Preventing Acute Malnutrition in Women and Children Through Livestock Interventions in Northern Kenya.

Abstract

Globally, undernutrition remains a significant challenge to the health of women and children and accounted for nearly half (>45%) of deaths in children <5 years in 2020. In 2022, stunting and wasting affected 22% and 6.8% of children <5 years, with the highest burden reported in Asia and Sub-Saharan Africa. In Africa, the burden of undernutrition is especially high in Africa’s drylands, where persistent global acute malnutrition consistently surpasses emergency thresholds. Nutrition – sensitive livestock interventions have the potential to prevent undernutrition in women and children through increased consumption of Animal Source Foods (ASFs), improved household income and women empowerment. However, empirical data on the impact of nutrition-sensitive livestock interventions in preventing undernutrition remains limited. This thesis addresses this dearth in knowledge by assessing the effectiveness and cost-effectiveness of livestock interventions in preventing spikes in acute malnutrition in women and children under five years of age among pastoralist communities in northern Kenya during drought periods. First, a systematic review and metaanalysis on the impact of livestock interventions on maternal and child nutrition outcomes in sub-Saharan Africa was completed. Next, a cluster randomized controlled trial (cRCT) to determine the effectiveness and cost-effectiveness of providing livestock feeds to milking animals during drought periods and enhanced nutrition counselling in preventing acute malnutrition in women and children <5 years in Laisamis area of Marsabit County in northern Kenya was conducted. A total of 1734 households assigned to one of three study arms: livestock feeding arm; livestock feeding and nutrition counselling; and control arm were recruited into the study. Each household was visited every 6 weeks and data on livestock species and numbers, household milk production, food consumption patterns and amounts by children and women, anthropometric measures of children and women, health data for people and their animals collected over a 2-year study period ( September 2019 – December 2021) covering four drought seasons. Biological samples were collected from both people and their livestock and tested for exposure to brucellosis and Q-fever as well as the association between child health and nutrition. Data analysis followed intention-to-treat principle employing mixed effects regression models to compare key study outcomes across the intervention arms. The systematic review and meta-analysis showed that nutritionsensitive livestock interventions were associated with significant positive impact on consumption of ASFs for children <5 years, OR = 5.39 (95% CI: 4.43, 6.56) and on the likelihood of meeting minimum dietary diversity, OR = 1.89 (95% CI: 1.51, 2.3). Based on GRADE quality of evidence assessment approach, the overall quality of evidence of this review was rated as low, mainly due to limitations of performance, inconsistency, and selection biases. Results from the cRCT showed that while controlling for herd sizes, births, veterinary interventions, and sources of income, households receiving livestock feeds consistently had higher milk yield per day compared to control group (1.6L vs 0.7L, p < 0.001). Intervention households sustained more milking animals, 1.4 and 0.6 more tropical livestock units (TLUs) compared to those in the control. While controlling for other covariates, livestock feeding was associated with an increase of 200ml (95% CI, 120ml, 280ml) in milk consumption for children; enhanced counselling was associated with consumption of an additional 40ml (95% CI: 10ml, 70ml) milk daily by children. Mothers in

households receiving livestock feeds consumed an additional 210ml (95% CI: 80, 330) of milk daily compared to those in the control arm. Among children < 5 years, livestock feeding was associated with statistically significant reduction in the risk of undernutrition by 11% (95% CI: 4, 17), 8% (95% CI: 2, 14), 9% (95% CI: 3, 15) and 11% (95% CI: 7, 14) for acute malnutrition (GAM), stunting (height-for-age), wasting (weight-for-height), and underweight (weight-for-age), respectively. Livestock feeding and enhanced nutrition counselling was significantly associated with improved household dietary diversity score (HDDS) by 3% (95% CI: 1, 5), minimum dietary diversity (MDD) for children OR=2.5 (95% CI: 2.3, 2.8) and minimum dietary diversity for women OR=4.22 (95% CI: 3.29, 5.42). Prevalence of brucellosis and Q fever in household herds was high at 26% (95% CI: 24, 29) and 84% (95% CI: 82, 86), respectively. Household level prevalence of brucellosis and Q fever in people was 13% (95% CI: 11, 15). Exposure to brucellosis and Q fever was not significantly associated with risk of acute malnutrition in children and women, OR=1.82 (95% CI: 0.67, 5.21, p=>0.69). Child health based on reported syndromes of fever/diarrhea/ARI was associated with an increased risk of acute malnutrition, OR = 1.64 (95% CI: 1.33, 2.03) and wasting OR = 1.22 (95% CI: 1.01, 1.47). Both livestock feeding only, and livestock feeding plus nutritional counselling were considered cost-effective in preventing acute malnutrition (wasting) at a cost of $5,326 and $3,086 per case of wasting averted, with a cost-effective ratio of 2.6 and 1.5, respectively. The cost per case of stunting averted by the feed only intervention was $7,293, with a cost-effectiveness ratio of 3.6 which was above the costeffectiveness threshold. In conclusion, the findings of this study underscore the significant impact of targeted livestock feed provision during drought periods, specifically focusing on milking animals. The results demonstrate that this intervention is not only effective in sustaining the health and productivity of livestock but also serves as a cost-effective strategy to prevent acute malnutrition in children. A key recommendation from this study is the adoption of livestock feeding targeted to milking animals during critical dry periods as an effective strategy for preventing acute malnutrition and building resilience in communities in the face of climatic shocks.