INNOVATIONS TO ADDRESS NUTRITION SPECIFIC AND NUTRITION SENSITIVE INTERVENTIONS Agnes Guyon, MD, MPH Child Health & Nutrition Advisor John Snow, Inc. Global Health Mini-University 4 th March 2016 PART I PART II
Presentation Overview PART 1. 1. Global context 2. The Nutrition Specific 3. Using multiple platforms 4. Some achievements 5. Lessons learned
High-Impact Nutrition Interventions Evidenced Based Direct Interventions to Prevent and Treat Undernutrition Promoting good nutritional practices: 1. breastfeeding 2. complementary feeding for infants after the age of six months 3. improved hygiene practices including handwashing Increasing intake of vitamins and minerals: Provision of micronutrients for young children and their mothers: 4. periodic Vitamin A supplements 5. therapeutic zinc supplements for diarrhoea management 6. multiple micronutrient powders 7. de-worming drugs for children (to reduce losses of nutrients) 8. iron-folic acid supplements for pregnant women to prevent and treat anaemia 9. iodized oil capsules where iodized salt is unavailable Provision of micronutrients through food fortification for all: 10. salt iodization 11. iron fortification of staple foods Therapeutic feeding for malnourished children with special foods ($6.2 billion): 12. Prevention or treatment for moderate acute malnutrition 13. Treatment of severe under-nutrition ( severe acute malnutrition ) with ready-to-use therapeutic foods (RUTF). 2010
2013 Multi-sectoralApproach
ENA focuses on the 1,000 days window of opportunity
Presentation Overview PART 1. 1. Global context 2. The Nutrition Specific 3. Using multiple platforms 4. Some achievements 5. Lessons learned
The Essential Nutrition Actions 2013
Life Cycle Approach to Nutrition
Women s Nutrition 1 Adolescents before & between pregnancies Promote & support key practices Diversified diet and appropriate amount Provide micronutrient supplementation Iron/Folic acid supplementation and treatment of anemia De-worming WHO ENA, 2013
Women s Nutrition 2 During pregnancy & lactation Promote & support key practices: Increase food and micronutrient intakes Consumption of iodized salt Supplementary feeding Prevention of malaria - Insecticide-treated bed nets (ITNs) Control & prevention of micronutrient deficiencies: Supplementation (Iron/Folic Acid, Vitamin A, Calcium) Treatment (Anemia, de-worming, intermittent preventive treatment of malaria) Women s nutrition in the context of HIV and emergencies WHO ENA, 2013
Infant Young Children 1 From birth up to 6 months Protect breastfeeding: Legislation & enforcement of breastmilk substitutes Promote & support key practices: Immediate initiation of breastfeeding Exclusive breastfeeding until six months Correct positioning & attachment Breastfeed day and night at least 10 times Empty one breast before switching to the other (Fore milk vs hind milk) Timely cord clamping Infant feeding in context of HIV and emergencies WHO ENA, 2013
Infant Young Children 2 From 6 up to 24 months Protect complementary feeding Codex Alimentarius & marketing of «baby» foods Promote & support of key practices Continue breastfeeding for two years & beyond Frequency Amount Diversity fruits, vegetables, animal source, fortified foods (iodized salt) Density from mashed to family food Utilization of handwashing, clean water, clean food & utensils Active feeding Increase breasfeeding and feeding during and after illnesses Management of moderate & severe acute malnutrition Nutritional care of HIV-infected children WHO ENA, 2013
Infant Young Children 3 Control and prevention of micronutrient deficiencies Consumption of Micronutrient Powder (MNP) Daily for at least two months for children 6-23 months Supplementation Bi-annual Vitamin A (6-59 months) Iron/Folic Acid for three months (6-23 months) Treatments Bi-annual De-worming Vitamin A for measles, acute malnutrition, pneumonia Zinc for diarrhea with oral rehydration therapy Iron/Folic acid for anemia Malaria prevention and treatment WHO ENA, 2013
Presentation Overview PART 1. 1. Global context 2. The Nutrition Specific 3. Using multiple platforms 4. Some achievements 5. Lessons learned
Nutrition Specific Within the Health Sector Use existing health contacts and community platforms Increase their performance PREGNANCY Diet, iron/folic acid, deworming, anti-malarial, iodized salt, calcium, vit A, preparation for breastfeeding DELIVERY Delay cord clamping, early & exclusive breastfeeding, iron/folic acid, diet POSTNATAL AND FAMILY PLANNING Support to breastfeeding, diet, iron/folic acid, FP-LAM WELL CHILD AND GMP Monitor growth, assess and counsel on child feeding, iodized salt IMMUNIZATION Support to infant and young child feeding, vit A, de-worming, assess and treat infant s anemia SICK CHILD & ACUTE MALNUTRITION counsel on infant feeding, assess and treat for anemia, check and complete vit A, de-worming, assess, treat and refer acute malnutrition
Nutrition Sensitive Across Sectors Use existing contacts to extend nutrition coverage Schools Keep girls at school Children & Adolescent De-worming Iron supplementation Health Immunization (Measles) Delay first pregnancy and Birth Spacing Case Management of child illnesses Agriculture Food diversification Food security Homestead Food Production Nutrition sensitive crops Social protection Poor of the poors Catch Transfer Essential Hygiene Actions Hand-washing Disposal of feces Clean water Use of latrines Micro-credit village savings and lending associations (VLSA) Women s farmers clubs Income Generating Projects Community Works Community Video Community Workers across sectors Mass media TV Radio Local broadcasting Mhealth Pre-service Education Doctors, Nurses, Midwives, Teachers, Agronomists Environment Clean environment, indoor air pollution Non-smoking Public health education
Presentation Overview PART 1. 1. Global context 2. The Nutrition Specific 3. Using multiple platforms 4. Some achievements 5. Lessons learned
Four regions in Ethiopia - more than 35 million Nutrition is one component among a comprehensive mix of maternal and child health interventions Embedded into the government system Behavior change communication as a back bone
100 80 % 70 Breastfeeding practices Monthly randomized follow-up surveys among 2,560 households 76 All results significantly higher in intervention area 79 79 73 60 40 58 2011 2012 2013 20 0 TIBF EBF TIBF: Timely Initiation of breastfeeding EBF: Exclusive breastfeeding 0-5 months *** p<0.001
100 Complementary feeding practices & 80 60 40 % 20 Vitamin A supplementation All results significantly higher in intervention area Monthly randomized Follow-up Surveys among 2,560 Households 87 87 83 75 76 71 70 61 62 59 61 56 2011 2012 2013 0 ICF6-8ms Frq6-11ms Frq12-23ms VAS6-23ms ICF: Introduction of Complementary Foods Frq: Frequency of feeding VAS: Vitamin A supplementation
Women s micronutrient supplementation Monthly randomized Follow-up Surveys among 2,560 households % IFAS: Iron Foclic Acid Supplementation VAS: Vitamin A Supplementation *** p<0.001 22
Presentation Overview PART 1. 1. Global context 2. The Nutrition Specific 3. Using multiple platforms 4. Some achievements 5. Lessons learned
The ENA framework pulls together existing vertical programs in a sensible 'action-oriented' way; greatly expands coverage of nutrition specific interventions to multiple health contacts and community platforms; and provides a practical tool to train service providers and community workers.
1. Work at all levels across sectors Health Agriculture Education Finance Trade Communities (families) National Regional Districts Gov t Planners Donors NGOs Academia Radio DJs Journalists District MOH Team District Agric Team Other District Teams NGOs Hospital Administration, etc Health Workers, Health extensions Workers School teachers Etc.. CHVs, Community Leaders Village Model Farms Existing Women s Groups Etc improved advocacy leading to better national policies, strategies and guidelines and increased investment in nutrition strengthened health, community & agricultural systems for nutrition improved service provider capacity through training & supervision support to community for improved family actions on nutrition
2. Build on what already exists at all levels Existing systems & interventions partners, donors, NGOs, associations, institutions, etc Multiple health contacts and community platforms Traditional community groups & systems, home visits, community meetings and events, Inter-personal communication, group events, and mass media
3. Emphasize small doable actions to demystify nutrition Short and practical training on ENA Build technical and counseling skills to improve delivery of nutrition encourage the adoption of practices. Messages are: Simple, specific, action-oriented, adapted to local context and tailored to the life cycle; From formative research and field tested to provide insight into the needs and motivations; Associated with images
4. Strengthen the systems of delivery Make available standard job aids, guidelines and references Follow training with supportive supervision using a standard checklist Initiate performance review meetings Ensure logistics (Vit A, IFA, Iodized salt, RUTF, Food Availability & Access) Monitoring and Evaluation
Conclusion The delivery of specific nutrition interventions can be improved through the health sector. we know what to do we have the contacts and systems
Thank you For additional information Visit: Contact: http://jsi.com agnes_guyon@jsi.com
Mini University 9 th March 2016 Nutrition sensitive agriculture- HKI s Homestead Food Production model Victoria Quinn, PhD Senior Vice President, Programs
NUTRITION SPECIFIC AND NUTRITION SENSITIVE 32
Ruel et. al. Lancet 2013 33
Ruel et. al. Lancet 2013 34
EXAMPLES OF DELIVERY PLATFORMS FOR ENA
EXAMPLES OF DELIVERY PLATFORMS FOR ENA
EXAMPLES OF DELIVERY PLATFORMS FOR ENA agriculture (homestead food production) child survival programs safe motherhood/family planning school health programs emergency activities micro-credit for women etc.
Objective of HKI s HFP program model To improve the nutritional status of vulnerable members of low income households through year-round home production of micronutrient rich crops (fruits and vegetables) and small animals, poultry and fish. local crops and animals traditional farming practices woman farmer centered
HKI s HFP Program model impact pathways 1. Increased availability of micronutrient-rich foods through increased household production of these foods. 2. Increased income (assets) through the sale of surplus production. 3. Increased nutrition knowledge and adoption of optimal nutrition practices including consumption of micronutrientrich foods. 4. Improved health practices through linkages with local health services.
Characteristics of a typical HFP program HKI works through local NGOs 3-year project cycle Selection of a Village Model Farmer (VMFs)or Farmer Field School (FFS) (demonstration plots) Create mother groups around the VMFs or FFS so women can learn improved farming techniques along with improved nutrition practices (e.g. support to ENA) Strong focus on FOOD + CARE + HEALTH in design
HKI s HFP experiences to date Where? Since 1990, now in 6 countries in Asia: Bangladesh, Cambodia, Indonesia, Nepal, Philippines and Vietnam. Now being adapted to Africa (different challenges!) Coverage? Cumulative to-date more than 1.25 million families reached (e.g. majority in Bangladesh) Who? Primarily target women farmers from poorer households How? Constantly improving HFP model with lessons learned
Action Against Malnutrition through Agriculture (AAMA) Project in Nepal
AAMA Project Undernutrition is significant in Nepal 49% stunted, 39% underweight and 13% wasted 25% of mothers are undernourished and 42% of pregnant women are anemic Before project started, national efforts mainly focused solely on addressing micronutrient deficiencies. Little focus on multi-sector actions to address causes of malnutrition
AAMA Project 4 year USAID funded Child Survival Grant (2008-2012) Implementation Districts: 4 districts Pilot project Implementation partners: Local NGOs Ministry of Health Ministry of Agriculture
AAMA - Program objectives Improve household food security and nutritional status of children under 2 years and their mothers Improve governance capacity within agriculture and health to strengthen multi-sectoral coordination for the joint identification, analysis and planning of nutrition and food security initiatives A young child having only rice in her meal.
AAMA - Program Beneficiaries Mothers and children under two (n=~13,500 HHs) Village model farms (n=360) Female community health volunteers (n=~1600) Government counterparts in agriculture and health sectors
AAMA - Interventions AAMA model built on Nepal s highly successful Female Community Health Volunteer (FCHW) program, introduces incentives to sustain their motivation Village Model Farm served as program platform to provide women beneficiaries with (1) agricultural training and (2) nutrition behavior change support (e.g. ENA) HKI s goal was to test whether model worked and if there was scope for expansion across Nepal A Village Model Farmer feeding her poultry
AAMA - 3 clusters of interventions 1. Homestead Food Production (HFP) Agriculture production Family consumption Income generation from sales of surplus 2. Essential Nutrition Actions (ENA) breastfeeding, complementary feeding, maternal nutrition, VAD, IDA/deworming, nutrition for sick child, Iodized salt 3. Behavior change communication cut across both agriculture and nutrition components Formative research 2-3 priority behaviors with focus on small do-able actions to start with Training in inter-personal counseling & negotiation skills Monthly VMF meetings and follow-up Development/use of IEC materials (e.g. job aids, flip charts)
HKI/Nepal s enhanced HFP model with FOOD-CARE-HEALTH components Groups of Women Farmers (two groups of 20 women per VMF) HEALTH FOOD CARE 50
GOVERNANCE ELEMENTS Reinforced government s strategy for multisectoral planning and collaboration to reduce malnutrition, including multisectoral nutrition plan National, regional and district planning workshops defined joint objectives and areas for integration VMFs were integrated into extension system District-level nutrition & food security working groups formed Recognized synergies and potentials between Agriculture, Health, Local Government 51
AGRICULTURE KEY ELEMENTS (1) Training NGO Master Training (10 days) VMF Training (3 days) Land usage/management Crop selection/diversity Animal husbandry/mgmt ENA principles Gender principles HFP Beneficiary Training (e.g. for mothers) (1 day) Agricultural inputs for VMF and beneficiaries Improved seeds Improved breeds poultry Improved-breed chickens are reared to focus on egg production. Chickens are brooded for 8 weeks, vaccinated and then distributed.
AGRICULTURE KEY ELEMENTS (2) VMF support to HFP Beneficiaries Training of mothers Providing agriculture inputs VMF also linked to government agricultural offices VMF Development: A VMF/FCHV works on her farm shortly after first planting
NUTRITION - KEY COMPONENTS (1) Formative Research Research conducted to identify beliefs, and constraints to improved practices Identify key messages NGO Master training on ENA/BCC FCHV/VMF Training on ENA Optimal breastfeeding Optimal complementary feeding. Nutritional care of the sick child Maternal nutrition Hygiene Counseling and negotiation skills Linkages with HFP activities A VMF/FCHV discusses ENA and doable actions with her HFPBs.
NUTRITION - KEY ELEMENTS (2) FCHV Training on BCC Small do-able actions Counseling and negotiation skills to convince mothers to adopt new practices FCHV Discussion with HFP Beneficiaries (mothers) Monthly meetings at VMF Home visits Links to health services, other projects Vitamin A supplementation Maternal iron supplementation A target mother feeding her children vegetables from the garden
AAMA MONITORING AND EVALUATION Evaluation Design: Baseline and endline surveys On-going Project Monitoring: Conducted by NGO and government partners every 6 months Various Methods: Lot Quality Assurance Sampling (LQAS) Qualitative assessments GIS mapping Tools: Structured questionnaire Observation checklists VMF register and HFP beneficiary register
Process/Output indicators Outcome indicators Impact indicators AAMA - Program Impact Pathways HKI, NTAG, SMJK, District Health, Agriculture and Livestock Offices, District Development Committee Input Process Outputs Outcomes Impact HKI partners with local NGOs and government Agriculture inputs including seeds, saplings and poultry Village Model Farms (VMF) established HFPB groups established Linkages to VMF, FCHVs and health services Supportive supervision Agriculturerelated training Nutrition & BCC-related education Improved and developed gardens established Small animal production established Beneficiaries understand agriculture training Beneficiaries understand nutrition education Increased production of nutrient-rich fruits & vegetables Increased animal source food production Increased Income Increased household consumption Improved child care and feeding practices Improved maternal and child health and nutritional status Project Monitoring and Evaluation
OVERVIEW OF RESULTS
OVERVIEW OF RESULTS Significant differences detected in each stage of the program impact pathways especially related to increased production, consumption and income. Significant improvements in maternal and child feeding practices and health seeking behaviors No significant reduction in child stunting, wasting or underweight Borderline reduction in child anemia Significant reduction in maternal underweight and anemia
AAMA LESSONS LEARNED Lengthy project start up process and short project length limited exposure window Other key determinants of child growth need much more attention especially water, hygiene and sanitation Design of USAID s bilateral nutrition project, Suaahara I (2011-2015) was directly informed by AAMA lessons. Much greater focus on hygiene, gender, social equity and coverage across country
Taking a step back Key design issues to consider in agriculture- based interventions to improve nutrition
REVIEWS ON IMPACT OF AGRICULTURAL INTERVENTIONS ON NUTRITION OUTCOMES 62
REVIEWS ON IMPACT OF AGRICULTURAL INTERVENTIONS ON NUTRITION OUTCOMES programs promoting home gardening and animal production are likely to increase production, may increase household consumption and individual intake, but may have little to no effect on children s nutritional outcomes unless their nutritional inputs are revisited and strengthened. Jef Leroy et. al. 2008 We attribute the lack of impact of agricultural interventions on child nutrition to methodological weaknesses of the studies reviewed rather than specific characteristics of these interventions. E. Masset et. al. 2011
Conceptual Framework of Undernutrition Nutritional Status Manifestations Diet Health Immediate Causes Household Food Security Care of Mother and Child Environ. Health, Hygiene & Sanitation FOOD CARE HEALTH Underlying Causes Human, Economic, and Institutional Resources Political and Ideological Structure Ecological Conditions Root Causes Adapted from UNICEF Potential Resources
REVIEWS ON IMPACT OF AGRICULTURAL INTERVENTIONS ON NUTRITION OUTCOMES Lack of consistent effects on nutrition likely due to: Inadequate program design (e.g. not enough attention to FOOD, CARE and HEALTH) Methodological weaknesses in M/E design (e.g. weak control, inadequate sample sizes, ) Difficult to design, implement and finance randomize control trials for agriculture programs with nutrition outcomes High cost of evaluation studies
Lessons Learned and Take Home Messages
Lessons Learned program design aspects of FOOD and CARE and HEALTH must be addressed strong links needed with local health services important strong behavior change communication, based on formative research, critical across ENA and HFP actitivies for adoption of new practices more attention needed on water, sanitation and hygiene for nutrition outcomes (informed design of current Suaahara project) plan to have adequate time for exposure to project interventions during 1,000 day window for results on nutrition outcomes (e.g. child growth) investment in strong M&E system
FINALLY, EVIDENCE FROM A RANDOMIZED CONTROL TRIAL! HKI and IFPRI tested EHFP AAMA style model in the Sahel using gold-standard randomized control trial. After 2 years: women increased their weight and improved their social status and role in household decisionmaking. prevalence of anemia in infants aged 3-6 months decreased by 15% prevalence of wasting (being too thin) among children 3-12 months reduced by 9% diarrhea (which can lead to wasting) reduced by between 10-16% Results published J of Nutr June 2015 First time ever we now have scientific evidence! Other RCT studies current in process 68
TECHNICAL RESOURCES WWW.SPRING-NUTRITION.ORG 69
TECHNICAL RESOURCES WWW.SPRING-NUTRITION.ORG THANK YOU!
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