking methods that reduce the time needed for collecting fuelwood. Women can use the time saved for more economically productive activities, and for taking care of themselves, young children and other family members. These interventions can also increase the impact of production-oriented interventions such as home gardening.
Monitoring
Food safety and quality
Relevance
The safety and quality of food can be severely compromised in conditions of overcrowding, inadequate sanitary facilities and social upheaval. This can lead to the contamination of food and water and the risk of food-borne illnesses, diarrhoea and cholera epidemics. Awareness of food safety and quality issues is relevant at all stages of the food chain, from crop, livestock and fisheries production, slaughter, harvesting, storage, marketing and distribution to processing, conservation and utilization within the home, or the sale of cooked foods outside the home.
Interventions in this area are relevant if:
the handling of food aid commodities does not meet minimum Sphere Standards (e.g. in terms of expiry date, storage conditions and containers);
there is widespread promotion and use of breastmilk substitutes that do not conform to the International Code of Marketing of Breastmilk Substitutes;
food is being lost because of inadequate storage facilities (through insects, rodents, mould, microbiological and chemical spoilage, and water damage) and/or inappropriate processing and preservation;
there is unofficial or informal slaughtering of animals for the sale of meat to the public;
water storage utensils are lacking or inadequate, which may lead to contamination, poor food hygiene practices and food safety risks;
there are difficulties in enforcing regulations for the use of agricultural chemicals, and in monitoring levels of pesticide residues in food;
in flood-affected areas, the water available for use in households or at major food processing/preparation locations (e.g. feeding programmes) is of inadequate quality;
contaminated water or night soil are used in agricultural operations, which can introduce a risk when fruit or vegetables are eaten raw.
Box 36: Examples of activities to promote food security and quality
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Feasibility
In conditions of overcrowding and inadequate water and sanitation facilities, safe food preparation and storage and the maintenance of household and personal hygiene become a challenge. Interventions within this context need to be relevant and feasible. Advice and education should be channelled though different media and be linked with the provision of basic equipment or facilities. Different population groups and their leaders need to be involved in developing appropriate messages and mobilizing the wider population for mass sensitization and clean-up campaigns. Adequate conditions for the transport, storage and distribution of food aid commodities need to be in place.
Effectiveness
In order to be effective, food safety and quality issues need to be incorporated into all interventions: from different perspectives (producer and consumer), through different channels (health centres, schools, market places), and at different levels (individual, homes, public spaces). Food safety interventions will be more effective when adequate latrines, water and bathing facilities are provided. The rearing and kraaling of livestock should be separate from human habitations.
Monitoring
Health provision
Relevance
The interrelationships among inadequate dietary intake, disease and malnutrition were outlined in Part I. Overcrowding, inadequate sanitary conditions and reduced access to health facilities can lead to epidemics and contribute to increased morbidity and mortality rates. Preventive and curative health interventions are particularly relevant if causal analysis has indicated that food insecurity may not be the major determinant of high malnutrition rates. The increasing prevalence of chronic illnesses such as TB and HIV/AIDS also underlines the relevance of preventive and palliative interventions to support local-level responses to these diseases.
Feasibility
The local health infrastructure may have been destroyed by natural events (e.g. floods, hurricanes) or deliberately as a result of war, or it may be chronically underequipped and understaffed. In the acute stage of a crisis, or when there is an imminent threat of an epidemic such as cholera, it may be necessary to bring in national- or international-level medical teams. Temporary and/or mobile curative facilities may be established to stabilize the situation in the short term.
However, it is also important to support the rapid re-establishment of primary health care activities, as these can contribute to building local capacity and will be more sustainable. The conditions necessary to achieve this include:
a core of trainers-of-trainers to train local-level primary health workers (trained birth attendants [TBAs], nutrition workers, family planning, malaria control workers, voluntary counselling and testing [VCT] and HIV/AIDS peer support groups);
a reliable supply of basic essential drugs and medical supplies;
where necessary, incentives or compensation for community health workers (CHWs) (e.g. commission on the sale of drugs/preventive services, local payment in kind, or government, donor or NGO subsidies);
an effective medical referral system;
a mechanism to promote integrated linkages among health, agriculture and social development activities at the local level (e.g. a local service centre for community support workers).
Effectiveness
Basic curative and preventive health services can have an impact on nutritional well-being. Management of diarrhoea, immunization campaigns for measles and deworming can contribute to reducing some of the precipitating causes of malnutrition. There is considerable scope for local participation, strengthening the role and status of women, and increasing the impact of other interventions.
Monitoring
Box 37: Examples of health interventions
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Water and sanitation provision
Relevance
Improving the quantity and quality of water is a relevant intervention in:
The situation assessment and analysis also indicate whether there are outbreaks of water-borne diseases (diarrhoea, typhoid), or a lack of water for personal hygiene has led to an increase in skin infections. In these cases, water and sanitation interventions are appropriate and should be reinforced by environmental hygiene measures (e.g. rubbish collection, clearing drainage channels and mosquito breeding areas) and public health education and promotion.
Feasibility
The hydrological and soil conditions often determine the type of technology that can be used (e.g. boreholes versus shallow hand-dug wells). The location and design of water and sanitation services should meet technical standards (e.g. Sphere) and be discussed with the affected and host populations to ensure access for both groups. Maintenance requirements and access to spare parts etc. should be discussed and negotiated during project design and planning. Group-run maintenance systems and privately operated services each have their own advantages and disadvantages. Local-level contributions could be raised via a sugar/bread/salt tax operated through local shopkeepers or market stall owners. Clear ground rules should be established as to how water sources cater for human, domestic, livestock and agricultural needs.
Effectiveness
Water and sanitation interventions provide the essential conditions that can make primary health care and public health and nutrition education actions more effective. When there is a source of safe water close at hand, the pressures on women's time can be reduced and family members do not fall ill and require additional care and attention.
A woman pumps water from a community well in Mozambique
FAO/G. Bizzarri
Box 38: Examples of water and sanitation interventions
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Monitoring
Relevance
A situation assessment and analysis should identify existing infant and child feeding knowledge and practices, in order to determine which practices should be protected and which could be improved. The social and economic upheaval in a crisis can contribute to negative nutritional practices, such as reductions in the duration of breastfeeding or early introductions of liquids and foods. In urban contexts, there may be greater exposure to commercially promoted breastmilk substitutes and infant foods. In some situations (e.g. when there are large numbers of orphaned or abandoned babies), the introduction of breastmilk substitutes for babies under six months of age may be justified.
In a population that is dependent on food aid, children of weaning age (from six months) will be vulnerable to malnutrition if traditional feeding practices are poor and/or the general food distribution does not include a locally available blended food suitable for complementary feeding.
Feasibility
Many factors influence infant feeding practices, including tradition, social status, education, income level, and peer pressure. Positive breastfeeding practices can be protected through promotion campaigns that acknowledge specific constraints. It may be necessary to supply an additional or special ration for lactating women. Mother- and baby-friendly spaces (e.g. breastfeeding stations) can be provided with counselling support from peer mothers. If necessary (e.g. for orphaned/abandoned babies), breastmilk substitutes should be provided under close support and supervision and in line with the international code on breastmilk substitutes. WHO recommends that HIV-positive mothers avoid breastfeeding if replacement feeding from birth is acceptable, feasible, affordable, sustainable and safe (AFASS). If these conditions are not met, then it is recommended that HIV-positive mothers practise exclusive breastfeeding for the first six months of life (WHO, 2004. What are the options? Using formative research to adapt global recommendations on HIV and infant feeding to the local context). This places demands on the provision of services and information to mothers or care takers so that they can make informed choices, and requires additional support and counselling staff.
The design and implementation of interventions to promote improved complementary feeding (from six months of age, in addition to breastfeeding) should take the following issues into account:
Complementary food mixes should be based on locally available foods, and should require only small modifications to the family diet.
Recipes need to be developed and pre-tested with different groups of mothers (poor, better-off, different religious or ethnic backgrounds). Ingredients should reflect the seasonal availability of foods, and additional time, water, fuel and other resource requirements should be considered carefully.
Complementary food mixes should be checked for nutrient density. If germination or fermentation techniques already exist, these should be encouraged to improve the digestibility and reduce the bulk of porridges. These methods also reduce phytic acid levels in wholegrain cereal flours, which can inhibit calcium and iron utilization.
Depending on context (access to group facilities, the cultural acceptability of common food preparation), feeding centres or group kitchens could be utilized for preparing complementary food mixes as an income generation activity for elderly or partially disabled people.
The use of complementary foods should be integrated with the promotion of breastfeeding to avoid the substitution of breastmilk in the first year after birth.
If a blended food is included in the general ration or through supplementary feeding programmes, practical nutrition information needs to be given and demonstration sessions organized so that mothers can learn how to prepare and feed the blended food appropriately.
Effectiveness
The promotion of breastfeeding is a very effective way of protecting infant health and nutritional status in areas where the water supply and environmental conditions are poor. Breastfeeding also enhances family planning efforts. In crisis situations, the promotion of breastfeeding needs to be complemented by strict enforcement of the International Code on Breast Milk Substitutes, and clear guidelines on the disposal of unwanted or inappropriate donations.
Complementary feeding interventions can have a high impact on the prevalence of moderate and severe malnutrition. Improved child health resulting from enriching or supplementing the local diet for young children will also benefit mothers/care takers, who will have to spend less time caring for sick children. The production and sale of local complementary foods can provide an income-generating activity for individual women or groups. Nutrition education and communication, together with information on food hygiene are essential components of a programme for developing and promoting complementary foods. Mothers and care takers also need to be able to discuss their concerns about the introduction of new foods and the potential attendant risks. Promoting improved infant feeding interventions can be matched with agricultural extension for the cultivation of appropriate crops, and nutrition education. This will require the training of respected women, TBAs and others at the local level in order to promote the specific crops and new practices.
Monitoring
Duration of exclusive breastfeeding period.
Age at introduction of complementary foods.
Increased knowledge and practice of appropriate complementary food preparation (both of blended foods distributed as part of a general ration and of locally available foods).
Reduced malnutrition in children receiving complementary foods (from six months).
Availability of local complementary food products in the market.
Women's status and socially vulnerable groups
Relevance
In many crisis situations there are periods of prolonged stress, conflict, family separation and the breakdown of social and kin networks. Identifying and promoting local-level and family mechanisms that recognize and support women's responsibilities and status and the care-related needs of socially vulnerable groups helps to ensure that that there is no further erosion of human rights.
Feasibility
These types of interventions are often given low priority in the acute stage of a crisis, which may be the time when women and young girls are most vulnerable because of social upheaval, family separation and living in unknown and uncertain environments.
Relief commodity distribution mechanisms and public facilities (water, latrines) should be designed to be safe for women and to enable access for people with disabilities (location of facility, timing of distributions). Physical structures may be needed to provide woman-and child-friendly spaces. Civic awareness campaigns may be needed to provide information on rights, and reporting procedures for confidential referral and accountability if these rights are violated. These types of interventions require training and skills (counselling, psycho-social, protection and legal), which are often overlooked.
Box 39: Examples of interventions to support caring and social networks
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Effectiveness
Support to the strengthening or re-establishment of social capital and networks will enhance the impact of interventions that address physical needs.
Monitoring
The chronically ill and people living with HIV/AIDS
Relevance
Crisis situations may increase the susceptibility to HIV infection through increased mobility, the adoption of risky livelihood choices, the deliberate use of rape as a weapon of conflict, and increased gender-based violence. Food insecurity and poor nutritional status also accelerate the progression from HIV infection to symptomatic AIDS. Some population groups may have been relatively isolated during a conflict, and the post-conflict context may lead to increased contact with population groups that have higher HIV prevalence. Relief operations increase the potential for transmitting HIV infection through the influx of relief and logistics personnel with disposable incomes, and through the abuse of relief commodities in exchange for sexual services. However, relief operations also provide an opportunity to implement a wide range of prevention, treatment, care and mitigation interventions for different target groups.
Feasibility
Food security and nutrition actions have a key role to play in all aspects of HIV/AIDS initiatives. The implementation strategy should depend on the HIV prevalence levels (where known), the stage in evolution of the HIV/AIDS crisis, and cultural and religious characteristics of the population groups affected. Food and nutrition interventions for HIV/AIDS-affected populations should be planned, taking into account HIV/AIDS activities and potential partners in other sectors. Rather than establishing parallel interventions for HIV/AIDS, it may be more appropriate to ensure that HIV/AIDS considerations are mainstreamed into all interventions by applying an HIV/AIDS "lens" to ongoing or proposed activities. This involves asking whether the objective of an intervention is still attainable in an AIDS context (e.g. how will the implementation of extension and nutrition education programmes be affected by increased morbidity and mortality among community-based workers?) and whether a proposed intervention is relevant and appropriate in the HIV/AIDS context (e.g. what are the labour implications for a proposed intervention?).
Effectiveness
HIV/AIDS awareness and sensitization activities are increasingly being included in relief operations (e.g. theatre groups during food distributions); however, it is more difficult to ensure that increased awareness leads to behaviour change. In order to achieve behaviour change, HIV/AIDS initiatives need to address four aspects - prevention, treatment, care and mitigation - through partnerships among different government departments or organizations, and synergies among interventions. It is only by offering hope and improved quality of life through treatment, supportive care and legal rights that the stigma attached to HIV infection can be reduced and people become motivated to take responsibility for their own actions and well-being.
Box 40: Examples of promoting food and nutrition actions in the HIV/AIDS context
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Monitoring
