innovations to address nutrition specificand …mini-university.com › wp-content › uploads ›...

INNOVATIONS TO ADDRESSNUTRITION SPECIFIC AND

NUTRITION SENSITIVE INTERVENTIONS

PART I PART II

Agnes Guyon, MD, MPH

Child Health & Nutrition Advisor

John Snow, Inc.

Global Health Mini-University

4th March 2016

PART 1.

1. Global context

2. The Nutrition Specific

3. Using multiple platforms

4. Some achievements

5. Lessons learned

Presentation Overview

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

Multi-sectoralApproach

2013

ENA focuses on the

1,000 days window of opportunity


PART 1.

1. Global context




5. Lessons learned

The Essential Nutrition Actions

2013

Life Cycle Approach to Nutrition

Women’s Nutrition 1

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

Adolescents before & between pregnancies

Women’s Nutrition 2

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

During pregnancy & lactation

Infant Young Children 1

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

WHO ENA, 2013

Protect breastfeeding: • Legislation & enforcement of breastmilk

substitutes

Infant feeding in context of HIV and emergencies

From birth up to 6 months

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

Protect complementary feedingCodex Alimentarius & marketing of « baby » foods

WHO ENA, 2013

Infant Young Children 2

From 6 up to 24 months

Management of moderate & severe acute malnutrition

Nutritional care of HIV-infected children

WHO ENA, 2013

Supplementation

• Bi-annual Vitamin A (6-59 months)

• Iron/Folic Acid for three months (6-23 months)

Consumption of Micronutrient Powder (MNP)• Daily for at least two months for children 6-23 months

Malaria prevention and treatment

Infant Young

Children 3Control and prevention of micronutrient deficiencies

Treatments• Bi-annual De-worming

• Vitamin A for measles, acute malnutrition, pneumonia

• Zinc for diarrhea with oral rehydration therapy

• Iron/Folic acid for anemia


PART 1.

1. Global context




5. Lessons learned

DELIVERYDelay cord clamping, early & exclusive breastfeeding, iron/folic acid, diet

PREGNANCYDiet, iron/folic acid, de-worming, anti-malarial, iodized salt, calcium, vit A, preparation for breastfeeding

POSTNATAL AND FAMILY PLANNING Support to breastfeeding, diet, iron/folic acid, FP-LAM

WELL CHILD AND GMPMonitor growth, assess and counsel on child feeding, iodized salt

SICK CHILD & ACUTE MALNUTRITIONcounsel on infant feeding, assess and treat for anemia, check and complete vit A, de-worming, assess, treat and refer acute malnutrition

IMMUNIZATION Support to

infant and young child feeding, vit A, de-worming, assess and treat infant’s anemia

Nutrition Specific Within the Health SectorUse existing health contacts and community platforms

Increase their performance

SchoolsKeep girls at school

Children & Adolescent De-worming

Iron supplementation

AgricultureFood diversification

Food securityHomestead Food Production

Nutrition sensitive crops

Essential Hygiene Actions

Hand-washingDisposal of feces

Clean water Use of latrines

Nutrition Sensitive Across SectorsUse existing contacts to extend nutrition coverage

Community WorksCommunity Video

Community Workersacross sectors

Micro-creditvillage savings and lending

associations (VLSA)Women’s farmers clubs

Income Generating Projects

Mass mediaTV

RadioLocal broadcasting

Mhealth

Pre-service Education

Doctors, Nurses, Midwives, Teachers,

Agronomists

EnvironmentClean environment, indoor air pollution

Non-smokingPublic health education

HealthImmunization (Measles)

Delay first pregnancy and Birth Spacing

Case Management of child illnesses

Social protectionPoor of the poors

Catch Transfer


PART 1.

1. Global context




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

58

73

79 79

70

76

0

20

40

60

80

100

TIBF EBF

2011

2012

2013

%

*** p<0.001

All results significantly higher in intervention area

TIBF: Timely Initiation of breastfeeding

EBF: Exclusive breastfeeding 0-5 months

Breastfeeding practices Monthly randomized “follow-up surveys” among 2,560 households

5661

83

71

59

70

87

75

62

76

87

61

0

20

40

60

80

100

ICF6-8ms Frq6-11ms Frq12-23ms VAS6-23ms

2011

2012

2013%

All results significantly higher in intervention area

Complementary feeding practices &

Vitamin A supplementationMonthly randomized “Follow-up Surveys” among 2,560 Households

ICF: Introduction of Complementary Foods

Frq: Frequency of feeding

VAS: Vitamin A supplementation

22

Women’s micronutrient supplementation

Monthly randomized “Follow-up Surveys” among 2,560 households

%

*** p<0.001

IFAS: Iron Foclic Acid Supplementation

VAS: Vitamin A Supplementation


PART 1.

1. Global context




5. Lessons learned

• 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.

The ENA framework…

Communities(families)

•District MOH Team

•District Agric Team

•Other District Teams

•NGOs

•Hospital Administration, etc…

•CHVs, Community Leaders

•Village Model Farms

•Existing Women’s Groups

•Etc…

National

Regional

Districts

•Gov’t Planners

•Donors

•NGOs

•Academia

•Radio DJs

•Journalists

…improved advocacy leading to better

national policies, strategies and guidelines

and increased investment in nutrition

… support to community for

improved family actions on

nutrition

… strengthened health,

community & agricultural systems

for nutrition

… improved service provider

capacity through training &

supervision•Health Workers,

•Health extensions Workers

•School teachers

•Etc..

1. Work at all levels across sectorsHealth Agriculture Education Finance Trade

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

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 testedto provide insight into the needs and motivations;• Associated with images

3. Emphasize small doable actions to

demystify nutrition

• 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

4. Strengthen the systems of delivery

The delivery of specific nutrition interventions can be improved through the health sector.

… we know what to do

… we have the contacts and systems

Conclusion

Thank you

For additional information

Visit: http://jsi.com

Contact: [email protected]

http://jsi.com/

Nutrition sensitive agriculture-

HKI’s Homestead Food Production model

Victoria Quinn, PhDSenior Vice President, Programs

Mini University9th March 2016

32

NUTRITION SPECIFIC AND NUTRITION SENSITIVE

33

Ruel et. al. Lancet 2013

34

Ruel et. al. Lancet 2013

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….

To improve the nutritional status of vulnerable members of low income households through year-roundhome production of micronutrientrich crops (fruits and vegetables) and small animals, poultry and fish.

local crops and animals traditional farming practices woman farmer centered

Objective of HKI’s HFP program model

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 micronutrient-rich foods.

4. Improved health practices through linkages with local health services.

HKI’s HFP Program model … impact pathways

• 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

Characteristics of a typical HFP program

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

HKI’s HFP experiences to date…

“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 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 - Interventions

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/de-worming, 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)

50

Groups of Women Farmers

(two groups of 20 women per

VMF)

FOOD

CARE

HEALTH

HKI/Nepal’s enhanced HFP model with

FOOD-CARE-HEALTH components…

51

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

GOVERNANCE ELEMENTS

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.

VMF Development: A VMF/FCHV works on

her farm shortly after first planting

• VMF support to HFP Beneficiaries

Training of mothers Providing agriculture

inputs

•VMF also linked to government agricultural offices

AGRICULTURE KEY ELEMENTS (2)

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.

• 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

NUTRITION - KEY ELEMENTS (2)

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

Impact

Supportive supervision

Project Monitoring and Evaluation

Input Process Outputs Outcomes

HKI, NTAG, SMJK, District Health, Agriculture and Livestock Offices, District Development Committee

HKI partners with local NGOs and government

Village Model Farms (VMF) established

Small animal production established

Increased production of nutrient-rich

fruits & vegetables

HFPB groups established

Linkages to VMF, FCHVs and health

services

Agriculture inputs including seeds,

saplings and poultry

Nutrition & BCC-related education

Improved and

developed gardens

established

Increased Income

Beneficiaries understand

nutrition education

Improved child care

and feeding practices

Beneficiaries understand agriculture

training

Increased animal

source food production

Increased household

consumption

Improved maternal and child

health and nutritional

status

Agriculture-related training

Ou

tco

me

in

dic

ato

rs

Imp

act

ind

icat

ors

Pro

cess

/Ou

tpu

t in

dic

ato

rs

AAMA - Program Impact Pathways

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

OVERVIEW OF RESULTS

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

AAMA LESSONS LEARNED

Taking a step back…

Key design issues to consider in agriculture- based interventions to

improve nutrition

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

Human, Economic, and

Institutional Resources

Nutritional Status

Health Diet

Household

Food Security

Potential Resources

Ecological Conditions

Care of Mother

and Child

Environ. Health,

Hygiene & Sanitation

Political and Ideological Structure Root

Causes

Manifestations

Immediate

Causes

Underlying

Causes

Adapted from UNICEF

Conceptual Framework of Undernutrition

FOOD CARE HEALTH

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…

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

Lessons Learned – program design…

FINALLY, EVIDENCE FROM A RANDOMIZED CONTROL TRIAL!

68

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 decision-making.

• 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

TECHNICAL RESOURCES WWW.SPRING-NUTRITION.ORG

69

THANK YOU!

TECHNICAL RESOURCES WWW.SPRING-NUTRITION.ORG

innovations to address nutrition specificand …mini-university.com › wp-content › uploads ›...

Documents