BackgroundThis study sought understand how the 2014–2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude.MethodologyThis qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures.ResultsThe EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement.ConclusionsInfectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings.

ObjectiveTo examine the association between household food insecurity and dietary diversity in the past 24h (dietary diversity score (DDS, range: 0–9); minimum dietary diversity (MDD, consumption of three or more food groups); consumption of nine separate food groups) among pregnant and lactating women in rural Malawi.DesignCross-sectional study.SettingTwo rural districts in Central Malawi.SubjectsPregnant (n 589) and lactating (n 641) women.ResultsOf surveyed pregnant and lactating women, 66·7 and 68·6 %, respectively, experienced moderate or severe food insecurity and only 32·4 and 28·1 %, respectively, met MDD. Compared with food-secure pregnant women, those who reported severe food insecurity had a 0·36 lower DDS (P<0·05) and more than threefold higher risk (OR; 95 % CI) of not consuming meat/fish (3·19; CI 1·68, 6·03). The risk of not consuming eggs (3·77; 1·04, 13·7) was higher among moderately food-insecure pregnant women. Compared with food-secure lactating women, those who reported mild, moderate and severe food insecurity showed a 0·36, 0·44 and 0·62 lower DDS, respectively (all P<0·05). The risk of not achieving MDD was higher among moderately (1·95; 1·06, 3·59) and severely (2·82; 1·53, 5·22) food-insecure lactating women. The risk of not consuming meat/fish and eggs increased in a dose–response manner among lactating women experiencing mild (1·75; 1·01, 3·03 and 2·81; 1·09, 7·25), moderate (2·66; 1·47, 4·82 and 3·75; 1·40, 10·0) and severe (5·33; 2·63, 10·8 and 3·47; 1·19, 10·1) food insecurity.ConclusionsAddressing food insecurity during and after pregnancy needs to be considered when designing nutrition programmes aiming to increase dietary diversity in rural Malawi.

Childhood stunting holds consequences for child development. A nutrition program delivering small-quantity lipid based nutrient supplements (SQ-LNS) to children 6-23 months and child feeding messages was implemented in Malawi to reduce stunting. This study sought to understand the facilitators and barriers to program participation using in-depth interviews, pile sorts, direct observations, and focus group discussions with caretakers, village leaders and program volunteers. Perceptions of the LNS were positive, and visible changes in child health contributed to program participation. Conflicting priorities that prevented monthly collection of SQ-LNS and limited knowledge of child feeding messages constituted barriers to program participation.

Objectives • to explore how and through what multi-level pathways the Ebola outbreak impacted the nutrition sector in Sierra Leone • to investigate the barriers and facilitating factors to implementing effective response strategies during the nutrition response • to develop an improved preparedness and nutrition response framework for consideration during future outbreaks of this nature. Methods This qualitative study had an iterative and emergent design. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations agencies and non-governmental organizations (NGO), and informants (n = 21; community members, Ebola survivors, front-line workers) until data saturation was reached. Multiple analysts worked collaboratively in a team-based coding approach to identify key themes and sub-themes using Dedoose software. Findings are presented as both salient quotations and tables/figures to illustrate the results. Results The Ebola outbreak and related response strategies, especially movement restriction policies, disrupted nearly every aspect of the food value-chain in Sierra Leone. Through production, storage and processing, distribution, transport and trade, and retailing, salient themes emerged across interviews with Government, United Nations, and NGO stakeholders, as well as community-level participants about the serious effects of the outbreak on food and nutrition. Data suggest that the effects of the outbreak had an aggregate negative effect on key pillars of food security as well as infant and young child feeding practices. Food-based response efforts were highly accepted, although sharing and selling of food assistance was reported by front-line workers and community members alike. Conclusions Infectious diseases such as Ebola have far-reaching effects that are not just directly bio-medical in nature but also indirectly impacting health through the entire food value-chain from agriculture agricultural disruption to individual nutritional status. A food value-chain approach therefore may offer a viable framework from which to position nutrition preparedness and response efforts for infectious disease outbreaks in other similar food insecure settings. Funding Sources UNICEF West and Central Africa Regional Bureau. Supporting Tables, Images and/or Graphs

ObjectiveTo evaluate the 18‐month impact of a program providing a daily lipid‐based nutrient supplement (LNS) and social and behavior change communication (SBCC) to promote infant and young child feeding practices from 6–23 months, on undernutrition (stunting, wasting, and underweight) and linear‐ and ponderal growth [length‐for‐age z‐score (LAZ), weight‐for‐length (WLZ), weight‐for‐age (WAZ) z‐score] in rural Malawi.MethodsTwo cohorts of infants (n=348), aged 6–7 months, were enrolled in the program (n=176) and comparison (n=172) districts, respectively, and followed‐up at 12, 18, and 24 months of age. Child weight and length were taken at each visit and converted to z‐scores using the WHO child growth standards. Multilevel mixed‐effects linear regression models estimated the program impact on growth, accounting for within individual and village correlations, and adjusted for age, sex, and baseline nutritional status.ResultsPercentages of children stunted and wasted were comparable at enrollment in both districts: 42.4% and 1.5% (districts combined), but underweight was higher in the program district (15.4% vs. 6.5%;p<0.01). A trend toward a higher LAZ emerged in the program district at 12 (+0.13 z;p=0.15) and 18 (+0.14 z; p=0.19) months of age, that was significant at 24 (+0.34 z; p=0.003) months. Similarly, significant program impact on WAZ was noted at 12 (+0.20 Z; p=0.03), continued at 18 months (+016 Z; p=0.08), and became larger at 24 months of age (+0.32 Z; p=0.003) in program over comparison district. No statistically significant differences between groups were notable for WLZ at any visit. Further, at 18 and 24 months of age, the percent of children underweight was lower by 8.3% (p=0.04) and 9.8% (p=0.02), respectively, in the program vs. comparison district. No significant reduction in the percent of children stunted or wasted between groups were found at any visit.ConclusionsFindings suggest that a daily provision of LNS and SBCC messaging from 6–23 months of age in rural Malawi may improve linear growth and underweight.Support or Funding InformationThis study was funded by the Children's Investment Fund Foundation, UK.