Interdisciplinary interventions for stunting and wasting in Zimbabwe, Zambia and Pakistan

Lead Research Organisation: Queen Mary University of London


Undernutrition underlies almost half of all child deaths and has far-reaching educational, economic and health impacts. We focus on stunting and wasting, the major forms of undernutrition, which are not explained simply by shortage of food. Stunting, or reduced height, impairs long-term educational attainment and earning potential in adulthood and has multiple underlying causes, but few effective preventive strategies. Wasting in its most serious form presents as severe acute malnutrition (SAM) and children have a high risk of dying in hospital or after discharge home. For children to survive, thrive and lead prosperous lives, we need new ways to tackle undernutrition. We aim to strengthen partnerships, draw on expertise beyond traditional nutrition disciplines, and conduct a long-term programme of research in three countries with a high burden of child undernutrition - Zimbabwe, Zambia and Pakistan. Our ambition is to improve child survival, health and potential by finding new ways of preventing stunting and treating wasting, to help reach the Sustainable Development Goals.

Our long-term research programme has three aims. Our first aim is to understand the network of environmental, social and biological factors that interact to cause undernutrition so we can find the most promising targets for intervention. Our second aim is to use this learning to evaluate new strategies for undernutrition. We will design packages of interventions that are often not used together, and test their effectiveness, first in small pilot studies and then in large clinical trials aimed at preventing stunting and treating wasting. Our third aim is to use the findings we generate to influence policy and development programmes so that new interventions are scaled up effectively to reduce undernutrition.

We plan to use this current grant opportunity to strengthen links with each country, build more south-south cooperation through collaborative meetings and a shared programme of work, and engage new investigators from outside the nutrition field. We will conduct four pilot projects to identify new approaches to undernutrition, which will start to inform our long-term programme. First, we will bring together experts in human, animal and environmental health to discuss the risks and benefits of livestock ownership for stunting and start to design a future intervention that increases the positive effects of livestock ownership whilst mitigating the negative effects. Second, we will work with social scientists to evaluate the attitudes and behaviours of mothers whose children are recovering from SAM. Strengthening the capacity of mothers to look after their children might help to deliver a package of care after discharge from hospital to improve the long-term outcomes of children with SAM. Third, we will explore whether giving high-dose vitamin D is a promising strategy to improve recovery of children with SAM in Zambia and Zimbabwe, as we recently found in Pakistan. We will measure vitamin D in our laboratory using blood samples collected from children with SAM during hospital admission and at discharge, to see whether vitamin D deficiency partly explains their poor outcomes. If so, high-dose vitamin D should be evaluated in a future trial. Finally, we will conduct a pilot study to treat maternal depression as a way of improving child growth. Poor maternal mental health can compromise caregiving and feeding practices and increases the risk of child stunting. Treatment of common mental disorders using a community-based intervention based on problem solving therapy, delivered by trained lay workers, is highly effective but is mostly used in urban areas currently. We will conduct pilot work to see if this intervention works for mothers in rural Zimbabwe, and whether it is a promising approach to improve child growth and development.

Technical Summary

Undernutrition underlies almost half of all child deaths and has educational, economic and health impacts. We focus on stunting and wasting, which are in need of new interdisciplinary solutions. We aim to strengthen UK-LMIC partnerships, engage interdisciplinary expertise, and conduct a long-term programme of research in Zimbabwe, Zambia and Pakistan, with three aims. Aim 1 is to understand the determinants of undernutrition to identify new targets for intervention. Aim 2 is to evaluate new multisectoral approaches to prevent stunting and treat wasting. Aim 3 is to develop skills to turn science into practice, so that new interventions are scaled up effectively.

We will use this grant to strengthen links with each country, build more south-south cooperation and conduct four interdisciplinary pilot projects to identify new approaches to undernutrition. First, we will hold a meeting that will discuss the risks and benefits of livestock ownership for stunting. A 'One Health' approach to undernutrition could generate solutions at the interface of animal, human and ecological health. Second, we will work with social scientists to evaluate the attitudes, behaviours and capabilities of mothers whose children are recovering from SAM. Strengthening the capacity of mothers to look after their children might help to deliver a package of care after discharge from hospital to improve long-term outcomes. Third, we will explore whether high-dose vitamin D is a promising strategy to improve recovery of children with SAM. We will measure 25-hydroxyvitamin D by ELISA in 590 children to see whether vitamin D status is independently associated with morbidity, mortality and nutritional recovery. Finally, we will conduct a pilot study to treat maternal depression using a community-based intervention to assess feasibility, acceptability and efficacy for mothers in rural Zimbabwe. This would form part of a multisectoral intervention for stunting reduction in our long-term programme.

Planned Impact

Our ambition is to improve child survival, health and potential by finding new ways of tackling undernutrition, to help reach the Sustainable Development Goals. Stunting affects 156 million children globally. Stunting therefore remains alarmingly prevalent and is declining too slowly to reach World Health Assembly targets. Over half the global stunting burden is concentrated in Asia, where 34.4% of children are stunted. In Africa, stunting prevalence remains remarkably stagnant and, due to population growth, absolute numbers of stunted children are increasing. Low-income countries have more stunted children today than 15 years ago. An estimated 43% of children fail to reach their developmental potential due to stunting and poverty, and in sub-Saharan Africa this rises to 66%. The effects of poor growth and development are far-reaching: stunted children are more likely to die from infections; enroll later and do less well at school; earn less money as adults; and have an elevated risk of chronic diseases in adult life. Wasting affects around 1 million children a year in its most serious form, severe acute malnutrition. Although many children can be managed in the community through nutrition programmes, those with clinical complications need to be admitted to hospital and mortality rates remain unacceptably high around 35%; there is a clear need for new approaches to improve outcomes.

New findings from our pilot projects will inform long-term research to test the impact of promising interventions in undernutrition and translate effective interventions from research tools to policy recommendations, ultimately benefiting children with stunting and wasting. Focusing interdisciplinary expertise on finding new evidence-based solutions to undernutrition has potential to benefit around one-third of children in low-income countries. Effective interventions will enhance health and wellbeing, educational attainment, economic prosperity and resilience across the life-course, conferring enormous individual and societal benefits, including national economic growth and stability. Improving child growth and development would be an effective way of preventing inequality, enhancing productivity and reducing poverty. Since stunting is intergenerational, investments in the current generation will be sustained into the next generation. Given the large number of stunted children, even interventions that have a small effect on growth at the individual level have the potential for large benefits at the population level.

To ensure that our research has impact, we have embedded south-south cooperation and knowledge exchange into our programme from the start, and we will ensure that our research agenda is based on local priorities. We aim to identify and include hard-to-reach populations in our research, by focusing on rural as well as urban undernutrition, and conducting home visits to reach caregivers of children with SAM who are difficult to follow up in inpatient settings. We will target both male and female family members in our focus group discussions. To maximise impact, one of our Research Themes specifically aims to bridge the evidence-action divide, by building capacity to engage and influence policymakers, bring data to implementation programmes and understand what works in different contexts. Advocacy, public engagement and research dissemination will be central to our long-term programme of work.

Our work has the potential to enhance the economy in each country by building a research agenda that requires human resources; training researchers in new skills, including the capacity to secure research grants; and enhancing the research ecosystem to retain talented individuals in each country. To ensure legacy, we will aim to establish a research 'cluster' through south-south collaboration and triangular cooperation to achieve more sustainable ways of working.




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Description Our achievements include:

1. We showed that the Friendship Bench - a low-cost, lay-delivered, problem-solving therapy for common mental disorders - is feasible to deliver in rural areas of ZImbabwe through community health workers, and is acceptable to postpartum women, with evidence of efficacy in reducing depression.

2. A One Health approach to stunting - the most common global form of undernutrition - needs to be considered, since there are both risks and advantages to animal ownership in terms of child nutritional status. We held an interdisciplinary meeting, published a review to outline our ideas and to define the research gaps in the field, and brought attention to the issue of managing animal waste in global sanitation strategies.

3. It is widely recognised that children recovering from Severe Acute Malnutrition (SAM), remain vulnerable to risk of death following hospital discharge due to a wide range of biological and social factors. In light of this heightened risk, we undertook a qualitative study which aimed to better understand the contexts that children recovering from SAM were recuperating in within the high density urban and suburban districts of Harare, Zimbabwe. Undertaken with the mothers and other primary caregivers of 10 children enrolled on a large observational cohort study (HOPE-SAM), we identified several dimensions of women's lives that impede their caring capabilities. Given the country's
status as a global 'hunger hotspot' (FAO/WFP, 2022), it should not be surprising that food insecurity featured prominently amongst these. Beyond this, we identified women's uneven access to informal social protection, experiences that are reflective of what recent scholarship refers to as examples of 'uncaring' or 'noncaring,' as well as their responses to discourses of shame and stigma within the community and hospital settings.
Exploitation Route The Friendship Bench is now being scaled up in Zimbabwe, including in rural areas, and could be adopted in other rural African settings, by leveraging the findings of our grant.

The research gaps identified in our One Health review could be tackled in future grants to identify new holistic strategies to reduce child stunting.

The findings from the qualitative work on SAM could be used to inform psychosocial interventions that would improve convalescence among children leaving hospital following management of severe acute malnutrition.
Sectors Environment


Description The Friendship Bench, which we showed was feasible and acceptable to implement in rural areas of Zimbabwe, is now being scaled up across the country, including in rural areas. Since there is currently very limited access to mental health services in Zimbabwe, this peer-delivered, low-cost intervention, has potential to expand access to evidence-based treatment for common mental disorders.
First Year Of Impact 2022
Sector Healthcare
Impact Types Societal

Policy & public services

Description Multimorbidity in children with HIV and severe acute malnutrition in sub-Saharan Africa
Amount £4,979,419 (GBP)
Funding ID NIHR201813 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 08/2021 
End 08/2025
Description Trial of high dose vitamin D in the treatment of complicated severe acute malnutrition (ViDiSAM)
Amount $538,232 (USD)
Organisation Thrasher Research Fund 
Sector Charity/Non Profit
Country United States
Start 01/2020 
End 12/2022
Description Cardiff University 
Organisation Cardiff University
Country United Kingdom 
Sector Academic/University 
PI Contribution We have forged a new collaboration between the Zvitambo Institute for Maternal and Child Health Research in Zimbabwe, and Cardiff University, to work together on future projects. Zvitambo conducted the SHINE trial which has provided data to inform new research ideas through this collaboration.
Collaborator Contribution Cardiff University brings expertise in parasitology, microbiology and anthropology which will form the basis for future interdisciplinary working to address the challenge of childhood diarrhoea.
Impact An Opinion Piece published in Lancet Planetary Health (Prendergast et al., 2019)
Start Year 2019
Description Human geography, QMUL 
Organisation Queen Mary University of London
Department School of Geography
Country United Kingdom 
Sector Academic/University 
PI Contribution We have enrolled several cohorts of women and children in urban and rural Zimbabwe with rich quantitative data collection
Collaborator Contribution Training, capacity building and research in qualitative methodology, thereby bringing a social science lens to several major global health challenges
Impact 1. Manuscript on a One Health approach to stunting ( 2. Manuscript on maternal mental health in rural Zimbabwe (DOI 10.1017/gmh.2021.32) 3. Co-investigators on joint grant submitted to NIHR (awarded) 4. Capacity building and training for three Zimbabwean social scientists
Start Year 2018
Description UNICEF Zimbabwe 
Organisation UNICEF
Country United States 
Sector Public 
PI Contribution We have formed a partnership with UNICEF Zimbabwe to help interpret the results of the HOPE-SAM study, and to undertake operational research to understand the reasons underlying poor clinical outcomes of children with severe acute malnutrition. We are working together to build on the findings of this study by developing a package of care for children being dischaged from hospital following management of SAM.
Collaborator Contribution UNICEF are a major policy and programming organization both globally, and locally in Zimbabwe. They are providing technical expertise, the capacity to bridge the evidence-action divide, and financial support leading on from the primary MRC funding, to utilise the data collected in this study and ensure that it is translated into policy and practice.
Impact Two "Brown Bag" meetings were held in March 2022 with actors from the Zimbabwean Ministry of Health, the academic community in Zimbabwe, NGOs, clinicians and policymakers, to present and discuss the results of the HOPE-SAM study. The first meeting focused on outpatient outcomes, and the need to refocus attention on convalescence to reduce mortality and improve nutritional recovery, and included a round-table discussion; the second meeting focused on reducing mortality among children hospitalized with severe acute malnutrition.
Start Year 2019
Description University of the Punjab, Pakistan 
Organisation University of the Punjab
Country Pakistan 
Sector Academic/University 
PI Contribution We forged a collaboration between QMUL and University of the Punjab, together with project partners in Zimbabwe and Zambia involved in severe acute malnutrition research, to develop future grant ideas and research collaborations.
Collaborator Contribution Dr Javeria Hasan joined a collaborative research meeting in Harare, Zimbabwe, in May 2018 to attend a scientific meeting on malnutrition and to plan a grant collaboration, currently in progress.
Impact Scientific meeting on malnutrition held for 2 days in May 2018
Start Year 2018
Description Caregiver dissemination event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact We held a caregiver dissemination event attended by almost 150 children and 250 caregivers in Harare, Zimbabwe. We provided flyers on the findings of several recent studies of severe acute malnutrition, had an interactive Q&A session about the findings, invited testimonials from study participants, and had a song and short drama from our community advisory board to explain the study findings. Children who had participated in the study had activities arranged by the Discovereum, a children's museum in Harare. The event triggered discussion about future research studies, what the participants' priorities were, and the multifactorial nature of malnutrition.
Year(s) Of Engagement Activity 2023
Description Friendship Bench community event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact As part of this award, we conducted a pilot study on delivering the Friendship Bench, a lay worker-delivered talking therapy for depression, in rural Shurugwi, Zimbabwe. We trained 10 Village Health Workers to deliver the intervention among 30 young mothers in Shurugwi and established support groups with income generating activities. As part of the process, we held a celebratory public event in November 2018 in which Village Health Workers used song, dance and drama to describe the impact of the Friendship Bench in the community; they also sold produce and goods that the women in the Friendship Bench had made as part of their income generation support groups. Local Chiefs, politicians, health workers and members of the public attended.
Year(s) Of Engagement Activity 2019