Mobilizing Communities to
Tackle Child Wasting in Indonesia
@UNICEF Indonesia/2023/Natalia
Key Messages
Background
• Child undernutrition threatens the lives of many Indonesian children. One in twelve children suffer from wasting (i.e., being too thin for their height/length) with devastating consequences — these children are 12 times more likely to die than their healthy peers.
• Effective prevention strategies exist and when prevention fail, evidence-based models for treating child wasting have been developed.
• Engaging communities in child wasting prevention, early detection, referral, and treatment are essential to ensure access to quality and coverage of these interventions.
• Community mobilization efforts are achieved through community assessment, community dialogue, and formulating a contextually- appropriate community outreach strategy.
• Several innovative community mobilization strategies have been developed and implemented in Indonesia. Such innovations should continue to be widely promoted to ensure that children with wasting are found early, appropriately referred, receive standard treatment, and are actively supported within their communities.
While child undernutrition rates are slowly declining in Indonesia, they remain a significant public health problem. The 2022 Indonesian
nutritional status survey showed that the prevalence of child stunting (i.e., being too short compared to their age) declined from 37.6 per cent in 2013 to 21.6 per cent in 2022 and child wasting
similar period. Despite these efforts, Indonesia still has the second-highest number of children affected by severe wasting in the world.
The impacts of wasting are dangerous as it weakened immune systems and wasted children face an increased risk of infection and death.
Strategies to tackle child wasting
Effective strategies to prevent wasting exist, and where prevention efforts fail, evidence-based treatment models have been developed. Global evidence indicates that more than 85 per cent of severely wasted children aged 6-59 months can be successfully treated at home without requiring inpatient care, if identified early, through
IMAM approach. This evidence-based approach proposes treating children under five based on the severity of wasting. The premise of IMAM is that children tend to develop severe wasting slowly, moving from having a normal weight to being moderately wasted to having severe wasting and finally, to having severe wasting with medical complications. If one can identify
children with wasting early, particularly Those with severe wasting are up to 12 times more likely to die than well- nourished children. Children with wasting also face an increased risk of suffering from long-term growth and development challenges, including stunting. In fact, a wasted child has a three times higher risk of becoming stunted than a healthy child1.
Preventing and detecting wasting early and treating children with wasting is critical to saving their lives and putting them on the path to healthy growth and development.
1 For more information on the links between wasting and stunting, please see a policy brief entitled: ‘Towards a Future in Indonesia without Child Undernutrition:
Managing child wasting and reducing the prevalence of child stunting.’
The Government of Indonesia is
committed to tackling this devastating form of malnutrition, aiming to reduce the prevalence of child wasting to less than 7 per cent by 2024. Additionally, the 2021 Presidential Decree on child stunting set a target to provide treatment to 90 per cent of severely wasted children by 2024. Scaling up the Integrated Management of Acute Malnutrition (IMAM) — a lifesaving program to prevent and treat child wasting across the country is thus a priority.
before complications arise, one can treat these children relatively easily without needing to admit them to hospitals.
An essential component of the IMAM approach is community mobilization to ensure that caregivers and communities at large understand child wasting, how to identify its signs as early as possible, and know where to seek treatment.
Community participation and
engagement is essential for
the success of child wasting
treatment interventions. It
is not something done for
the community but by the
community.
What is Community Mobilization and why is it important?
Community mobilization encompasses a broad range of sensitization and outreach activities that aim to increase participation, support, and ownership of IMAM services. It involves a far broader set of individuals than just those working within the health
system, including government officials (for example, community leaders, village-level government officials and sub-village heads), health workers (including village midwives) and other community members (including cadres, or community health volunteers), Early Childhood Education (ECE) teachers, religious and traditional leaders, community outreach volunteers, community groups including
Family Welfare and Empowerment (Pemberdayaan dan Kesejahteraan Keluarga/PKK) associations, local non- governmental organisations, media professionals as well as agriculture extension workers and social workers.
Community mobilization is important as it promotes better responses to the needs and concerns of communities and ensures that wasting services are more accessible, contextually appropriate and community owned.
It fosters active participation,
engagement, and ownership among community members, empowering them to take charge of their own health and that of their children.
Community mobilization aims to:
• Increase communities’ knowledge and understanding of wasting and of treatment services available.
• Facilitate the identification and referral of wasted children to Puskesmas (primary healthcare centre), ensuring timely and appropriate care.
• Enable the follow-up of particularly at-risk and challenging cases to support these children’s treatment and recovery.
• Engage communities to facilitate joint problem-solving in relation to the barriers to service uptake.
Ultimately, community mobilization enhances the effectiveness, reach, and sustainability of IMAM interventions, leading to improved nutritional
outcomes and the well-being of communities affected by acute malnutrition in Indonesia.
@UNICEF Indonesia/2023/Natalia
In 2020, UNICEF piloted an evidence-based innovation, known as the Family-led MUAC approach, to strengthen the early detection and referral of child wasting by caregivers in two districts in East Nusa Tenggara (NTT) Province.
The Family-led MUAC approach recognises that families are best placed to identify early signs of nutrition problems and reinforces their role in protecting and promoting their children’s health. It empowers caregivers to monitor child wasting at home, through the provision of Mid- Upper Arm Circumference (MUAC) measurement tapes, to facilitate the early identification of child wasting and gives instructions on what to do if wasting is detected. Caregivers are also equipped with relevant knowledge and awareness to understand the risk of child wasting and effective prevention and treatment strategies. With modest training, it has been found that caregivers can accurately measure their children’s MUAC, and they have a greater urgency to bring their children to Puskesmas when needed, compared to caregivers of children who were found and referred by cadres.
Mid-Upper-Arm-Circumference (MUAC) tape
Community Mobilization Spotlight: Empowering Caregivers through Family-led MUAC
The Family led MUAC pilot in NTT results show that:
• Caregiver screening correctly identified and confirmed 15 children aged 6-59 months (100 per cent of those screened) with severe wasting and an additional 260 children (93 per cent of those screened) with moderate wasting.
• Caregiver screening was highly accurate and not inferior to that of Community Health Volunteers.
Given these results, the approach was expanded and by the end of 2023, it has been introduced in more than 40 districts across seven UNICEF-supported provinces.
Facilitating community engagement
There are a number of activities involved in community mobilization including, community assessment, community dialogue, formulating a community outreach strategy, developing and disseminating messages and materials,
In 2022, UNICEF, the Ministry Of Health and the Ministry of Education and related agencies began piloting an initiative to build the capacity of ECE teachers around child wasting, including how to identify and appropriately refer children with wasting, in NTT, Papua and South Sulawesi provinces. On a monthly basis, ECE teachers screen children in their centres for child wasting using MUAC bands, a simple tool to detect wasting and refer children at risk of wasting to Pukesmas.
ECE teachers also conduct monthly parenting sessions to ensure that caregivers understand the consequences of child wasting and how to identify and seek treatment for child wasting. Caregivers are also provided with MUAC bands to further support in the identification of wasting at home.
Community mobilisation spotlight: Engaging ECE centres
training on community outreach, active case-finding and referral, home visits and follow-up, and linking with other community services, programs and initiatives.
Stages of implementing community mobilization
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4
5
1. Community Assessment
In 2022, the Lombok Tengah District Government - West Nusa Tenggara (NTB) Province integrated child wasting screening and education into their local initiative, called Gawe Gubuk – a community-based activity focusing on providing child
protection services and social assistance to the community.
Different stakeholders at village, sub-district, and district levels are involved in this activity, including local government authorities, cadres, health workers, and civil society organizations. Early detection and referral of child wasting is part of a continuous effort to identify children who are vulnerable to becoming wasted in order to prevent child wasting and stunting.
In 2023, the district government scaled up the initiative from five to ten villages.
Community mobilisation spotlight: engaging local government An assessment of the community is
an important first step in developing effective community mobilization strategies. Community assessments aim to identify any potential barriers to accessing services and to ensuring that services are used. Community assessments are typically done through a review of secondary/
existing data sources, primary data collection methods as well as consultations with local authorities.
This analysis explores elements such as community understanding of child wasting and its causes, health- seeking behaviors, sociocultural and religious characteristics that may
impact health-seeking behaviors as well as exploring any barriers and boosters to wasting treatment in the community. Community assessments further examine what existing
community-based initiatives exist in the community, who the influential actors are that should be involved in community mobilization activities and what channels will be most effective in disseminating messages around child wasting. It maps out community networks, groups, activities, and
initiatives to identify potential synergies and opportunities to link wasting
services.
2. Community Dialogue and Formulation of a Community Outreach Strategy
3. Developing Messages and Materials
Based on the findings of the community assessment, an outreach strategy is developed together with the main community stakeholders. The strategy includes a plan for awareness raising, methods for effective early case finding and referrals as well as a plan for follow- up and home visits. Such a strategy aims to be a living document, evolving based on the changing needs and realities of the community. Regular community dialogue is needed to enable adaptations to the strategy and
Messages and related community awareness materials need to be based on the community assessment findings to ensure they speak to the barriers and boosters identified. They should be delivered in local languages and incorporate traditional practices and beliefs.
Key messages should include:
• An understanding of child wasting and its effects on children, families, and communities at large,
can help identify new boosters and potential barriers, providing timely solutions to such barriers. Community dialogue is essential to ensure that community members are involved in decision-making processes so that interventions are truly ‘community- owned’. Additionally, fostering an inclusive and participatory decision- making process that is community- owned will ensure sustainability and effectiveness of IMAM interventions.
• Information on where to seek treatment,
• The importance of proper and timely health-seeking behavior, and
• Why it is critical to adhere to treatment until a child is fully recovered.
Appropriate dissemination channels will be identified based on the community assessment and community dialogues.
Training for community mobilization is essential to ensure that key community figures are able to disseminate key messages and train others on child wasting as well as enhancing their ability to identify and refer children at risk of wasting.
Training should ideally cover: the different forms of undernutrition and their causes, the identification of undernutrition, particularly child
Creating awareness about child wasting must be a continuous process. Every opportunity can and must be used to increase understanding of child wasting and to identify cases of wasting as early as possible. Community awareness
A women’s empowerment organisation (PKK) in NTT province has supported IMAM service implementation in its 22 model villages across all 22 districts since 2020, allocating budget for capacity building, monitoring and supervision as well as the procurement of Ready-to-use therapeutic food (RUTF) and MUAC tapes.
Additionally, PKK promote the use of the Family-led MUAC approach in its’ model villages across the province.
Community mobilisation spotlight: engaging women’s empowerment groups wasting (including how to measure a child’s MUAC and identify oedema, i.e. swelling in a child’s body), and the treatment options available for child wasting. Training should also explore how to actively screen for child wasting in order to identify cases as early as possible. This can include screening at Posyandu’s, during community meetings, market days, and within house-to-house visits.
4. Community Mobilizing Training
5. Community Awareness Raising
is particularly important when a community program is about to be launched to promote understanding of the services available, where and how to access them and to promote ownership of the program.
Communities and community platforms can also play a role in the follow-up of nutritionally vulnerable children and conduct home visits to children who are at risk of defaulting from wasting treatment interventions. Community Community and community platforms play a critical role in early identification and referral through active case-
finding. If one can identify children with wasting early, particularly before complications arise, then you can treat these children relatively easily without
leaders and stakeholders already tend to have a good sense of children who may be nutritionally vulnerable and thus can support in identifying such cases and ensuring that they receive suitable attention within IMAM services.
having to admit them to hospitals. The research found that approximately 85- 90 per cent of severely wasted children can be successfully treated at home if found early, with only 10-15 per cent of all wasted children needing inpatient/
hospital treatment.
Finally, community mobilization efforts also include a monitoring and evaluation component including supportive supervision, routine data monitoring, and overall program
6. Active Case Finding and Referral
evaluation. Monitoring should include both quantitative and qualitative measures and explore the overall impact and outcomes of community mobilization-related interventions.
7. Follow-up and Home Visits
8. Monitoring and Evaluation
This publication was prepared and reviewed by Natalie Sessions (Consultant),
Blandina Rosalina Bait, and Julia Suryantan with leadership and technical guidance from Mamadou Ndiaye from UNICEF Indonesia Country Office.
Technical reviewers and contributors: David Colozza and Sri Sukotjo Editor: David Challanger
Layout: Andri Ruay
Contact Details: Blandina Rosalina Bait | Nutrition Specialist | [email protected]
Acknowledgements
Locally led strategies are essential to meet the needs of every community across Indonesia and ensure contextual solutions to child wasting. Such
strategies can only be developed through community mobilization and engagement. The text boxes in this document explore some of the ways that the Indonesian Ministry of Health and partners, including UNICEF, are engaging communities to ensure the
early identification of child wasting and facilitate the successful treatment of child wasting. Such innovations should continue to be widely promoted to ensure that children with wasting are actively supported within their communities and to ensure the strengthening of activities, foster
ownership and ensure the sustainability of interventions.
Prioritizing Community Mobilization in Indonesia
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