Count Me In

Proper nutrition, safe feeding, and nurturing care during early childhood lay the foundation for lifelong health and wellbeing, yet two intersecting groups of children do not always have access to high-quality care: children with disabilities and children living outside of family care. Children with disabilities are three times more likely to be malnourished than their typically-developing peers, and SPOON has found rates of malnutrition as high as 93% for children in institutions. This malnutrition is usually driven by a lack of health services adapted to their unique needs and accessible support and training for their caregivers. Caregivers often have the best intentions to provide safe and nurturing care for their children, but lack the guidance and resources to do so. Without solutions that empower caregivers to improve both what and how these vulnerable children are fed, they are at high risk for delayed development, lifelong poor health, and early death. Globally, an estimated 290 million children have a disability, and 10 million live outside of family care. Due to the intersection of disability and lack of services, SPOON estimates that 250 million children worldwide are at particularly high risk for malnutrition. Despite this extreme need, significant gaps in data on these children have effectively rendered them invisible in the global health sector.

Count Me In is a web-based digital health app solving malnutrition and feeding difficulties for children with disabilities and children living outside of family care. Count Me In allows trained service providers (i.e., community health workers, rehabilitation workers, nurses, and social workers) to assess and monitor children’s health over time and support caregivers to safely feed and nourish the children in their care, resulting in improved growth and development for vulnerable children and improved confidence of their caregivers to meet their unique needs.

Count Me In assesses children’s health status in three areas:

1. Growth: Count Me In shows trends in children’s growth so service providers know when they are growing at a healthy rate. Service providers are prompted to measure children’s growth based on a standard schedule. The app tracks weight, height/length, head circumference, and mid-upper arm circumference and plots the results on the World Health Organization’s growth charts. It then uses sophisticated logic to interpret the results and provide specific recommendations to caregivers. 
2. Anemia status: Iron-deficiency anemia is easy to detect and straightforward to treat, and it is one of the most common forms of malnutrition. Count Me In prompts service providers to screen for anemia, provides instructions for measuring hemoglobin, measures results, and, if the child is anemic, recommends supplementation and dietary improvements. 
3. Feeding: Using a simple set of questions, Count Me In walks service providers through mealtime observations so they can screen children for feeding difficulties. If detected, the app makes specific recommendations to improve feeding, including educational content and specialized techniques for feeding children with disabilities. Service providers use these recommendations to support caregivers to use best practices when feeding children, such as holding infants during feeding, using child-sized spoons, and interacting with children during meals. 

Count Me In is built around a training curriculum developed by SPOON that focuses on critical elements of nutrition, child development, feeding, disability, and growth. Once service providers receive this training, Count Me In assists them as they put it to use. Count Me In is architected as a web app designed for use in low bandwidth contexts. By relying on simple technologies, it is accessible to users with very modest mobile technology, and it is extremely inexpensive to maintain in-house.

By combining evidence-based care with digital technology in an easy-to-use format, Count Me In has proven an incredibly effective tool for equipping service providers and caregivers to improve the health and wellbeing of vulnerable children. Count Me In is built for scale, and to date it has been translated into six languages and deployed in sites across ten countries. In this way, Count Me In offers indispensable, big-picture insight into the feeding and nutrition needs of underserved children around the world and the solutions that best meet these needs. SPOON and our partners use the data collected through Count Me In to advocate for funding, policies, and systems towards improved equity and better nutrition for these children, ensuring that they are seen and counted in the global health sector. 

Count Me In serves those who care for two populations of children that often overlap: children living outside of family care (i.e., residential institutions) and children with disabilities. Children are institutionalized for a variety of reasons that include poverty, family breakup, disability, and lack of community-based services. Limited opportunities for attachment and stimulation, sub-optimal diets, poor hygiene, and unsafe feeding practices such as being fed while lying down contribute to delays in emotional, physical, and neurological development for children living in institutions. Children with disabilities are similarly vulnerable and experience stigma, health care provider biases, and lack of adapted services. This results in high care, emotional, and economic burdens for their caregivers, contributing to high rates of both malnutrition and institutionalization.

These two groups of children often require specialized nutrition and feeding care, but they are largely left behind by global nutrition efforts and training structures. Nutrition programs typically reach children through their families, missing the millions of children in institutions. Similarly, community-based services often fail to reach children with disabilities or do not include strategies adapted to their unique needs, such as specialized feeding techniques or adapted growth monitoring practices.

Even further, these groups of children are also often overlooked on a systems and policy level. Many of the services that children need are governed by policies, budgets, and national strategies. Policy makers often seek to target resources to the areas of highest need and use data to guide these decisions, including what to prioritize in nutrition strategies, what training to recommend for health staff, and how to measure progress. Most nutrition data come from population surveys that seek to understand the average rate of child malnutrition in a given country. Commonly, these surveys either do not include these high-risk groups of children or do not collect data on disability or family care status. This means that estimated national averages cannot be broken down to show the needs of these groups of children. Without comprehensive data, the needs of children with disabilities and children living outside of family care are not seen by policy makers.

The lack of inclusion of these children in both programming and policy stands in stark contrast to their level of need, so SPOON developed Count Me In as a concerted effort to fill this gap.

On an individual level, Count Me In meets the need for solutions that facilitate the delivery of quality, adapted nutrition and feeding interventions for children with limited access to specialized treatment and care. By collecting and interpreting children’s growth measurements and hemoglobin levels and recommending individualized interventions when malnutrition or unsafe feeding practices are identified, Count Me In allows service providers to independently and sustainably implement nutrition and feeding best practices into their systems of care and equip caregivers with the knowledge, skills, and confidence to overcome preventable causes of malnutrition.   

On a global level, Count Me In meets the need for practical, up-to-date information on the feeding and nutrition needs of vulnerable children and the most effective solutions to meet those needs. As SPOON scales Count Me In to sites around the world and its users monitor children’s growth over time, SPOON can anonymize the data collected and use them to call attention to the needs and potential of these groups of children, make specific policy recommendations, and advocate for inclusive policies and programs. In this way, Count Me In can have an impact on the lives of millions of children beyond the sites where it is used on the ground.

Mishelle Rudzinski and Cindy Kaplan co-founded SPOON in 2007 after they each adopted children severely impacted by malnutrition. Through this experience, they identified a previously unrecognized gap in nutrition and feeding services for children in orphanages. Realizing that no organization addressed this issue, they established SPOON. Today, SPOON is the only organization dedicated solely to transforming nutrition and feeding for children with disabilities and children living outside of permanent family care. With 15 years of experience addressing feeding and nutrition for these specific groups of children, our expertise in nutrition, disability, and digital health; our vision for scale; and our highly collaborative approach make us well-positioned to deliver and scale Count Me In.

SPOON’s strategy is rooted in partnership and collaboration. We form strategic partnerships with local agencies, organizations, and government entities to ensure that our programs are locally owned and sustained. We complete initial needs assessments for each new project in tandem with our local partners to ensure that our programs are adapted to the local context and meet the most urgent needs. We then build the capacity of our partners to deliver training, monitor projects, and encourage service providers and caregivers to employ best practices in feeding and nutrition. Our projects are structured so our partners can own and run the programs, reaching out to us only for technical assistance as needed once training is complete.

In addition, SPOON seeks to engage those whose experiences and expertise are most relevant to the needs of the community we serve in our internal decision-making. SPOON has two board members with disabilities, and three of SPOON’s board members and one staff member were separated from their families of origin at young ages and experienced malnutrition and/or feeding difficulties. 

Our goal is to use Count Me In to assess the feeding and nutrition of 10,000 children over the next two years. We believe that such a robust dataset on children who traditionally have been uncounted will capture the attention of global decision-makers and lead to inclusive funding, policies, and programs for the underserved 250 million children who need access to high-quality nutrition and feeding care. With sustained use of Count Me In at some sites for nearly five years, SPOON has made steady, though slow, progress toward this goal. However, as outlined in the business model section below, we have historically relied on a triangulated partnership model where SPOON provides tools and training to an implementing partner, with both SPOON and the partner funded by a third party. We believe there is potential to improve upon or expand this business model to more efficiently reach more children. Changes to how we partner, seek funding, and/or deliver our services could yield dramatic increases to our programs’ reach. We are applying to Solve because we seek mentorship, coaching, and strategic advice from experts on our business model and service distribution to support us to more effectively and efficiently scale Count Me In to reach our goal.

SPOON launched Count Me In in 2016 after identifying a demand for individualized, adapted nutrition and feeding care for children living outside of family care and children with disabilities. Despite the ubiquity of digital health apps, none specifically addressed the unique needs of these two groups of children. By providing structure and process for monitoring the growth and nutrition of underserved children, providing clinical recommendations powered by artificial intelligence, and supporting decision-making at the site level through comprehensive reports, Count Me In supports individual children and their communities. Unlike mainstream nutrition services which typically focus solely on what children are fed, Count Me In supports service providers and caregivers to assess how children are fed as well, allowing them to holistically address the root causes of malnutrition.

Key innovations within the app include the following:

• Simplified interpretations and recommendations of growth measurements and growth charts
• Internal logic for the treatment of anemia
• Ground-breaking, simple logic for detecting and troubleshooting feeding difficulties and feeding positioning

However, what truly makes Count Me In catalytic is its potential for broader impact. The data it collects illustrate disparities in growth between typically-developing children and those with disabilities, as well as between children living in families and those living in institutional care. It highlights the prevalence of feeding difficulties, changes in growth that accompany shifts in feeding practices, and where anemia is particularly prevalent during key stages of development. SPOON and partners are using these indicators – among others generated by the app – to work with local health ministries, funders, and NGOs in the health, disability, and care reform sectors to systematically improve outcomes for vulnerable children.

SPOON’s one-year goal is to gather baseline data on 5,000 children in Count Me In, with a total of 10,000 children at the end of two years. We believe that this increase in our dataset size is essential to strengthening our advocacy voice, allowing us to demonstrate to decision-makers the needs of our target populations and the interventions that best meet these needs.

Our five-year goal is to catalyze change in the systems that lead to inequities in nutrition for children with disabilities and children living outside of family care. Using our data, by 2027 we aim to change policies, programs, and investments that will reach at least 10 million children through the following channels: 

• Influence development and implementation of at least 2 national policies, one global policy, and 4 sector-related agendas
• Equip at least 100 existing professional and grassroots advocates in the nutrition, child welfare, and disability rights sectors to drive change in their spheres of influence
• Inform inclusive program designs for at least 3 large NGOs
• Compel at least one large funding institution to shift funding practices to reflect inclusive nutrition practices

As an evidence-based organization, SPOON utilizes data to make programmatic decisions, evaluate impact, and advocate for policies that better support vulnerable children. Through our suite of quantitative and qualitative evaluation tools, we collect baseline and outcome data for the children, caregivers, and institutions impacted by our programs. We collect data from our trainees and partners through evaluations and surveys as well as through interviews conducted either in person or over Zoom. In addition, we collect data through Count Me In itself. Within the app, we can see real-time reports on the following: number of active projects, number of active sites, and number of children served. We can also see data on malnutrition rates among the children in our programs, including rates of wasting, underweight, stunting, and anemia (indicators for SDG Target 2.2). Our feeding data on individual children is detailed and includes indicators such as type and texture of food, positioning for meals, implements used, and instances of choking or other indicators of high-risk feeding. Through all of these metrics we gain insight into child health; caregiver knowledge, skills, and attitudes; and site-level use of best nutrition and feeding practices, which we then use to assess our impact.

We measure progress of our advocacy through outputs (publications, stakeholder meetings, digital campaigns, etc.), indicators of success (such as increased knowledge and support from our target audiences, recognition of the issue in public documents or statements, and inclusion in related advocacy platforms), and outcomes (changes in policies, programs, and investments). Due to the political and fluid nature of advocacy work, we balance a clear theory of change with dynamic pathways to create change. 

SPOON ensures that children with disabilities and children living outside of family care have equitable opportunities to be healthy, well-nourished, and stimulated as they grow. This is only possible when their caregivers are empowered and supported to provide them with nutritious diets and to feed them safely and positively. For this to be achieved, we need service providers who are well-trained and qualified in nutrition and feeding specific to the needs of these vulnerable children, quality services and tools, and an enabling policy environment guided by data and evidence. Therefore, our theory of change focuses on three interconnected implementation strategies: training, service delivery, and data generation.

Training

• Activities: Service providers receive SPOON’s training on feeding and nutrition for vulnerable children and use of Count Me In.
• Outputs: Service providers gain competency in feeding and nutrition topics, counseling best practices, and the use of Count Me In.
• Short-term outcomes: Service providers demonstrate ability to identify and address nutrition and feeding concerns for vulnerable children and to counsel their caregivers.
• Long-term outcomes: Service providers mentor and train others in nutrition and feeding for vulnerable children, enhancing national capacity.

Service delivery

• Activities: Service providers use Count Me In to assess children’s growth, anemia status, and feeding and counsel caregivers on individualized care plans generated by the app.
• Outputs: Caregivers gain competency in making appropriate nutrition choices and following feeding best practices and specialized feeding techniques.
• Short-term outcomes: Caregivers feed their children a nutritionally adequate diet using safe and responsive feeding techniques; caregivers demonstrate confidence and self-efficacy in managing their children’s nutrition and feeding difficulties and building their feeding skills.
• Long-term outcomes: Children grow and develop to their full potential.

Data generation

• Activities: SPOON and partners disseminate baseline and longitudinal nutrition and feeding data and evidence generated by Count Me In to advocate to governments, funders, and other stakeholders for changes in policy, practice, and funding for vulnerable children.
• Outputs: Governments, funders, and other stakeholders gain awareness of the need and impact of nutrition and feeding interventions.
• Short-term outcomes: Governments, funders, and other stakeholders demonstrate a commitment to including vulnerable children in policies, funding strategies, and programs.
• Long-term outcomes: Vulnerable children are prioritized and included in policies, funding strategies, and programs at national and global levels.

SPOON’s theory of change has been implemented in Zambia, our longest-running program. So far, 90 service providers from 17 facilities in Zambia have received training and implemented Count Me In. To date, 6,599 nutrition and feeding assessments were conducted on around 757 children with disabilities and 238 children living in residential care in the country. Overall, the preliminary baseline prevalence of stunting (66%), wasting (23%), underweight (58%), anemia (55%), and feeding difficulties (76%) was alarming. Over an average of 11 months, the prevalence of wasting and anemia attributed to iron deficiency decreased by 25% and 34%, respectively. Using these data, SPOON and our local partners in Zambia advocated to the Zambian Parliamentary Committee on Health, Community Development, and Social Services for increased prioritization of children with disabilities and children outside of family care in the 2019 Public Welfare Awareness Scheme and the 2020 National Food and Nutrition Bill.

Count Me In is built on a standard web framework and is served by standard cloud-based infrastructure. It employs decision-tree-based algorithms throughout in generating recommendations for the different types of assessments it uses. It incorporates Social Behavior Change-based facilitation techniques to ensure our training is contextualized, assimilated, and made actionable. 

SPOON believes that the only way we can promote equity for populations of children who have historically been excluded is to place a high value on diversity, equity, and inclusion throughout our organization. We clearly communicate to staff that we are an equal opportunity employer, we have an equal pay for equal work policy, and we give annual pay increases rather than performance-based pay increases. We have reviewed and continue to review all of our staff policies and practices with an eye to equity in order to create an environment that promotes diversity and inclusion for staff.

In 2020, SPOON prioritized becoming an anti-racist and anti-oppressive organization, starting with an equity audit by an outside organization. The goals of the audit were to analyze and evaluate the employee experience through the lens of diversity, equity, and inclusion and identify best practices that SPOON could implement to strengthen our anti-oppression and anti-racist practices, policies, and procedures.The following goals were identified, all of which have been addressed: 1) drafting a DEI statement, which will be used as a guiding principle to further support our staff, board, and community in the DEI work that we have already begun; 2) revising our hiring and board recruitment policies, including our HR manual, with a DEI lens; and 3) making our existing racial justice group (previously optional) mandatory and meaningful. Our goals for next year include comprehensive DEI training for staff and board.

SPOON’s value proposition is to 1) deliver training on feeding and nutrition for children with disabilities and those living outside of family care, 2) provide tools, including our digital health app Count Me In, to service providers around the world, resulting in improved health outcomes for vulnerable children and increased confidence of their caregivers to meet their needs, and 3) provide meaningful data that partners can use to measure progress and make a case to funders to support their work.

Key activities within our business model are the training and mentoring of service providers, which happens within discrete projects. Service providers continue to use Count Me In to independently and sustainably integrate interventions and counsel caregivers after the training phase of projects wind down. We encourage use of Count Me In after our role ends in order to ensure continued benefit for the programs as well as ongoing collection of data that can be used by both the partners and SPOON.

We partner with local organizations based in the countries where our projects take place. Revenue typically comes from a third party, such as a foundation or government grant, and is project-based. In some cases, our partners pay for projects more directly. 

SPOON relies on diverse income sources to fund our work, including individuals, institutions, government agencies, and earned income. In FY21, 41% of our income came from foundations, 30% from individuals, 16% from government, 4% from corporations, and 4% from earned income. SPOON has a sound financial track record, having met or exceeded our budgeting goals since our inception. In FY22, we began an ambitious plan to expand our revenue by identifying and pursuing prospects in each of our revenue streams (individual, corporate, foundation, government, and earned income). We are always refining our approach to fundraising, and are committed to growing all revenue streams to ensure that our programs are funded and our organization operates sustainably.

As mentioned above, SPOON has always met or exceeded budgeting goals. Noteworthy sources of funding include: the M.J. Murdock Charitable Trust ($256,000/3 years); UNICEF in Lesotho ($148,000) and Belarus ($115,000); GHR Foundation ($400,000/3 years); Happy Family Brands ($10,000); and over 10 individuals who give at the $10,000 or more level each year. We have been successful in leveraging our Board's networks, our program partnerships, and our outreach materials to gain connections to additional funding opportunities.