Transcript Health nutrition and development

Supporting families for child well-being. The role of
community nurses and home visiting outreach services
Ankara, 14-17 May, 2012
ECD, the most important
equalizer: supporting child
well-being at the household
level
Giorgio Tamburlini MD PhD
European School for MNCAH
UNICEF Consultant
Why invest in interventions at
household level?
“Community-based interventions are
generally more equally distributed than
service-based interventions, which indicates
that additional efforts are needed to reach
the poorest with such interventions”
AJD Barros et al. Equity in MNCH: review of survey data
from 54 countries, Lancet, April 2, 2012
Why invest in early childhood
nutrition and development?
 Increasing knowledge on the importance
of early experience and nutrition on the
architecture of the developing brain
 Evidence on benefits of early
interventions for school performance,
social outcomes, and overall societal
development
Shonkoff, J et al. . The Science of Early Child
Development. Harvard Center for the Developing
Child and National Scientific Council 2007
ECD: a powerful equalizer
“A more comprehensive approach to
early life is needed, building on
existing child survival programmes
and extending interventions in early
life to include social/emotional and
language/cognitive development.”
WHO Commission on Social Determinants of Health
(2008)
Maximal growth in brain function:
the critical time is first 2-3 yrs.
The 2011 Lancet series
• Reviews new evidence on:
– causes of developmental inequality
– effective interventions to promote young child
development
• Provides evidence to set priorities for ECD policies
and to design effective programmes to reduce
inequalities
• Estimates the cost of not investing in early childhood
programmes
New evidence from the Lancet
series: biological risks
• Further evidence for key biological risks: chronic
undernutrition, iron and iodine deficiency
• Three additional biological risks:
– intra-uterine growth restriction
– severe and/or repeated malaria attacks
– HIV infection
New evidence from the Lancet
series: psychosocial risks
• Lack of learning opportunities and poor quality
caregiver-child interaction – major risk for poor
development
• Three additional psychosocial risks:
– maternal depression
– exposure to societal violence
– institutional rearing
New evidence from the Lancet
series: protective influences
• New evidence identifies protective influences which
promote child development
– breast feeding
– responsive caregiver-child interaction
– opportunities for young children to play and learn
– maternal education
New evidence from the Lancet
series: returns on investment in
early childhood are substantial
• Early childhood is the most effective and costefficient time to ensure that children can benefit
from school and later opportunities.
• Investment in ECD programmes to reduce risks and
support development can break the cycle of inequity
faced by children and their families
The pathways of development of
inequality
New evidence from the Lancet
series: the good news
• We can reduce inequality by addressing multiple risks
children face
• Interventions can effectively reduce developmental
delays, particularly if interventions are early, of high
quality, community based, and integrated
Parents play a crucial role
..by providing food, protection, interaction and care: some
of them have not or were not given the capacities to do so
Parents may not fully recognize their needs or may not be
informed about their rights or may not be empowered to
make decisions about themselves and their children
To help children reaching their full physical mental and
emotional potential we need to work with parents and to
reach out for them if they cannot/are not able to access
the services and if services are not able to talk with them
and provide cultural appropriate advice
Parental role is based on interaction
The “Serve and return” effect
 Brain
requires
responses
for synaptic
growth
 1-way
stimulation
is not
enough
What is Parental Responsivity?
Sensitive to infant cues
Prompt, developmentally
appropriate response to infant
cues
Interaction and play: ancient models
Interventions for parents and
families
• Interventions that improve parents’ ability to provide
stimulation and quality interaction
• Provided through home visits, guidance and support
from health providers, and group parent training
• Can be delivered by para-professionals
New evidence from the Lancet
series: parenting interventions
• Impacts are larger when:
– both parents and children participate
– interventions involve modeling and practice of
behavior.
– most disadvantaged children targeted
New evidence from the Lancet series:
early childhood education interventions
• For children 3 years and older centre-based
programmes (preschools) are appropriate and effective
in improving children's cognitive and social-emotional
development and school readiness
• Community-based programmes benefit development
and improve opportunities for families to take
advantage of the existing services, and promote
demand for them
How to promote responsive and
interactive parenting
Example 1: Responsive Feeding
Not only what the child is fed – but
HOW the child is fed can:
 increase how much the child eats
 increase language and socioemotional learning
 helps child learn autonomy
Example 2. Incorporating Care for
Development in IMCI. Evaluation in
Central Asia
 Did health workers make more
recommendations on play and
communication?
 Did families do different activities?
 Did children perform better
Tajikistan and Kyrgyzstan
HW Gave significantly more Care for
Development recommendations in all 3
countries.
% recommend looking at child and smiling
% recommend giving ojbects for play
100
100
80
60
Series1
40
Series2
20
percent
percent
80
60
Series1
40
Series2
20
0
Kazakhstan
Tajikistan
Kyrgyzstan
0
Kazakhstan
percent
% recommend colorful objects for child to see and
reach for
70
60
50
40
30
20
10
0
intervention
Control
kazakhstan
Tajikistan
Kyrgyzstan
Tajikistan
Kyrgyzstan
More intervention mothers than control
tried out “new activities” with the child in
all 3 countries
60
percent
50
*
40
30
20
*
*
10
0
Kazakhstan
Tajikistan
Intervention
Kyrgyzstan
Control
Kyrgyzstan question is “how often” ; others are “last week”
Tajikistan: intervention children scored
significantly higher at 0-12 and 13-37
months.
Differences in Child Scores by
Intervention Group in Kyrgyzstan for
children 4-36 months
53
52
51
50
P<.0
08
*
P<.0
06
49
48
Interventi
on
Control
47
46
45
44
43
42
N= 234 for Intervention, 144 for control; Ages and
Supporting home visits with
materials for parents
leaflets

examples
nutritional supplements
books

Communication materials combined ECD
and sprinkles
Materials for community
volunteers
Materials for parents – 10
recommendations from Care for
Development
Each
child
received
a book
Offering services is not sufficient!
We need also to reach out for those who for
various reasons do not access services, or
are excluded from services
We need also take action to support
demand for services, including for ECD
Underlying determinants: barrier to
access
Percentage of women receiving no antenatal care
by education in Armenia (2005)
Source: Trends in maternal mortality: 1990 to 2008. Estimates developed by
WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization,
2010
Barriers to access. Women not assisted
by a skilled attendant skilled attendant at
delivery: those left out
(MICS
Database)
Beyond averages: disadvantaged and discriminated
population groups
Reasons for not visiting a doctor in spite of feeling sick among the Roma
Supply
factors
Demand factors
Source: EDIS S.S., European Survey on Health and the Roma Community, 2009
MDG 3, 4 and 5: the crucial links
Adolescent health
MDG 6
HIV/AIDS
MDG 5
Maternal
health
Reproductive
health
MDG 4
Child
Health
MDG 3
Gender equality
and women’s empowerment
MDG 1 and 2
SE status and education
At the roots of inequity in health outcomes:
why the poor and discriminated have
worse outcomes
• Increased exposure and
vulnerability to risk factors
(WASH, nutrition, hazardous
working conditions etc.)
Social determinants
• Low demand: SES, women’s
status, education and cultural
factors
• Service delivery issues:
- Barries to access
- Worse quality of care
Health system
issues
The challenges: action at three levels
3. Action to implement effective
service delivery and interventions
at family and community level
and health facility level
along the continuum of care
Health
facilities
Family and
community
2. Action on health systems functions:
Governance
Creating Resources
Service Delivery
Information System
1. Cross sectoral action to
address the main determinants
of MCH:
Nutrition
Gender equality
WASH and safe
environments
Health
systems
Government
policies and plans
Action at the basis of the pyramid affects underlying determinants of
health and has sustained long term effects
Action on the top of the pyramid has short term effects and needs to be
supported by action to strengthen health systems
ECD, equity and community-based
interventions
• Reaching out for all households and paying
particular attention to reaching out for those
most in need is crucial to promote ECD in an
effective and equitable way
• The health sector can play a fundamental
role in facilitating this and making this
possible
Summary
 ECD is a critical component of
interventions to promote health,
wellbeing and achieve equity
 Parents play a crucial role particularly
in the first years and need to be
supported in their role
 Community-based services including
reach out for those most in need are
the most effective way to improve
ECD