Discussion
We identified 91 publications from 1990 and 2018 that described the delivery of nutrition interventions to women and children affected by armed conflict in LMICs, mostly reported in African region. Less than half of the included publications reported on research findings, and nearly 40% were sourced from the grey literature. Studies published between year 1990 and 2000, majorly focused on GFD and disease prevention and management. Studies published between year 2001 and 2010 also focused on disease prevention and management and on micronutrient supplementation, and studies published after 2011 focused on nutrition assessment, GFD and SAM/MAM treatment. GFD, micronutrient supplementation and nutrition assessment were the most frequently reported interventions, with most publications reporting on intervention delivery to refugee populations in camp settings and using community-based approaches (figure 4).114 Limited data on intervention coverage or effectiveness were captured from the included literature, preventing inferences to be drawn about how these vary by different delivery approaches in conflict settings. Very rarely were quantitative estimates reported, but delivery mechanisms and barriers and facilitators were more comprehensively described in the grey compared with the indexed literature. Insufficient resources, including nutritional commodity shortages, security concerns due to ongoing conflict, limited inter-cluster coordination, and difficulty accessing and following beneficiaries up due to population movements and sometimes limited cooperation were key delivery barriers. Community advocacy and social mobilisation, effective monitoring, and integration of nutrition and other sector interventions and services were key delivery facilitators.
Figure 4Summary of evidence. IDP, internally displaced person; IYCF, infant and young child feeding; SAM/MAM, severe acute malnutrition/moderate acute malnutrition.
Our results yield important insights about the nutrition delivery and important gaps. It is evident that much of the documentation of nutrition interventions and programmes implemented in conflict and likely in emergency settings more generally, exists in the grey literature generated by UN agencies, NGOs and other humanitarian implementers actively working in the field rather than from government reports and indexed literature. Second, the limited number of included studies and variation in population behaviour and in context such as country, underlying health system, disease outbreak, and type and severity of conflict has curtailed us from studying the impact of nutrition intervention on women in conflict setting in greater depth.
In addition, much of the literature focused on nutrition interventions delivered to camp-based refugees, with relatively little reported on populations displaced or non-displaced populations. It is difficult to know whether the lack of reporting on non-camp and non-displaced populations reflects actual nutrition intervention delivery patterns on the ground, or rather a failure to document.
With respect to the types of interventions, the relatively higher frequency of reporting on food distribution and the management of acute malnutrition is understandable, given the high prevalence of food insecurity and the high morbidity and mortality burden of malnutrition. It was somewhat surprising to find relatively little on the delivery of IYCF interventions, though there were some examples of innovative practices to provide safe spaces for women to breast feed. Moreover, we captured just as many publications reporting on infant formula distribution as on breastfeeding promotion interventions.
We also found that many publications reported on nutrition intervention delivery at household level or through outreach approaches. We also note that the CMAM has been adopted as national policy by several governments including Ethiopia, Jordan and Sudan. Given these experiences, the humanitarian nutrition sector may be particularly well-placed to further innovate and test community-based approaches that might overcome or circumvent the specific implementation challenges across sectors.
In context to barriers of delivery; destruction of health facilities, targeted attacks on facilities and health workers, as well as disruption of supply chains were key issues, which further added to the existing weak governance and healthcare system infrastructure. Thus, the actors should identify effective strategies for delivering interventions through planning which must addresses the security concerns of health service providers and beneficiaries. Moreover, gathering support and acceptance from local influencers and communities, including local authorities, appears to be critical, while maintaining the perception of their impartiality and neutrality.
Finally, literature reports on multi-sectoral programming approach with the nutrition cluster collaborating with the health and WASH clusters, but has failed to report its integration with early childhood development and mental health, which is an emerging issue. Moreover, there is no data on gender equality and social inclusion. Thus, future studies should untake gender analyses, to investigate the gendered differences in access, needs and uptake of healthcare services.
This systematic review of the literature is the first, to our knowledge, to focus on the delivery of nutrition interventions in armed conflict settings, and thus makes a novel and important contribution to the field. However, in addition to the limitations inherent in the existing literature itself, discussed above, we must also acknowledge that by restricting our review only to publications published in English, and by undertaking a comprehensive but not exhaustive search of the grey literature, we have inevitably excluded other relevant publications that may have provided different information from what we have captured presently.