Summary of a report on the Underlying Causes of Malnutrition in Twic County, Warap State, South Sudan. August 2007

Author(s): Terry Theuri, Nutrition Coordinator, GOAL, South Sudan

Consecutive surveys in Twic County have shown constantly high levels of malnutrition despite the interventions currently being carried out. GOAL, together with other NGOs, has been carrying out feeding responses to alleviate malnutrition, and more recently food security awareness. Programme coverage and meeting international emergency feeding standards have been a challenge due to the low attendance in the various feeding sites.

To understand the underlying causes of malnutrition hence has become inevitable to identify appropriate interventions. Focus group discussions and key informant interviews were conducted in order to understand the community’s perspective on various issues. The discussions and interviews were based on UNICEF’s conceptual framework of causes leading to malnutrition, morbidity and mortality. This approach identifies three levels of factors leading to malnutrition: immediate causes, underlying causes and basic causes.

The general findings show that malnutrition is a multi-deficiency syndrome, linked with inappropriate care practices, substandard levels or access to health services, water supply, hygiene & sanitation, inadequate health education and a poor understanding of the importance of food quality, quantity and diversity. In addition women’s heavy workloads and cultural beliefs and traditions which probably originated from what could be coping strategies also play a big role in malnutrition.

A keynote to the approach towards alleviating malnutrition is to modify the strategy used in carrying out the interventions recommended. Impact on behaviour change at individual and household level is still wanting. This has always been a challenge because most interventions take a top down approach and disregard the cause of the underlying problems. Behaviour change campaigns have to consider cultural beliefs and traditions, social pressures, and community motivation towards the key positive messages they are passing on.


A focus group meeting (Terry Theuri)

While disseminating the messages, community prioritised, interactive, participatory methods should be used. To enable this means that capacity building of health promoters is necessary to ensure that they are at a level where they understand the above mix.

Chart 1 summarises the main underlying causes of malnutrition in Twic County and their basic contributors. Chart 2 shows the food availability, seasons and principal morbidities – see below.




  • The majority of the underlying causes of malnutrition fall under the social and care environment, showing that, to have an impact on malnutrition in Twic County, this is where programmatic resources should be directed. Nutrition interventions in Twic (based heavily on feeding programmes) do not address these causes adequately at present. Feeding programmes should therefore be discontinued unless there is an emergency, and resources re-allocated to prevention of malnutrition orientated activities.

  • Review and strengthen the current CTC (Community Therapeutic Care) approach to prevention and treatment of malnutrition in Twic County that GOAL is currently implementing in partnership with Action Against Hunger-UK

  • Consider other intervention strategies that tackle malnutrition in a sustainable way.

  • Nutrition key messages need to be focussed to address key underlying problems found here.

  • Messages need to be given in a culturally sensitive way, be participatory and content needs to be correct. To achieve this, community health educators need to be trained on methods for public health message dissemination and behaviour change communication. 

  • Develop a culturally appropriate high-energy complementary recipe that uses low cost, locally available foods, and teach it to mothers through cooking demonstrations.

  • Continuation and expansion of food diversification initiatives such as seed distributions and introduction of fruit trees with the necessary training, support and follow-up.

  • Inclusion of fishing equipment with seed distributions to improve household access to fish. 

  • Support to breastfeeding and complementary feeding through initiatives that enable mothers to spend more time at home. For example, the introduction of energy saving stoves made from locally available materials and water purification initiatives (such as filtration and chlorination) that allow mothers to collect water from a near-by source.

  • Improve Vitamin A supplementation to post-partum women (to ensure sufficient Vitamin A in breastmilk and to increase mothers’ levels ahead of the next pregnancy) through encouraging up-take of postnatal care.

  • Investigate culturally acceptable ways for improved sanitation.

  • Ensure all GOAL programmes are run in a gender sensitive way, or with a gender bias towards women. 

  • Increase soap distributions from the clinics as a way to promote hygiene, and further investigate soap making for promotion within the community.



Chart 1 Causes of malnutrition in Twic County

Underlying causes

Household food insecurity

Inadequate social and care environment

Poor public health

  • Small number of meals per day
  • Lack of food variety
  • Lack of meat in diet


  • Women’s heavy workloads
  • Poor complementary feeding
  • Lack of exclusive breastfeeding
  • Limits on women’s food intake during pregnancy and lactation
  • Unfair prioritisation for eating within families
    • Low up-take of healthcare services.
  • Lack of availability and accessibility of healthcare services
  • Poor sanitation and hygiene practices
  • Use of unsafe water sources


Basic causes

  • Gender inequality
  • Lack of teachers, schools & education systems for primary, secondary and tertiary education
  • Lack of formal government healthcare system
  • Lack of infrastructure (roads, electricity, communications)
  • Intermittent, unpredictable insecurity
  • Fragile political situation
  • Seasonal floods, droughts and hunger gap


Chart 2 Twic County - Food availability, seasons and principal morbidities


For full report email Terry Theuri at nutco at