Literature Review by THP Program Team chaired by Rowlands Kaotcha
I. Unpacking “ending hunger”
“Hunger” is not a scientific term; it represents a basket of multiple nutrition issues. Thus, studies have focused on the specific interventions for each nutrition component which together make up “ending hunger.”
The G8 commitment to food security (G8, 2009) followed by the launch of the Scaling-Up Nutrition Movement and the Thousand Day Partnership established that the key focus for ending hunger needed to be on adolescent girls, pregnant and nursing mothers, as poor nutrition up to age two caused irreversible loss of intellectual and physical development. The Lancet published a series (Black et al 2013) that established a framework of 19 nutrition actions that must all come together to end hunger and the seven actions required to build an enabling environment to make that possible. This framework has been adopted by all the major agencies as outlined on the Scaling Up Nutrition Movement site.
For the purposes of this literature review, we used The Lancet’s 19 nutrition actions as our definition of “ending hunger.”
II. Unpacking “community-led development”
The first outcome in the Lancet framework is the enabling environment for ending hunger, and they call for 7 actions to build that enabling environment. These enabling actions map closely to the 11 characteristics of community-led development which the Collaborative Research Group of MCLD identified in 2019 when a group of 30+ program and MERL professionals from 20 organizations, along with a global advisory council of academic, practitioner and methodology experts set out to determine what it is that organizations actually do when they say they do CLD.
For the purposes of this literature review, we used The Lancet’s 7 enabling actions as a framework for unpacking “community-led development. –- image by Gunjan Veda
III. Literature selection criteria
Based on the above definitions of “ending hunger” and “community-led development,” task force members conducted a literature review to explore the link between
- Building the enabling environment for nutrition interventions and programs
- Community-led approaches to the 19 interventions and programs.
IV. Our main findings
The diagram of the Lancet framework begins with “Building an Enabling Environment” that makes possible the three “green box outcomes”: food security, caring practices and access to health and hygiene, which in turn result in the three “blue box” nutrition outcomes.
Building an Enabling Environment
All the nutrition outcomes depend on an enabling environment, and the essence of community-led development is facilitating community members to create that environment. Here is what we found in the literature on the seven actions called for by the Lancet.
- Rigorous evaluations: CLD asserts that community members must be owners, participants and chief clients of monitoring, evaluation and learning (MEL), and Characteristic #10 is adaptability: that CLD programs use learning and adapting strategies based on current context and data. An academic study of the literature on Participatory M&E (Onyango 2018) identified five key principles, and summarized its advantages: it yields empowerment among stakeholders by enhancing stakeholders ‟capacity, self-reliance, confidence and shows that their views count as they take action and promote change… PM&E offers a more equitable voice for all stakeholders during the monitoring and evaluative process by ensuring equitable participation in the process. This process yields more accurate and more socially just and equitable development strategies” (pg 432)
- Advocacy strategies: CLD Characteristic #2 is Voice – building the confidence of people to speak up. CLD organizes communities – and marginalized groups within communities – to have voice in the decisions that affect their lives. The Hewlett Foundation’s Global Development and Population Program, for example, supports grassroots advocacy in Africa along two dimensions. The first of these emphasizes the role of women—a straightforward acknowledgment that addressing gender disparities and reproductive health problems plays a central role in combating poverty around the world. The second promotes transparency, participation and accountability in government and civic affairs, and the use of the best available evidence in policy making.
- Horizontal and vertical coordination. In CLD, horizontal coordination is achieved through strengthening community-level governance and their role in all key public services – whether this is through coordination of sectoral subcommittees in panchayats, municipios or epicenters. It supports vertical coordination by strengthening upward voices as well as stronger links between community members and ministerial staff.
- Accountability incentives, regulation, legislation. The Lancet series specifically calls for strengthening the incentives for decentralized leadership to be accountable for nutrition. The World Bank’s Global Partnership for Social Accountability supports civil society and governments to close the accountability gap between them.
- Leadership programs. Characteristic #9 is community leadership – leadership “with” rather than leadership “over.” CLD creates an environment where every community member is seen and sees themselves as a leader (active citizen) who can affect change. The focus of community leadership is co-creation.
- Capacity investments. Characteristic #4 of CLD is the program is rooted in the belief that communities have the capacity and capability to script their own development; hence the program invests considerably in facilitators, as well as the capacity strengthening development of local groups, including locally elected government.
- Domestic resource mobilization. Characteristic #3 of CLD is that the program identifies, mobilizes, and celebrates local resources including finances, material goods, and local knowledge and time. This in itself also constitutes a distinct strand of community development known as “Asset Based Community Development (ABCD)”. ABCD has been popular in Scotland, Canada, South Africa and many other parts of the world but has its critics. A recent theory-based evaluation (Ward 2021) concluded that “ABCD can generate locally led activity and build social networks but is unlikely to achieve a ‘tipping point’ from activity generation into wider community association without pre-existing resources being in place. Community association relies on pathways of activism that support local action incrementally and require resources in support of this.” (pg 1) This is consistent with the more comprehensive CLD approach of integrating self-reliant action with policy advocacy for greater devolution of resources.
Nutrition Sensitive Programs and Approaches
Once the enabling environment is in place, the Lancet series identifies the first set of outcomes that require nine nutrition sensitive programs: Here are highlights of the literature on community-led action to implement them.
- Agriculture and food security: IFAD reports “Most CDD projects had a positive impact on food security. This often resulted from demand-driven investments in irrigation systems and other infrastructure to improve livestock and fisheries production, coupled with technical skills training for farmers. The demand-driven nature of CDD projects meant that investments were often multisectoral, contributing in turn to improved food security and nutrition.” (IFAD, 2020, p vii). A detailed analysis of Food Sovereignty (Burdock & Ampt, 2017) argued that Food insecurity is not generally a result of insufficient production or availability but is usually linked to the politics of inequality, and that the Global Strategic Framework for Food Security and Nutrition needed to be altered to be based the rights of the individual to participate in the food production system and determine their own food future. A 2019 study (El Ouaamari et al., 2019) shows how collective and community-led action in a village in Senegal increased income, access to nutrition and foods for the farmers and families.
- Social safety nets. Social safety nets are a top-down program to protect households and producers against shocks. They are often plagued by corruption, nepotism and political misconduct. (Khan, 2020). One solution to this failure has been to establish community-based programs to target these resources (Conning & Kevane, 2000). “Local community agents often have better information on household characteristics, needs and recent events upon which to condition beneficiary eligibility than do outside welfare agents who must often rely on crude and outdated proxy indicators. Better information allows for fewer targeting errors of inclusion or exclusion. Better information may also greatly reduce administration costs and total deadweight loss compared to programs administered by less informed welfare agents who must rely on screening and monitoring devices such as costly audits and indirect incentive systems that place constraints on the amount and types of benefits delivered.” (p 16)
- Early child development. IFPRI (Gelli et al., 2018) has demonstrated that using a community-based early childhood development center as a platform to promote production and consumption diversity increases children’s dietary intake and reduces stunting in Malawi. There are many studies on how nutrition affects child development, but this is one of the few that shows how child development affects nutrition.
- Maternal mental health. Mental health disorder, particularly depression, is one of the leading causes of ‘disease related disability’ in women that both affects the women and has an adverse effect on their children. This can have an impact on mothers’ capacity of child care which ultimately increases the risk of infection, malnutrition, impaired growth and behavioral problems in children that might extend to adulthood. (Singh et al., 2021). Professional mental health care is virtually nonexistent in much of the world. The London School of Hygiene and Tropical Medicine has shown how community-led innovations are taking root.“Peer support gives people we speak to a sense of hope that recovery is possible. It builds self-esteem and confidence. The peers gain acceptance of self and the community at large. By speaking to peers we enable them to come out and challenge and fight stigma. I see peer support as my social responsibility and contribution to my community at large.” (Cousins, 2019, pg number)
- Women’s empowerment. The 2010-2011 State of Food and Agriculture report stated that “Women make significant contributions to the rural economy in all developing country regions. Their roles differ across regions, yet they consistently have less access than men to the resources and opportunities they need to be more productive. Increasing women’s access to land, livestock, education, financial services, extension, technology and rural employment would boost their productivity and generate gains in terms of agricultural production, food security, economic growth and social welfare. (FAO, 2011, p.148). Closing the gender gap in agricultural inputs alone could lift 100–150 million people out of hunger. That “gender gap” is a function of deeply entrenched social norms, and a key role for CLD is to change harmful gender norms (Cislaghi, 2019). “Two well studied examples are the SASA! Program in East Africa and Tostan in West Africa. SASA! facilitates discussions around power as a way to help community members achieve more gender-just relationships (particularly reducing domestic violence). Abramsky et al. (2014) conducted a five-year, mixed-method randomized control trial (RCT) to measure how SASA! contributed to transforming gender norms and reducing domestic violence. After the programme, male participants reported increased equitable decision-making in the family, as well as greater appreciation of their partners’ work inside the household, among other outcomes. Tostan’s Community Empower Program (CEP) changed the gender norms that had sustained child marriage and Female Genital Mutilation (UNICEF, 2008) and increased access to health and education.” An IFAD review reports “ performance ratings (for 347 projects) show that CDD projects performed better than non-CDD projects in promoting gender equality and women’s empowerment. Overall, there were 85.6 percent satisfactory ratings for CDD-related projects compared to 76.3 percent for non-CDD operations.” (IFAD, 2020, p vii)
- Child protection. Protecting children from violence is clearly necessary to secure their nutrition. A chapter of the book “Children and Peace” (Kostelny, 2019) states: “Although community-led approaches have not been widely used in child protection work, they have shown promising results. In Sierra Leone, rural communities chose to address teenage pregnancy using a combination of their own locally grown approach to family planning, sexual and reproductive health, and life skills. This work was notably holistic and entailed making connections between health and child protection sectors. Before the community-led action was scuttled by the Ebola crisis, it had achieved significant reduction in the levels of teenage pregnancy. Also, it achieved high levels of community ownership, with significant leadership by children and participation by people who had been marginalized previously (Wessells, 2015). In this respect, it contributed to social justice within the community.”
- Classroom education. Schools are key platforms for both nutritious meal programs and nutrition education, and local communities are largely responsible for primary schools. “Community Schools,” a community-led approach, have been shown to be an effective school improvement strategy (Maier et al., 2017). “Four key pillars of community schools—integrated student support, expanded learning time and opportunities, family and community engagement, and collaborative leadership and practice—promote conditions and practices found in high-quality schools and address out-of-school barriers to learning.”(pg number)
- Water and sanitation. The importance of clean water and sanitation affects nutrition in more ways than just water-borne disease. Since sanitation is primarily behavioral and socially normative, the strategy of “Community-led Total Sanitation (CLTS) has proven “most effective to date in tackling the sanitation challenge at scale. (IDS, 2014). Randomized control trials in Mali (Pickering et al, 2015) show that “CLTS intervention reduced stunting by 6 percentage points and improved child height by 0.18 HAZ [height-for-age Z scores].”
- Health and family planning services: Access to family planning, pre- and post-natal care is a critical component of improving 1,000 Day Nutrition – reducing early pregnancy, facilitating safer child spacing and providing ENA education. A study of the role of community-based health planning and services (CHPS) strategy in involving males in the provision of family planning services (Adongo, 2013) revealed a “general high perception of an improved health status of children… yet also revealed that spousal approval was still relevant for women in the use of contraceptives… Males were more involved in FP services in communities with functioning CHPS than those without.”(pg 1)
Nutrition Specific Interventions and Programs
Once the above outcomes are in place, nutrition outcomes become possible. Below are highlights of key research findings relating to community-led development and each of the 10 Nutrition Specific Interventions and Programs. These are the activities most closely linked to guidance from WHO, Unicef and the UN Standing Committee on Nutrition, all of which call strongly for community-led approaches.
- Adolescent health and preconception nutrition. Results from a multicountry, longitudinal study (Prentice et al., 2013) reveal an additional “window of opportunity” – good nutrition during adolescence results in girls growing taller, and this results in better nutrition for children born of both adolescent and adult mothers. This was cited in the new WHO Guidelines (WHO, 2018) calling on community stakeholders to transform social structures and norms to encourage adolescents to adopt and maintain optimal nutrition. Participatory Action research on community-led iron supplementation in Wardha, India (Dongre et al., 2011) reduced anemia from 73.8% to 54.6% among adolescent girls.
- Maternal dietary supplementation. Digital Green carried out a community-led strategy promoting maternal dietary supplements in Odisha, India through training communities in a randomized selected group of villages to create and disseminate their own promotional videos shown to citizens on small tablets. USAID’s Spring-Nutrition program evaluated this program (USAID/SPRING, 2014), demonstrating that the demand for these videos was high and acceptability of the intervention was strong.
- Micronutrient supplementation or fortification. A review of Public Health Interventions to Combat Micronutrient Deficiencies (Harrison, 2010) concluded that the “Essential Nutrition Actions (ENA)” of community-led maternal education on breastfeeding and complementary feeding has now been demonstrated to be effective in some of the poorest countries. THP has integrated ENA into its CLD programming.
- Breastfeeding and complementary feeding. This same UCLA review of ENA also provided clear evidence on its impact on Breastfeeding and complementary feeding. In addition, a literature review on Community Breastfeeding Interventions (USAID 2012) found that “including communities in decisions and actions to improve their wellbeing, and providing comprehensive support for breastfeeding – encompassing policy, the health system, and community protection, promotion and support for breastfeeding, and for breastfeeding mothers can result in significant synergy and, on occasion, highly significant increases in early initiation, EBF [exclusive breastfeeding] and EBF duration.” (p.xi)
- Dietary supplementation is a contentious issue and is not promoted by Unicef. The WHO Guidelines state that “In undernourished populations, balanced energy and protein dietary supplementation is recommended for pregnant women to reduce the risk of stillbirths and small-for-gestational-age neonates” while “high-protein supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.” (WHO, 2018, p7). This is based on a review of studies (Prentice, 1991) concluding that “supplementation during late pregnancy can have a significant beneficial effect on birthweight in women who are genuinely ‘at risk’ due to an inadequate home diet.” We could find no studies of community-led interventions for dietary supplementation.
- Dietary diversification. Improving women’s dietary diversity that can be addressed through nutritional training. The USAID-supported Kenya Accelerated Value Chain Development Program (AVCD) has carried out a community-led solution that improves nutrition outcomes in Kenya’s pastoral communities . Over the past six years, it has “passed on messages to mothers and caregivers about the value of consuming nutritious food and promoting dietary diversity to reach households with children below 2 years of age. These efforts have created public awareness on the nutrition value of diverse, safe and nutritious foods that include leafy green vegetables, fruits, tubers, nuts, grains and animal products… Through this work, community ownership and sustainability of agri-nutritional interventions has increased.” (Njiru, 2020). IFAD reports “Half of the CDD projects report that target groups benefited from more diverse diets, thanks to investments in kitchen gardening, irrigation schemes, small livestock and livestock-related infrastructure/services, such as pig sties, water points or veterinary services. In general, however, the investments made across different sectors potentially contributed more to nutrition outcomes than reported.” (IFAD, 2020, p 53).
- Feeding Behaviors and Stimulation. This is a key part of the ENA package incorporated into CLD nutrition programming by THP and many others. A cluster-randomized field trial (Aboud & Akhter, 2011) found that a brief behavior-change program by community peer educators that focused on modeling and practice in stimulation and feeding benefitted children’s nutrition and language development.
- Treatment of severe/acute malnutrition. Community-based Management of Acute Malnutrition (CMAM) is one of the more famous “scaled up” community-led nutrition interventions, as the alternative – placing children in hospitals on IV drips – is out of reach for most people. An independent evaluation of Unicef-supported CMAM programs in North Korea found that “Through the evaluation, the context-adapted programme strategy was validated,” and “the highly effective programme averted an estimated 7,581 under-five children’s deaths in 2015-2016 and provided appropriate treatment for 180,000 acutely malnourished children” (Binns & Guerrero, 2018). Highlighting the importance of community health workers, a quasi-experimental study from Tanzania found that, “using CHWs to treat children with uncomplicated SAM was superior compared to the standard OTC model. Children treated by CHWs attained a higher cure rate and were less likely to default compared with those treated in health facilities. Moreover, the intervention increased coverage of SAM treatment services.” (Wilunda et al., 2021) A review of 44 CMAM programs in 21 countries concluded that “the most important barrier to access was lack of engagement with beneficiary communities” and called for “innovative delivery strategies—especially community-based delivery platforms—for the scale-up of SAM services are urgently needed.” (Wilunda et al., 2021)
- Disease prevention and management: The National Academy of Medicine concluded in 2012 that social characteristics such as socioeconomic status, social cohesion, social capital, and friendship networks are associated with health and well-being. They found that clinical approaches only reach small numbers of high-risk people, while community strategies can prevent large numbers of people from developing lifestyles that harm their health. (Institute of Medicine, 2012).
- Nutrition interventions in emergencies: Localization of humanitarian action was the centerpiece of the “Grand Bargain” established at the 2016 humanitarian summit. Studies in Yemen (Kurdi et al., 2020) and the DRC (Balaluka et al., 2012) have shown that community volunteers recruited in humanitarian situations were more effective at nutrition training than simply providing services or support.
This literature review has therefore established that the second Lancet Series in 2013, which is a key milestone in the world’s understanding of ending hunger, widely adopted by both UN and bilateral agencies, can serve as a useful framework for the Theory of Change for Gender-Focused, Community-led Development programming.
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