Abstract
Summary
Owing to its major health and social consequences, malnutrition in the Sahel region of Burkina Faso is a determinant of noma. The ‘Projet de Sensibilisation et de Renforcement des Capacités pour la Prévention du Noma’ (PSRCPN/BF) aims to reduce morbidity due to malnutrition and noma through an integrated community-based approach. This article presents the nutrition component of this project.
Methods
The PSRCPN/BF has three main objectives: prevention of malnutrition, improvement of oral and dental health, and management of noma cases. The nutrition component targets pregnant and breastfeeding women as well as children aged six to 23 months via integrated strategies: awareness-raising via community groups, malnutrition screening, referral of detected cases to health centres and distribution of enriched rations of infant flour. Partnerships with NGOs, local associations and public health structures have helped to implement the program in 104 villages.
Results
The project achieved significant results between 2021 and 2024. 6,030 awareness-raising groups were created with women volunteers, with an effective participation rate of over 96% of the target audience. 134,804 children were screened each year. All children screened positive were referred to health centres. The prevalence of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) were 0.93% and 3.68%, respectively. These numbers decreased from 1.35% in 2021 to 0.57% in 2024 for SAM, and from 4.53 to 2.10% for MAM.
Conclusion
While malnutrition has declined significantly, its prevalence remains a matter of concern and the fight against it must be intensified. The project findings suggest the effectiveness of integrated strategies and highlights the importance of implementing a community-based, multi-sectoral approach.
Keywords: Noma, Community health, Sahel
Introduction
The WHO defines malnutrition as deficiencies, excesses or imbalances in a person’s energy and/or nutritional intake. Undernutrition plays a role in almost 50% of deaths among children under 5 worldwide [1]. These deaths occur mainly in low- to middle-income countries. The economic, social and medical consequences and the developmental repercussions of the global burden of malnutrition are severe and persistent for individuals and their families, as well as for communities and countries [2].
According to the United Nations Food and Agriculture Organization (FAO) [2] and the WHO [1], the sub-Saharan region has one of the highest rates of malnutrition worldwide. Over 20% of its population suffers from chronic undernutrition, i.e. not receiving enough calories and essential nutrients to lead a healthy life. Together with other factors such as poverty, conflict, natural disasters and problems of access to healthcare, undernutrition contributes to the scale of malnutrition in the sub-Saharan region. In children, malnutrition has major consequences on their health, growth, development and survival: stunted growth, weakened immunity leading to a higher risk of illnesses such as diarrhoea, respiratory infections and malaria, impaired cognitive development (learning ability, memory, concentration and IQ), anaemia, increased risk of mortality, and long-term sequelae. Preventing and treating child malnutrition is therefore crucial to safeguarding their health, development and survival.
Malnutrition in the Sahel region: from emergency to action
Child malnutrition is particularly acute in the Sahel region owing to several interdependent factors, including chronic problems of food insufficiency due to adverse climatic conditions, frequent droughts and land degradation, which limit people’s access to adequate, nutritious food. Widespread poverty also limits families’ financial means to purchase nutritious food, access adequate health services and implement essential hygiene practices to prevent malnutrition. People in the Sahel often have limited access to basic health services, including maternal and child health services, immunization programs and nutrition services, all of which contribute to the prevalence of child malnutrition. Inadequate feeding practices such as early weaning, lack of exclusive breastfeeding during the first months of life, consumption of non-nutritious foods and inadequate meal preparation, are other aggravating factors. Finally, infectious diseases such as malaria, respiratory infections and other illnesses common in the Sahel region can accentuate malnutrition by affecting children’s ability to absorb nutrients and maintain a satisfactory nutritional status [3, 4].
In West Africa, several nutrition-focused interventions have been implemented to address malnutrition. These include targeted supplementation, mass distribution of fortified foods, and peer-support groups for breastfeeding promotion. Comparative analyses have shown that integrated, community-based approaches may outperform vertical programs in terms of coverage and sustainability [5].
In short, child malnutrition in the Sahel region results from several interconnected factors which require a holistic, multi-sectoral approach to be mitigated effectively. Several programs and initiatives are run by non-governmental organizations in the region and aim at fighting child malnutrition through various approaches. These programs are coordinated with governmental strategies. This article presents the nutrition component of a project to combat noma in the Sahel region of Burkina Faso.
Methods
Presentation of the PSRCPN/BF project
PSRCPN/BF: a network of stakeholders mobilized in the Sahel region
The ‘Projet de Sensibilisation et de Renforcement des Capacités pour la Prévention du Noma’ (PSRCPN/BF) was set up in 2011 by the Network for Oral Health Promotion and Research in Africa (NOHPRA) and the German NGO Gegen Noma, in collaboration with the Ministry of Health of Burkina Faso and with the contribution of the French NGO Vaincre Noma. The grassroot actions of the PSRCPN/BF were launched in 2012 in the Sahel region and have been continued and strengthened over the past decade thanks to co-financing by the German Federal Ministry for Economic Cooperation and Development (BMZ) and other donors such as the Fondation Pierre Fabre (France) and Hilfsaktion Noma e.V. (Germany). The project has prioritized the Sahel region because it has some of the country’s lowest nutritional and health indicators.
The PSRCPN/BF is a multilevel project which focuses on children, pregnant women and mothers of young children as well as the general population, healthcare providers and community intermediaries. It was designed after an extensive community consultation including town councils, associations, health professionals and community representatives. Its guidelines are regularly revised according to the changes in the country’s situation and in national and international recommendations on noma, oral health, nutrition and the fight against Covid-19.
The overall aim of the project is to promote oral health and to help reduce noma-related morbidity and mortality, with the guiding principle of relying on community resources, i.e. populations, organizations and health workers, to act on the determinants of noma and limit its consequences. Concretely, this means providing technical assistance to the various structures involved in the fight against noma, developing the capacities of those involved, ensuring social mobilization and raising awareness among the population.
The program has three components, each of which comprises actions to be implemented progressively. The first one aims at fighting malnutrition through the education of pregnant women and mothers, screening for malnutrition and nutritional supplementation (i.e. the subject of this article). It therefore focuses on the main determinant of noma in a population that is subject to deteriorating living conditions. The second component targets oral health by educating the population about dental hygiene, mobilizing community stakeholders in terms of preventive care and referral, and building the prevention and management capacities of health care services (i.e. health care providers, community health workers). Finally, the third component aims to identify and manage both medical and surgical cases of noma by educating the population about screening, encouraging community stakeholders to identify cases, and building the capacity of health care providers to seek out and manage cases (Tapsoba H, et al: Strategy for capacity building, social mobilisation and community involvement in the promotion of oral health and the fight against noma: more than a decade of intervention in the Sahel region of Burkina Faso (2011–2023), submitted).
The nutrition component of the PSRCPN/BF project
Although it has improved in recent years, the nutritional situation in Burkina Faso remains a matter of concern. In 2019, 25.4% of children under the age of five were stunted, 17.3% were underweight and 8.1% were emaciated. Micronutrient deficiencies persist with anaemia affecting nearly 62% of women of childbearing age, more than eight out of 10 children under five and nearly 7% of school-age children [6]. Several factors contribute to malnutrition in the country including poverty, limited access to nutritious food, inadequate dietary practices, infectious diseases and low coverage of health and nutrition services. The Sahel region is one of the areas most affected by severe acute malnutrition owing to poverty, humanitarian crises and adverse climatic conditions.
NGOs and the government of Burkina Faso have set out to tackle these challenges with specific programs that address malnutrition as holistically as possible. Together with institutional and NGO partners, the German NGO Gegen Noma and the Network for Oral Health Promotion and Research in Africa designed an innovative, community-based strategy that has been running in the Sahel region since 2012: the PSRCPN/BF (2011–2024). Noma is a severe, mutilating and fatal disease of the orofacial sphere. Although progress has been made, the situation in the Sahel region remains concerning. Undernutrition is one of the main determinants of noma and plays a decisive role in the onset of the disease in all sufferers. Therefore, although initially focused on the screening and management of the disease, the PSRCPN/BF started targeting the issue of malnutrition in 2018, in consultation with Burkina Faso’s regional health directorate. This focus on nutrition was aimed particularly at pregnant and breastfeeding women.
Objective of the nutrition component of the PSRCPN/BF project
The main objective was to help fight noma sustainably by preventing malnutrition among pregnant and breastfeeding women and children aged 6–23 months in selected villages of the Sahel region. To achieve this objective, it was necessary to: (i) improve the knowledge and practices of pregnant women and women with children aged 0–23 months through educational talks on oral health, noma, risk factors and prevention, especially the diet of children under the age of two; (ii) provide access to appropriate nutritional supplements for children aged 6–23 months living in the intervention villages in the Dori and Sebba health districts, in order to reduce the risk of severe malnutrition.
These objectives are in line with national and international recommendations in terms of nutritional safety. At the national level, they are based on strategic theme 2 (Developing human capital) of the National Economic and Social Development Plan [7] and on strategic theme 1 (Reducing undernutrition) of the Multisectoral Nutrition Policy [6], which aims to promote optimal feeding practices in infants and young children, and to reinforce nutrition-oriented food safety and social protection interventions. At the international level, these objectives are aligned with the WHO global nutrition targets for 2025, especially targets 1 and 5 which aim to reduce stunting by 40% and to reduce or maintain emaciation below 5% in children under five, respectively [8].
Strategies
There are four strategies: raising awareness among pregnant and breastfeeding women, screening children aged 6–23 months for malnutrition, referring screened children to health centres, and distributing enriched flour-based protective rations to children aged 6–23 months.
Awareness-raising for pregnant and breastfeeding women on good nutritional practices for young children
The PSRCPN/BF set up outreach groups called GASPA-ANJE (Groupes de Suivi et de Promotion des Pratiques d’Alimentation du Nourrisson et du Jeune Enfant) to reach pregnant or breastfeeding women (FEFA) and children aged 6–23 months in 104 villages of the Sahel region. Three types of groups were set up in these villages: pregnant women, women with children aged 0–5 months, and women with children aged 6–23 months. The project began in 2019 and continues to this day.
The number of women per group is limited to 20 to allow them to participate actively in the awareness sessions and to enable the facilitators to organize the meetings appropriately. Each facilitator is responsible for six to eight groups. In collaboration with the regional health directorate and the health care services, the project team established themes for discussion based on visual kits on noma and on the essential health/nutrition practices recommended by the PSRCPN/BF and the nutrition department of the Ministry of Health. A total of 12 visual kits were produced, eight of which focused on nutrition: food groups, nutrition for pregnant women, nutrition for children aged 0–5 months, nutrition for breast-feeding women, nutrition for children aged 6–11 months, nutrition for children aged 12–23 months, hand hygiene, and environmental hygiene.
The project concerned 104 out of the 721 villages in the region. They were chosen in consultation with the region’s stakeholders according to multi-sectoral criteria (nutritional, health, socio-economic, etc.). Consistency, complementarity and synergy with similar initiatives were also considered in order to pool resources and avoid duplication. Priority was therefore given to areas where other projects or organizations were not already active.
Several associations were recruited to implement this intervention. The 104 villages were grouped into six lots. A call for applications was launched to invite associations to apply for the lots. The applications were then reviewed by a multidisciplinary team, which finalized the list of associations selected by district and their assigned lots. Six associations were chosen in the end. They recruited a total of 208 community facilitators to run the activities. The latter were responsible for recruiting women in the intervention villages, setting up groups, holding group sessions and filling in the various monitoring tools on a monthly basis. They also receive additional assistance to carry out their actions more effectively.
Screening for malnutrition
Screening for acute malnutrition was performed using an upper arm circumference tape, aka a Shakir band. The tape is color-coded at different intervals. Green indicates a healthy status, orange shows that there is a risk of undernutrition, and red points to the most serious cases, i.e. severe acute malnutrition, which must be treated urgently as it presents a high risk of death.
Reinforced referrals for malnutrition diagnoses
Screened children (orange or red) were systematically referred to the care centre to begin appropriate treatment.
Distribution of enriched flour-based protective rations to children aged 6–23 months
In 2023, fortified flour-based rations were distributed to beneficiaries of the project aged 6–23 months. This three-month supplementation began in the Dori health district at the start of the first quarter of 2023. It involved two partner associations working with the GASPAs, each association covering 16 villages. Each child received supplementation in accordance with the three-month ‘blanket feeding’ standard recommendation, i.e. 6 kg per child per month. To achieve this, women leaders were recruited and trained in each village (Tapsoba H, et al: Women’s leadership and health in the community: challenges and examples from the strategy to strengthen social mobilisation and community involvement in the fight against noma in the Sahel region of Burkina Faso, submitted). In practice, they are asked to promote supplementation by visiting homes to ensure that the recommendations presented in the GASPA sessions are applied. They also spot any women who do not attend the GASPA sessions. Home visits are an entry point for following up and helping women, monitoring noma and malnutrition, promoting good practices, and above all ensuring that the flour for the infants really reaches the homes. They also lend a sympathetic ear for women’s concerns and offer their assistance. Women leaders also assist group leaders in distributing the flour. Community-based health workers trained as group leaders are responsible for distributing the flour to the beneficiaries. Together with representatives of community-based organizations, they transport the flour from the health centre to the village or site where it is to be distributed. They collect data which they then forward to the associations’ managers. It is the partner association which has overall responsibility for receiving the flour at the place where it is stored, transporting it to the place of distribution and supervising its distribution. In practice, some villages find it easier to come to the associations and stock up on the flour directly. The Dori health district participates in the joint supervision of the stakeholders involved, while the regional health directorate coordinates implementation. The flour was provided by the PSRCPN/BF project.
Monitoring and assessment
Continuous data collection enabled us to monitor the implementation of the project territory by territory, its coverage in terms of number of beneficiaries and its results in terms of malnutrition. An evaluation report was produced each year, from which the following results are extracted. They cover the years 2021 to 2024.
Data sources for this article
This article is based on the exploitation of annual project reports. All data collection activities followed a standardized protocol, including the use of standardized data collection tools. Investigators and data collectors were trained and worked under the supervision of team leaders, who were themselves overseen by the project coordination team. Data collected by the investigators underwent a quality audit, which involved cross-checking 10% of the collected data against source documents. No data were collected specifically for this paper. The presented data are not individual data but aggregate data from the reports.
Thus, this article does not involve human subjects directly or indirectly (data or material). The Declaration of Helsinki is therefore not involved, and there is no need for ethical approval or individual consent to participate.
The research support project was conducted in accordance with Burkina Faso Ministry guidelines. Intervention protocols and procedures for monitoring and evaluation data collection were approved by the Ministry. Data collection was carried out only after obtaining prior verbal informed consent from each individual participating in an interview and/or questionnaire, with clear information provided, including the right to refuse. Confidentiality was strictly maintained, notably through the anonymization of all documents prior to transmission.
Results
The project produced the expected results in terms of awareness-raising, screening for malnutrition, referral of screened children and reduction in malnutrition.
Awareness-raising
In all villages, targets were enrolled in accordance with the overall objectives of the project. Over the 2021/2024 period, a mean of 27,302 women were enrolled per year, including 70,489 pregnant women, 85,530 women with children aged 0 to 5 months and 117,004 women with children aged 6 to 23 months. The same women may have been approached several times over the period. In total, 6,030 awareness groups were set up with women volunteers, with an effective participation rate of over 96% (i.e. participation in at least one group session).
Screening
Systematic screening for malnutrition in children aged 6 to 23 months concerned 95% of the target population. Note that the same children may have been screened several times over the period. A total of 5,030 cases of SAM and 19,862 cases of MAM were identified, representing rates of 0.93% and 3.68%, respectively. These rates decreased dramatically over the period, from 1.35% for SAM in 2021 to 0.57% in 2024, and from 4.53 to 2.10% for MAM (Table 1).
Table 1.
Annual screening results and trends in acute malnutrition among children aged 6–23 months in target villages
| Year | Children Screened | SAM (n) | SAM (%) | MAM (n) | MAM (%) |
|---|---|---|---|---|---|
| 2021 | 117,182 | 1,584 | 1.35% | 5,314 | 4.53% |
| 2022 | 153,181 | 1,531 | 0.99% | 6,816 | 4.44% |
| 2023 | 176,403 | 1,324 | 0.75% | 5,929 | 3.36% |
| 2024 | 92,448 | 591 | 0.57% | 1,803 | 2.10% |
SAM Severe Acute Malnutrition, MAM Moderate Acute Malnutrition
Referral and management
Over the period, 100% of the SAM and MAM cases detected were referred to health centres.
Supplementation
By 2023, 5,223 children had received supplementation out of a target of 5,621. This target corresponds to the number of children eligible for supplementation during the supplementation periods, which do not cover the entire duration of the program.
Discussion
The project remains ongoing in 2025, despite the need to adapt to substantial operational constraints. The Sahel region has experienced increasing insecurity due to terrorist activity, resulting in the displacement of a significant proportion of both health personnel and the local population. These conditions have severely hindered the continuity of field operations, negatively affecting access to health services and the implementation of nutrition interventions. Despite this context, the three components of the project were successfully implemented, with a significant reduction in the prevalence of malnutrition. However, the malnutrition rate remains high in our intervention area, which remains in a state of alert according to the food safety classification framework. Efforts thus need to be pursued, as the situation is not far from being judged as ‘acceptable’. These results must be interpreted in light of an overall context marked by growing nutritional insecurity. In 2024, the Central Sahel was facing a worsening humanitarian crisis, with malnutrition among children under five increasingly driven by armed conflict, population displacement, and climate-related shocks [9].
Considering this context, these results are encouraging. One should bear in mind that this nutrition strategy is in line with what other programs have implemented, which makes it possible to identify several ‘key functions’, i.e. factors underpinning the effectiveness of a strategy. These include: (i) the promotion of exclusive breastfeeding for the first six months of life, (ii) micronutrient supplementation including vitamin A, iron and zinc, which help prevent nutritional deficiencies in children and strengthen their immune systems, (iii) the introduction of age-appropriate nutritious complementary foods after six months of exclusive breastfeeding, (iv) age-relevant nutrition programs that take into account the various nutritional needs of infants, young children and older children, (v) family awareness and education on healthy eating, good hygiene practices and child care, and finally (vi) access to basic health services, including mother-and-child care, immunization and nutrition services [10–13]. This strategy was a population-based approach. The value of such an approach, compared to a more targeted one, has already been highlighted [14].
The PSRCPN/BF nutrition strategy not only incorporates these key functions - education, community screening, systematic referral, home visits, distribution of supplementation products - but also ensures the quality of their implementation, i.e. the associations adapting their interventions to meet the needs of pregnant and breastfeeding women, spotting women who do not attend the sessions, etc.
In addition to these key functions, several prerequisites should be considered for these programs to be able to fight child malnutrition effectively and sustainably.
First, an integrated approach should be adopted by combining complementary nutritional interventions to meet the children’s needs in a holistic manner. The nutrition component of the project clearly meets this objective by mobilizing all possible levers to work towards the same goal, in line with the recommended holistic approach.
Second, these programs must be made accessible to the target populations by taking geographical, economic and cultural barriers into account, to ensure participation and commitment. There is the challenge of integrating these programs into healthcare systems, in particular through support for front-line resources, intersectoral collaboration and community involvement. The involvement of community stakeholders in this respect is essential [15, 16]. Moreover, mobilizing women leaders and community stakeholders has made the implemented actions sustainable, accessible and adapted to local needs by tailoring the narrative, searching for non-attendees and organizing home visits. This participatory foundation of the project relied on existing local resources, mobilizing them in a complementary manner and strengthening them through training, practice analysis, and provision of equipment. Thanks to the commitment of communities and diverse health actors including health workers, community health workers, and traditional healers, the project has successfully achieved its objective of fostering the cultural acceptance necessary for the effective implementation of its strategies. The importance of community-based approaches has been frequently emphasized [17–19], and this project provides a concrete contemporary illustration of such an approach.
Third, the quality of health services must be maintained, including the training of health care workers, the availability of adequate medical supplies, and regular follow-up services for malnourished children. Thanks to the project, the equipment needed for the distribution of supplements and the supplementation itself could be purchased. While the project did not set out to strengthen the national malnutrition care and management system per se, the indicators on the screening strategy can serve to assess the performance of the care system and adjust it, if necessary. In addition, the project has trained associative stakeholders in terms of screening, thereby strengthening the care system, as in other programs such as the Programme de Nutrition et Santé Maternelle et Infantile in Niger, which trains local health workers in the detection and management of cases of acute malnutrition in children, while ensuring the availability of the necessary nutritional inputs (https://www.unicef.org/niger/nutrition).
Fourth, the programme has achieved its target of raising awareness and educating families about the importance of a balanced diet, exclusive breastfeeding and the prevention of malnutrition. In fact, this is the central feature of the project for the GASPAs, around which all the other components revolve. Establishing strong partnerships with governments, NGOs, academic institutions and businesses is also essential to ensure effective coordination in the fight against child malnutrition. This project was carried out within the framework of multiple partnerships involving the Burkinabe government, NGOs, community and healthcare system stakeholders, and the general population. These partnership-based approaches have been highlighted as a key success factor for nutrition programs [20].
Limitations
This study is based on aggregate programmatic data rather than individual-level data, which introduces limitations in terms of causal interpretation and generalizability beyond the project implementation sites. Potential biases include inaccuracies in routine data collection, variations in reporting across regions, and lack of independent verification of outcomes. Although these limitations do not invalidate the trends observed, they should be considered when interpreting the results. In addition, no programme can have a lasting effect without implementing monitoring and evaluation mechanisms to assess the impact of actions, identify gaps and opportunities for improvement, and ensure accountability to stakeholders. At this stage, the sustainability and scale-up of these interventions remain major challenges. In Burkina Faso, despite the demonstrated effectiveness of community-based malnutrition management programs, obstacles such as limited integration into the national health system, insufficient resources, and lack of advocacy have hindered their long-term sustainability and scale-up [21]. In parallel, initiatives aimed at strengthening organizational capacity at the municipal level have been undertaken to support the expansion of nutrition interventions under the 2020–2024 National Multisectoral Nutrition Plan [21]. These efforts highlight the importance of a multisectoral approach and effective coordination across different levels of governance to ensure the sustainability of nutrition programs. These key factors are present in the current program. Our hope is that this article provides food for thought as to how this approach can be replicated in other geographical areas and on other public health issues. To this end, a formal evaluation of the project’s outcomes and long-term health impacts was planned. However, it had to be postponed due to the deteriorating security situation. The findings from this evaluation will be instrumental in assessing the conditions for the program’s sustainability and potential scalability to other regions of Burkina Faso, and possibly to other countries.The project has already been extended to another of Burkina Faso’s 13 regions since 2024. This extension is planned for two other regions.
Acknowledgements
The authors would like to thank all the women mobilized in the Sahel region (pregnant and breastfeeding project beneficiaries, women leaders) and the members of their respective communities, all those involved in organizing the project (partner associations, health districts, regional department of health). They also wish to thank the technical and financial partners of PSRCPN/BF, especially NGO Gegen Noma (Germany), NGO Vaincre Noma (France), the German Federal Ministry for Economic Cooperation and Development, and the Ministry of Health in Burkina Faso.
Authors’ contributions
HT: Project design, project financing, coordination of overall implementation. PSAY: contribution to data collection and study design. SB: contribution to conception of data collection. Contribution to project implementation. AI: Data verification. Contribution to the supervision of field activities. HT drafted the initial manuscript. All authors reviewed and approved the final version of the manuscript.
Funding
NGO Gegen Noma (Germany), NGO Vaincre Noma (France), the German Federal Ministry for Economic Cooperation and Development.
Data availability
On reasonable request to the corresponding author.
Declarations
Ethics approval and consent to participate
This article is based on the exploitation of annual project reports.
No data were collected. The data presented are not individual data but aggregate data from the reports.
Thus, this article does not involve human subjects directly or indirectly (data or material). The Declaration of Helsinki is therefore not involved, and there is no need for ethical approval or individual consent to participate.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
On reasonable request to the corresponding author.