Sustainable Emergencies: The Paradox of Community Management of Acute Malnutrition Programs

124 Pages·2014·0.98 MB·English

by  Kelly Delaney

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Publicly Accessible Penn Dissertations
2013
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Kelly Delaney
University of Pennsylvania, [email protected]
Follow this and additional works at: https://repository.upenn.edu/edissertations
Part of the Nursing Commons
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Delaney, Kelly, "Sustainable Emergencies: The Paradox of Community Management of Acute Malnutrition
Programs" (2013). Publicly Accessible Penn Dissertations. 850.
https://repository.upenn.edu/edissertations/850
This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations/850
For more information, please contact [email protected].
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SUSTAINABLE EMERGENCIES: THE PARADOX OF COMMUNITY
MANAGEMENT OF ACUTE MALNUTRITION PROGRAMS
Kelly Delaney, RN, MS, PHD
Alison Buttenheim, PHD, MBA
In 2008, the World Health Organization (WHO) formally endorsed the community management of acute
malnutrition protocol as the preferred method of treatment for the approximately 13 million acutely
malnourished children in the world (Collins, 2007; WHO, 2008). This protocol reflected a change in
treatment strategies from the hospital to the community. Health care providers who respond to nutrition
emergencies (referred to as emergency nutrition workers for the purpose of this study) were tasked with
understanding the complex nature of a community's structure and culture, in addition to providing
medical treatment for acutely malnourished children. To implement the WHO protocols successfully,
emergency nutrition workers must be able to translate international standards into a culturally and
contextually appropriate emergency nutrition program. This qualitative descriptive study describes the
experience of emergency nutrition workers regarding community participation in program assessment,
design, and implementation following declaration of a nutrition emergency.
There is a lack of understanding concerning what personal and professional beliefs and structures
influence how emergency nutrition workers interpret their environment and define the community
structure they are working within when developing assessment and implementation strategies.
Bronfrenbrenner's (1977) social ecology theoretical framework was utilized to guide a review of literature
concerning environmental influences that may affect community participation during emergency nutrition
programs. In the study, a cross-sectional qualitative descriptive design was utilized in a deterritorialized
setting. English speaking emergency nutrition workers who responded to a nutrition emergency as an
employee of an international non-governmental organization in the previous twelve months were recruited
through a maximum variation, purposeful sampling technique. Participants were recruited through
professional networks, NGO headquarters, and an online professional forum until saturation is reached.
Semi-structured interviews conducted by the researcher were the primary form of data collection for this
study. Interviews were conducted over the Internet using voice over Internet protocol (VOIP) technology.
Directed content analysis was utilized for data analysis.
The study results included an identification of five themes that influence the ways in which an emergency
nutrition worker engages with local communities during Community Management of Acute Malnutrition
(CMAM) programs: (1) Dimensions of Community in CMAM; (2) Learning Through Field Experience; (3)
Partnerships for Success; (4) Disconnects in Funding Priorities; and (5) Sustainability in Emergencies.
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Alison Buttenheim
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This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations/850

Dedication
To my parents, Tom and Kathy Delaney, you had the vision for my future long before I
knew what road in life I would take. Your undying support has made me who I am
today.
And to Heidi, you have seen me through the highs and lows of this journey. I will be
forever grateful for your daily encouragement and support. I love you.

ii
Acknowledgements

I would like to acknowledge my chair, Dr. Alison Buttenheim, whose mentorship
over the past year has helped me transform from a student into a researcher. Her
guidance and support has made the development of this body of work possible. I would
also like to acknowledge, the rest of my dissertation committee. Dr. Eileen Sullivan-
Marx’s role in my doctoral studies over the past six years has helped be gain the
confidence to believe in myself and the work that I am doing. Dr. Marjorie Muecke’s
global health focus helped me to develop my professional lens from one of a nurse in the
field to a nurse researcher who values the impact research can have on global health
policy. Dr. Allison Squires helped me to truly appreciate qualitative research and inspired
me to dream about where my career in global health can go after my PhD.
I would like to express my sincere gratitude to the Center for Health Incentive and
Behavioral Economics at the Leonard Davis Institute whose funding made this research
project possible. I would also like to acknowledge the qualitative working group at Penn
Nursing who helped inspire and challenge me to be the best qualitative researcher that I
could be.
Finally, I would like to acknowledge my friends and family whose support
through this journey has been incredible. I am so lucky to have such loving and
supportive people in my life. John, thank you for bringing me such laughter and joy
throughout this whole process. Egan, thank you for showing me how to approach every
day with strength, fearlessness, and a smile.

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ABSTRACT
SUSTAINABLE EMERGENCIES: THE PARADOX OF COMMUNITY
MANAGEMENT OF ACUTE MALNUTRITION PROGRAMS
Kelly Delaney
Alison Buttenheim
In 2008, the World Health Organization (WHO) formally endorsed the community
management of acute malnutrition protocol as the preferred method of treatment for the
approximately 13 million acutely malnourished children in the world (Collins, 2007;
WHO, 2008). This protocol reflected a change in treatment strategies from the hospital
to the community. Health care providers who respond to nutrition emergencies (referred
to as emergency nutrition workers for the purpose of this study) were tasked with
understanding the complex nature of a community’s structure and culture, in addition to
providing medical treatment for acutely malnourished children. To implement the WHO
protocols successfully, emergency nutrition workers must be able to translate
international standards into a culturally and contextually appropriate emergency nutrition
program. This qualitative descriptive study describes the experience of emergency
nutrition workers regarding community participation in program assessment, design, and
implementation following declaration of a nutrition emergency.
There is a lack of understanding concerning what personal and professional
beliefs and structures influence how emergency nutrition workers interpret their
environment and define the community structure they are working within when
developing assessment and implementation strategies. Bronfrenbrenner’s (1977) social
ecology theoretical framework was utilized to guide a review of literature concerning
iv
environmental influences that may affect community participation during emergency
nutrition programs. In the study, a cross-sectional qualitative descriptive design was
utilized in a deterritorialized setting. English speaking emergency nutrition workers who
responded to a nutrition emergency as an employee of an international non-governmental
organization in the previous twelve months were recruited through a maximum variation,
purposeful sampling technique. Participants were recruited through professional
networks, NGO headquarters, and an online professional forum until saturation is
reached. Semi-structured interviews conducted by the researcher were the primary form
of data collection for this study. Interviews were conducted over the Internet using voice
over Internet protocol (VOIP) technology. Directed content analysis was utilized for data
analysis. The study results included an identification of five themes that influence the
ways in which an emergency nutrition worker engages with local communities during
Community Management of Acute Malnutrition (CMAM) programs: (1) Dimensions of
Community in CMAM; (2) Learning Through Field Experience; (3) Partnerships for
Success; (4) Disconnects in Funding Priorities; and (5) Sustainability in Emergencies.
v
Table of Contents
Dedication ........................................................................................................................... ii
Acknowledgments.............................................................................................................. iii
Abstract .............................................................................................................................. iv
List of Tables .......................................................................................................................x
List of Figures .................................................................................................................... xi
Chapter One: Introduction and Study Overview .................................................................1
Introduction ..............................................................................................................1
Study Purpose and Objectives .................................................................................6
Study Significance ...................................................................................................6
Chapter Two: Theoretical Framework and Literature Review ..........................................10
Introduction ............................................................................................................10
Theoretical Framework ..........................................................................................10
Social Ecology Model for Emergency Nutrition .......................................12
Case Example: The Social Ecology Model As Applied to Acute
Malnutrition in Sub-Saharan Africa...........................................................14
Review of Literature ..............................................................................................18
Emergency Nutrition Programs: An Intersection Macrolevel of Systems .............18
Macrosystem Institutions: Defining the Scope of Work............................19
Macrosystem Institutions Defining Acute Malnutrition and Nutrition
Emergencies ...............................................................................................20
Macrosystem Institutions: Funding Priorities ...........................................22
Macrosystem Institutions: Emergency Nutrition Program Protocols .......23
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The Intersection of Macrosystem Institutions and Emergency Nutrition
Workers: A Summary ................................................................................24
The Role of Exosystem External Actors ................................................................25
Exosystem Institutions: International Non-Governmental Organizations .25
Exosystem Institutions: NGO Consortiums ..............................................27
Exosystem Institutions: Country Coordination .........................................28
Exosystem Organizational Culture Intersections: A Summary .................29
The Mesosytem and Microsystem Environment of Emergency Nutrition
Workers ..................................................................................................................29
Microsystem Environment: Emergency Nutrition Worker.......................30
Microsystem Environment: Community-Based Organizations ................32
Microsystem Environment: Local Infrastructure ......................................32
Microsystem Environment: Communities Affected by Emergencies ......33
Summary of the Review of Literature ...................................................................34
Chapter Three: Research Design and Methods ..................................................................35
Design ....................................................................................................................35
Setting ....................................................................................................................36
Sample....................................................................................................................36
Data Collection Procedures ....................................................................................39
Recruitment ................................................................................................39
Interviews ...................................................................................................42
Interview Setting ........................................................................................42
Interview Guide .........................................................................................44
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