Nutriţie comunitară de intervenţie în regiunea Munţii Rwenzori din Uganda

Introduction

Uganda’s Ministry of Health estimates an astonishing 54.8% stunting rate among the Bakonzo living in or near the Rwenzori Mountains, almost 10% higher than in any other tribe from Uganda⁽¹⁾. In a multi-year nutrition project, we found unique circumstances that prohibit development in mountainous regions. This fact is well recognized by the international development community (see FAO’s #mountainsmatter and Mountain Partnership initiative)⁽²⁾. In fact, the growing socioeconomic inequity of mountain families is alarming, with little to no connection to government services like roads, electricity, and running water. This is unfortunately intensified by climate-related disasters that destroy lives and livelihoods.

The Mountain Research Initiative recently issued a brief noting that the UN’s Global Goals (SDGs), while addressing biodiversity and environmental protections in the mountains by 2030, do not adequately address mountain people and their livelihoods⁽³⁾. This fairly represents the Bakonzo of Uganda, keepers of the “Mountains of the Moon” (the Rwenzori Mountains) which is a critically important cultural icon and glaciered water tower serving the entire region. It has been described as a public good⁽⁴⁾ that needs to be proactively preserved, especially given forecasts that these majestic glaciers will melt away by 2040⁽⁵⁾. Into this unique ecosystem, GlobalRise organization directs its resources to evolve a Digital Food System (DFS). This multi-thematic, inclusive governance model deploys a community nutrition program to improve the health status of babies and families. It concurrently provides a technology platform that seeks to improve production using digital imaging/intelligence and linking mountain farmers to markets with cargo drones. Finally, using a systems approach, a DFS builds a workforce that can educate the youth in ICT, drone aviation, health IT, and more in conjunction with Rwenzori International University, our university partner. A key component of a Digital Food System involves the development of a contextualized community nutrition program. GlobalRise accomplished this over three years, with the help of Mbalhamia Healing Forest, an indigenous NGO based in Kilembe that is nestled in the foothills of the Rwenzori Mountains.

Nutrition and food security in this area is an enormous development challenge. To understand the parameters of this effort, GlobalRise undertook a household survey in 2019-2020 to isolate food and nutrition security factors and other relevant data. Our primary goal was to use the data to inform a program of interventions that provide families of rural, mountainous communities in the Kasese District with nutrition-related practices and knowledge to overcome stunting and other forms of malnutrition. We call this our Community Nutrition Program or CNP.

Household survey objectives

• Gather basic information on food and nutrition, as well as the sociodemographic and geographic aspects of the studied population.

• Establish a baseline of nutritional aspects of the targeted population.

• Identify nutrition-related needs in the community that can be addressed by health sector programs.

• Identify key families or households that can become enablers for future interventions.

• Establish approaches to intervene in the families’ nutritional status that include food availability, access, consumption and utilization of food, as well as care and feeding practices and sanitation.

Materials and method

The survey used cross-sectional and randomized research to discover the nutritional aspects of the targeted population. We developed a standardized interview instrument and implemented several focus groups to react to survey results which added a rich cultural context behind the data.

Population characteristics

The selected population was Kirembe Village, Cell 1, a subdistrict of Kasese District. Our criteria for participation were the location of households within Kirembi’s defined territorial limits. The sample size was calculated using a confidence level of 95% with a margin of error of 5%. The final sample number for the study was 207 households, including a 10% no response rate.

This village was intentionally selected because of its size, uniqueness for isolating meaningful factors related to nutrition, and proximity to GlobalRise’s partner organizations, Christalis Home and Mbalhamia Healing Forest.

Gaining trust is vital for collecting accurate data. Christalis Home, where we initiated operations by developing an orphanage food system, maintains strong bonds in the community by assisting families with education and healthcare. Mbalhamia Healing Forest is a trusted community resource that trains farmers on soil fertility, has implemented micro-financing for over 120 farmers, and is a center of indigenous organic, medicinal and cultural knowledge. The group lends significant credibility to our effort and we eventually designated it as our first site for the “DFS Mountain Center” prototype.

The survey, designed to interview participants within households, was comprised of seven sections with sixty questions overall, evaluating household structure, nutrition, health status, finance, sanitation, and food access with open and closed questions. It was complemented by the Food Insecurity Experience Scale (FIES) developed by the Food and Agriculture Organization in 2013⁽⁶⁾.

The survey was validated and tested prior to application with the help of local expertise in nutrition, agronomy, Bakonzo culture, and linguistics. It was specifically intended to be answered by the person in charge of food preparation in the household and did not require a consent paper to be signed. It also included GPS mapping to cross-correlate the studied variables with the geographical conditions present in the targeted population, an innovative practice we have called “Geospatial Nutrition Profiles” or GNPs. In fact, walking the muddy paths with two field local field workers that we trained, who knew the local language and many of the people, markedly influenced our thinking around potential solutions.

Two community focus groups were organized by our field partner. These groups were invited to respond to the results of the survey using open questions that invited discussion by all attendees. The conversation was documented.

Results

The demographics of the population surveyed consisted mostly of young adults aged 21-40 years old (58%). According to the World Bank, by 2019 more than 75% of Uganda’s population was below the age of 30, a result of Uganda having one of the highest fertility rates in the world over the past 40 years.

Of the surveyed participants, 73.4% occupied the role of “mother”. We found that women were the household managers that provide food, nutrition, water, health, education, and many other needs. This obviously impacts prenatal care, pregnancy, breastfeeding, child nutrition and nutrition in the lifecycle (all aspects of importance for our CNP).

Within the focus groups, 17 out of 28 participants (60%) were female and most were head of the household. One of the concerns expressed by these women was “family dysfunction” in that the responsibility for food is on the shoulders of one or two people and typically falls heaviest on the mother. Part of this challenge is the lack of male presence (specifically the father) in the households.

This cultural issue affects the successful development of the household. It was actively discussed during the focus groups. The findings suggest that the absence of the father in most households leads to the mother not having sufficient financial support to buy food. This then puts the family and children at risk of poor health outcomes.

Given these circumstances, we found that mothers must be the key subjects for the implementation of a nutrition program. Culturally-sensitized education on prenatal care, pregnancy, breastfeeding, child nutrition and nutrition in the lifecycle, presented with basic nutrition information and guidelines, can provide mothers with the information needed for care-taking roles and responsibilities and must also reach into the lifestyles of girls and young women given the fertility rate of the region.

Providing mothers with information and skills regarding cooking and agriculture may help influence the heads of households to evolve healthy behaviors in food purchase and planning, cooking, sustainable soil use, planting, and harvesting among others. These behaviors may contribute to improved health outcomes for all members of the household.

In the surveyed village, we found a low percentage of literacy among heads of household (38%). Considering the high percentage of mother-lead households in our survey, as sole parent and provider, our finding of a low literacy rate highlights a critical need for developing nutrition education with culturally-accepted resources such as music, images, hands-on activities with local materials, instruments, or ingredients that will strengthen impact.

The main income-generating activity reported in the survey was farming, with 59%, followed by food vendor (9.6%) and casual labor (8.5%), all being related to agriculture. As the survey took place in a rural and mountainous area, it was expected to find farming or agriculture as the main income-generating activity. The sampling included households from hillside farms as well as near the center of the community; therefore, activities referred to as “business” are present in our survey, but they represent a small percentage of total occupations.

The participants in the focus groups said they recognized that the lack of alternative sources of income is a major challenge for their nutrition, given that their level of funds determines the quality and quantity of food they can access. This has an impact on their income, as farming or agriculture-related activities are seasonal. While there may be times of sufficient income, there are other times when the economic resources are scarce or completely absent.

As farming is the most common source of income, agronomic skills are highly valued in this population.
Enhancing existing farming practices to promote healthy eating practices for farming households can yield better diets. Education on soil fertility, crop planning, and diet structure can be highly useful for both the participants’ financial success and dietary quality. Well-nourished people can turn into a more productive labor force and build human capital for communities. Conversely, when the nutrition and health status of the community declines, especially due to stunting, individuals may have difficulty in the job market, and this directly impacts income.

Most households report access to farming land (95.9%). The majority (98.8%) report using the land to cultivate crops that can be divided into two types: household consumption (99.4%) and selling in the market (84.8%).

Growing food for personal use is an excellent point of intervention for nutrition programs because people are more receptive to enhancing their current routines than starting new ones. The nutrition program should provide awareness on those aspects that need to be improved in the daily regime while at the same time providing information.

Many other factors were assessed in the survey relating to household composition: finance, access to healthcare, access to farmland (95% have various forms of access), top household needs (improving soil fertility was a primary issue), and more.

Evolving the Community Nutrition Program

With a solid understanding of local population needs, GlobalRise organization developed a Community Nutrition Program (CNP) with targeted interventions that include education, WASH, balanced plates, recipes and a focus on soap making, that impacts a number of problem themes at the household level. The CNP was field-tested in 2022 using a research design that organized three groups of families over a three-month period.

As part of this process, during the pandemic, GlobalRise held virtual meetings with field partners. Through these meetings, original research from our survey, literature searches, and reviews by over 16 interns in nutrition (masters and PhD candidates), we evolved our CNP. It consists of six lessons that range from WASH, nutrition basics, soap making, food diversity, and more. The CNP uses graphical elements and photos to optimize the comprehension of users. We use as few words as possible given low literacy rates. 

With a draft CNP in hand, GlobalRise went back to Kasese for three months to test adoption, “train trainers” and establish an implementation cycle. The participants for training were selected based on experience, ability to speak the native tongue of Lukonzo, and understanding of local customs and level of education in nutrition. They underwent one week of training with a “Train the Trainers” program that was prepared by our nutritionist.

Our next phase involved 2-3-week cycles of training 15 heads of household over a two-week cycle, consolidating and integrating learning into the CNP, and then engaging trainers in improvement exercises. We then implemented the updated CNP with the next focus group. We measured results with metrics applied against both trainer and household baselines. Those finishing the program were rewarded with a certificate of completion and agreed to a follow-up schedule to collect data for outcomes reporting.

Discussion

Today, the CNP has evolved into a demonstrative and hands-on class that takes place during a full training day. In this class, a trainer presents topics related to sanitation, nutrition, health and farming, using a standard flipchart with images that represent concepts and ideas developed and refined in our testing cycles. CNP concludes by awarding participants with a certificate of participation endorsed by GlobalRise and Mbalhamia Healing Forest. Soon, the university will begin student rotations through the program to learn how to impact mountainous families in areas of nutrition, WASH, precision farming, and more.

During 2022 and 2023, the program has impacted 337 people through 52 trained heads of household, 91% of whom were women. Six households have chosen to continue soapmaking at the training center to supplement income, all women. Follow-up information is collected by trainers every three months by house visitations and observation. This is helping us to understand changes in knowledge, attitudes, and practice. Notably, a primary aspect of data collection is following-up on the growth of children below 5 years old and pregnancy cases. By doing so, we can intervene with assistance and education and even prevent and/or reverse stunting.

As part of an overall, community-co-created plan for improving food and health equity in Kasese, the CNP has become a primary entry point. The CNP alone, however, is unsustainable. We have witnessed a number of projects that have come and gone. The CNP must be part of the broader effort to build a Digital Food System that includes income generation. For example, we are planning to test a cargo drone platform that will lift crops from the mountains to the markets, automatically exchanging funds (like Uber), which can improve income. Our design or policy is that prior to onboarding the platform, households must attend Village Training/CNP, agree to follow-up and implement other items like soil fertility inputs that promote climate mitigation and a digital health record. The “packaging” can evolve based on community needs. The income production platform, however, is necessary to achieve sustainability^(7,8).

Conclusions

Our concept of Digital Food Systems, developed using a systems approach promoted by Rockefeller Foundation (USA), seeks to leverage existing community investments to facilitate equitable and nourishing access to food, health, and more. With it, we hope to create a platform economy that mountain communities can access – a benefit that lies outside of their reach today. The CNP is our “round one” to foster food and health equity for extremely poor communities that need development help.  

Conflict of interest: none declared  

Financial support: none declared 

This work is permanently accessible online free of charge and published under the CC-BY.