UK-Africa network to improve the nutrition of infants and young children living in poverty (NINO LIP) in urbanising subSaharan African countries

Globally, more than a quarter of children under the age of five years are stunted (undernourished). Stunted children experience lifelong problems with their health and are more likely to die early. The time at which an infant transitions from receiving only breastmilk to needing additional foods (complementary feeding) has been shown to be associated with increasing problems with stunting. Currently only 22% of Kenyan and 8% of Malawian children aged 6-23 months receive the minimum acceptable diet, down from 39% (Kenya) and 19% (Malawi) between 2008 and 2014. It is estimated that interventions which promote optimal infant and young child feeding (IYCF) practices could prevent 20% of deaths in under-fives in countries with high levels of child deaths. Approximately one-third of urban residents in low and middle income countries live in slums, with an additional 100,000 moving in daily. Children living in slums are more likely to suffer from under-nutrition than other urban children. Nevertheless the literature tells us that there is a lack of evidence regarding nutrition interventions in slum environments, and almost no evidence regarding the potential for 'nutrition-sensitive' interventions that target the drivers of poor nutrition such as poverty, cultural and social practices, and poor physical environments. Successful design of these types of intervention requires a well-integrated interdisciplinary approach. In addition to nutrition expertise, contributions from other disciplines are needed to understand the cultural, social, physical and economic environments that influence IYCF practices.

We therefore propose an interdisciplinary network with the aim to produce evidence to drive future research and inform policies to improve the nutritional status of IYC living in poverty in sub-Saharan African countries (SSA) experiencing rapid urbanisation. The network is led by Loughborough University with Kenyan partners at the African Population and Health Research Centre and Malawian partners at the University of Malawi and The Lilongwe University of Agriculture and Natural Resources as well as UK partners at The Universities of Sheffield and Southampton. The specific network objectives will be to: 1) Prepare a rapid review of evidence documenting interventions for the urban poor to improve the nutrition of IYC in SSA; 2) Convene the first network workshop (to include stakeholders) to firstly guide analysis of existing data sources on this topic, to secondly consider the current evidence base and policies identified in the rapid review and finally to ask key stakeholders to identify highest-ranking evidence/research gaps for improving IYC feeding programmes and policies; 3) Undertake analyses of existing data from demographic and health surveys in sub-Saharan Africa and pre-existing data from slums in Nairobi to explore how the various drivers of IYCF practices are influenced by urbanisation and to consider whether those drivers vary for the urban poor compared to other urban populations; and finally 4) Facilitate end-of-project workshops to develop research proposals informed by evidence from the first three objectives and to present findings of the secondary analysis and discuss these with stakeholders (including Ministries of Health, NGOs, communities) and policy-makers. The network will also foster the development of skills in data analysis and evidence synthesis in early career researchers in the UK, Malawi and Kenya, thus helping to ensure a sustainable group with potential for evolving future leadership. In the longer term we will develop a UK-Africa interdisciplinary network with expertise to support interventions to promote optimal IYCF practices in rapidly urbanising environments. It is envisaged that such interventions will improve the human capital of developing countries by reducing under nutrition, thus promoting optimal cognitive and physical development, and thereby increasing prospects for economic prosperity.

Globally, >25% of children under the age of five years are stunted. Currently only 22% of Kenyan and 8% of Malawian children aged 6-23 months receive the minimum acceptable diet. Approximately one-third of urban residents in low- and middle-income countries (LMICs) live in slums, with an additional 100,000 moving in daily. Slum children are more likely to suffer from under-nutrition than other urban children. Nevertheless evidence-based interventions to improve infant and young child (IYC) health/nutrition in slums are lacking. We will form a Loughborough University-led interdisciplinary network with partners in Malawi, Kenya, Southampton and Sheffield with the aim to produce evidence to drive future research and inform policies to improve the nutritional status of IYC living in poverty in sub-Saharan African countries (SSA) experiencing rapid urbanisation. The network has four main objectives:1) Prepare a rapid review documenting current evidence on nutrition-specific/sensitive interventions for improving the nutrition of IYC who are receiving complementary foods in the context of rapid urbanisation for the urban poor in SSA; 2) Convene the first network workshop (to include stakeholders) to a) Guide secondary data analysis, b) Consider the current evidence base/policies identified in the rapid review, and c) Apply the DELPHI method with stakeholders to identify highest-ranking evidence/research gaps for improving IYC feeding programmes/policies; 3) Undertake secondary data analysis of existing African demographic and health surveys and pre-existing data from slums in Nairobi to explore how various drivers of IYC feeding practices are influenced by urbanisation and to consider whether those drivers vary for the urban poor compared to other urban populations; and 4) Facilitate end-of-project workshops to a) Develop research proposals informed by evidence from the first three objectives and b) Present and discuss findings with local policy-makers and stakeholders.

The impact of our 12 month global nutrition and health network; "UK-Africa network to improve the nutrition of infants and young children living in poverty (NINO LIP) in urbanising sub-Saharan African countries" will be to mobilise an interdisciplinary research and policy agenda to promote optimal infant and young child feeding (IYCF) practices in rapidly urbanising environments in sub-Saharan Africa (SSA), with a focus on the urban poor and those living in slums. Our longer term impact goal is to improve nutrition at a critical point in the life-course through the development of nutrition-sensitive interventions and holistic approaches to reduce infant and young child (IYC) stunting in SSA countries; this will be our route to achieving change across the global nutrition/health research landscape.

The benefit of this project to LMICs is that the research need has been identified by researchers and partners in Kenya and Malawi, and that impact activities are an integrated component of the 12 month network. We have already engaged with key stakeholders in preparation of this proposal, and in order to build our global nutrition network. Our early engagement is evidenced through the letters of support already received from UNICEF, Kenya; the Ministries of Health in Kenya and Malawi, and the African Nutrition Society. Further stakeholders will be identified through the extensive links of the UK, Malawian and Kenyan investigators and their respective institutions. By the end of the 12 month network, we will have extended our stakeholder links to other African countries. Starting our global nutrition and health network with two African countries at different stages of economic development will allow a better understanding of the barriers and opportunities for nutrition-sensitive interventions in the different cultural contexts.
Within four months of the network's inception, we will host our first stakeholder meeting in Nairobi, Kenya. The workshop will be used to present findings from the rapid review of interventions to reduce the risk of stunting among the urban poor, and will then use a ranking method to identify the highest rated gaps in evidence and research. We will consult stakeholders in preparation of the workshop and at regular intervals throughout the 12 month project. A second stakeholder engagement workshop will take place in Malawi at the end of the project, with stakeholders from Kenya and Malawi invited. The workshops will help stakeholders to understand the key evidence gaps in the promotion of optimal IYCF practices in rapidly urbanising environments in SSA for the urban poor. Based on the findings of the secondary data analysis, workshops will also identify predictors of stunting in slum communities and whether these are comparable to other African environments . This project will produce two academic publications by the end of 12 months and will lead to the development of a UK-Africa interdisciplinary network with the knowledge, evidence and skills to develop interventions to improve IYCF. The stakeholder workshops, along with the research findings and ideas generation with the investigators in SSA, will stimulate global nutrition research, and form the basis for larger-scale funding applications aimed at improving IYCF and reducing stunting in SSA countries.