Preventing Acute Malnutrition: Addressing a Global Evidence Gap

An interview with Bridget Fenn, REFANI research project principal investigator in Pakistan

Editor’s note: The Research on Food Assistance for Nutritional Impact (REFANI) is a three-year research project funded by UK aid from the UK government, and co-financed through humanitarian aid from the European Commission (ECHO). The REFANI Consortium is comprised of Action Against HungerConcern Worldwide, the Emergency Nutrition Network (ENN), and the University College London (UCL)

Bridget Fenn, a consultant with the Emergency Nutrition Network and Principal Investigator of the REFANI project, discusses the challenges and benefits of doing research on nutrition in complex and challenging environments. 


Acute malnutrition in children under the age of five is an urgent global public health issue. Children with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) have, respectively, a three- to nine-times greater risk for death when compared to children that are not acutely malnourished. During humanitarian emergencies, the prevalence of acute malnutrition can increase sharply, contributing to high rates of death and suffering.

Food assistance is a major component of the global humanitarian response to emergencies, designed to ensure that communities have assured access to enough nutritious food to meet their daily survival needs. However, rations provided through general food distributions may not meet the greater nutritional requirements of children and pregnant and nursing mothers and thus, they may fail to prevent acute malnutrition among those most vulnerable. Although much food assistance in emergencies is now being provided to affected populations in the form of cash transfers and food vouchers rather than direct distributions of food, there is very little evidence on the impact of these three different forms of food assistance on the nutrition status of those who receive it.

In PakistanNiger, and Somalia, REFANI will investigate how food assistance—either as cash or vouchers—can have the greatest impact on the prevention of acute malnutrition in emergencies when it is complemented by other interventions to address both the immediate and underlying causes. REFANI also aims to identify the mechanisms through which this impact is achieved and their cost effectiveness. Learn more about REFANI at

Q&A with Bridget Fenn

Q: You are an epidemiologist–a specialist who studies the patterns, causes, and effects of health and disease in defined populationswith a background in nutrition. What kind of research do you usually conduct in your work?

A: I’ve mainly worked on projects in Pakistan, Niger, and the Amhara region in Ethiopia related to the evaluation of humanitarian interventions which have nutrition-specific or nutrition-sensitive objectives. Nutrition-specific interventions address the immediate causes of undernutrition – such as not having enough food, inadequate feeding or care practices, or having a high rate of infectious diseases. Meanwhile, nutrition-sensitive interventions address the underlying causes of undernutrition – including access to health services and a safe and hygienic environment. The research I conduct focuses on determining whether, and to what extent, the humanitarian interventions are achieving their nutritional objectives (or not).

Q: What are some of the challenges you've faced working on projects in countries experiencing humanitarian crises? 

A: Adequate planning is a critical but an essential challenge in designing and implementing research in humanitarian contexts. However, researchers often have a difficult time anticipating potential problems or obstacles when they are setting up the study. This is especially true in emergencies or crises where the context is changing rapidly. Still, we do everything possible to plan ahead, monitor the situation closely, and adapt as much as we can, while still maintaining consistency in the quality of data collection.

While we often encounter security-related challenges, there are also a wide variety of other challenges that spring up once we’ve already begun to implement a study. For example, excessively high temperatures can not only be exhausting to work in (causing a loss of focus and reduction in outputs), but can also cause problems with equipment. In Pakistan during data collection for REFANI, our hemocues (which measure the amount of hemoglobin in the blood) overheated in the temperatures above 50°C (approximately 122°F). We had to keep them wrapped in damp cloths and positioned next to our car air conditioning units to prevent them from automatically turning off! However, judgments on the quality of this data are yet to be made!

Q: How do you try to mitigate these challenges?

A: I always say, let’s think in solutions not problems. A committed team which has the ability to approach these situations with flexibility and think creatively in problem solving is also necessary. For example, we had a difficult time recruiting female data collectors for the REFANI project in Pakistan, but working closely and negotiating with the Action Against Hunger team in Pakistan resulted in them providing us with some of their female staff, allowing us to proceed with our research in a timely and appropriate manner.

Q: Most recently, you’ve evaluated programs which provide cash as humanitarian assistance. What are some of the evidence gaps that exist in this type of intervention?

A: The causal connections between cash transfer programming and nutritional outcomes are very complex, especially in humanitarian contexts. When we give unconditional cash transfers (UCTs), we are giving program beneficiaries the liberty and flexibility to decide themselves how they want to spend the cash resources, and it is often difficult to account for this behavioral element – what will people do with the cash given to them? Will they use it to buy more nutritious foods for their children? Will they use it to pay down their debt? Or will they use it to buy farming equipment? Everyone decides differently and the options are many.

Yet, all of these decisions – whether they are directly related to nutrition or indirectly related – can have an impact on the nutritional outcomes of beneficiary individuals and households. In terms of evidence gaps, we don’t really know what type of intervention works better to achieve a nutrition objective, and in what circumstances. Every agency runs their cash transfer programmes (CTPs) in a different way, just as research projects conduct their investigations with different designs in different contexts, which further contributes to the lack of robust generalizable evidence on what works best to improve and protect nutritional status.

Q: How and where do you see REFANI's research contributing the most?

A: In the REFANI literature review, we outlined both what we do know and what we don’t know about the relationship between food assistance (in-kind, cash, and vouchers) and nutritional impact in humanitarian contexts. We’ve designed REFANI’s research questions specifically to provide some evidence that could be used to fill some of these knowledge “gaps” – particularly around the complex pathways through which cash transfers may achieve nutritional outcomes. REFANI isn’t the first of these studies, but considering the amount of academic and operational input that has gone into its design, more evidence will be produced, and hopefully, similar studies will be conducted in the future, encouraging more research for this field, and ultimately more funding for this evidence which in turn will improve humanitarian programming.

Results from the REFANI project are expected in early 2017. In the meantime, the REFANI-Pakistan protocol has been published and can be viewed here

Donate Now. Help Save Lives.

Help us save lives, empower communities, and ensure more children can grow up strong.

About Zvia Shwirtz

Action Against Hunger logo

Zvia manages communications and research uptake for REFANI, a three-year research project focused on the nutritional impact and cost-effectiveness of cash- and voucher-based food assistance programs.