P1.2. Pathways to household nutrition in Asia-Pacific region


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Helen Keller International

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  • This conference is taking place in part in the context of renewed global investment in three interlinked pathways to development: Agriculture, nutrition, and gender equality. These are obviously synergistic development pathways, and this investment climate and political will brings great opportunities and partnerships to develop effective, gender-transformative, nutrition-sensitive agriculture approaches. HKI has a long practical history of integrating these sectors, in our program- and project-based models. This conference aims for broader, at-scale, systemic approaches to multi-sectoral collaboration, but our on-the-ground experience may give some useful insights for expanding partnerships and research agendas.
  • HKIsit at the intersection of agriculture and health/nutrition sectors, and straddles research and implementation. We are known for establishing rigorous data systems (nutrition surveillance), and we partner frequently with IFPRI and other CGs to generate evidence-based models. We have four core issues in Asia (Vit. A, IYCF, women’s nutrition, and food-based nutrition—homestead gardens.)Our agriculture-based models for nutrition developed to address micronutrient deficiencies, but we have been expanding into broader food security and livelihoods models, as we explore different approaches to support women farmers along the income pathway while not losing the nutrition outcomes that are core to our programs. Whether it’s through an agriculture program, mainstreaming nutrition into the health system, or developing a surveillance system to collect food security and nutrition data for policy makers, the aim is to build the sustainable structures and capacities to provide nutrition services and meet nutrition problems. Creating a supportive environment for nutrition means making the linkages and breaking down the barriers between sectors to build nutrition-sensitive communities; and addressing the underlying causes: specifically, and especially in South Asia, gender inequalities. I will just provide a few localized examples/case studies of how we are working to build locally-owned nutrition capacities and services; and creating an enabling environment—specifically through addressing gender equity issues—for nutrition.The last points—on the issue of scalable models and building the evidence base—bring us to the question of partnerships with others in this field and in the research community.
  • HKI has been working on nutrition-focused agriculture in Asia for about 30 years. Specifically, agriculture support for improved micronutrient intake—to correct Vitamin A deficiency and prevent night blindness and nutritional blindness. Along the say, the program has evolved, and has many variations in different contexts. The core is: the measurement of nutrition outcomes (dietary diversity, anthropometry, food security), and nutrition education is central to every intervention.The first and critical step in establishing any food-based program is that of establishing the institutional links—partnering with the local NGOs, local governments –health, agriculture, livestock—and the agriculture research station. We intervene to fill a service gap (lack of nutrition knowledge, poor seed supply, lack of extension services), but we aim to leave the underserved population (smallholder women farmers) with sustainable links to obtain agriculture, market, nutrition services.
  • We set up the demo farms (initially) to address dearth of extension services, particularly catering to women smallholders. But we want to link women (excluded and not recognized by the government) to the government services; and the demo-farm system is also a pathway to sensitize the agriculture system about nutrition AND about needs of women farmers. We always invite livestock services to trainings; in part because they know that the community-based vaccinators provide a valuable service in minimizing disease. We provide the names of our demo farmers to the Dept. of Ag., and link our farmers to seed suppliers, so that there are lasting networks. We work with the Department of Health—often providing the institutional support to help them integrate nutrition into their services. Depending on the local context, we may work through the health volunteers as demo farmers, or we may set up new demo farmers. We make the link between them and the extension services. The most systematic model of institutional integration we have is a governance approach in Nepal. Thanks to decentralization, we were able to work with the Ministry of Local Development to link the Health and Agriculture departments, and built capacity and consensus down to the Village Development committee level. VDCs were able to access block grants to address community issues. The project helped build the capacity to set nutrition and food security priorities, and to secure funds toward food security and nutrition priorities. In this project, the link between the health and agriculture sectors was also cemented by selecting Village Health Workers as the demonstration farmers, who receive and provide agricultural training on home gardening and poultry as well as nutrition. Collaboration:DADO trained to AAMA village model farmers (VMFs) in mushroom cultivation, supported groundwater irrigation systems DLSO provided poultry vaccination training to VMFs HFs provided refresher ENA to VMFs VDCs provided funds for vegetable seeds, poultry, vaccinations, chicken coops, bio-pesticide drums, ENA/HFP training to women
  • What this project achieved was a model for practical multi-sectorial work, and shared responsibilities for nutrition and agriculture. The committees established by the project were absorbed into the government systems . And the AAMA model has also been taken up and held by USAID as a model for other ag programs (for instance,within Feed the Future). We are not always able to institutionalize to this level, but it is always critical to directly link women to the agriculture services AND the health services. Our interventions are a catalyst; in many programs we need to build the capacity of the health services to address nutrition. Community-based vaccinators: Able to get vaccine supply from DLS; provide a service to the DLS, and also earn a livelihiood.
  • “Several reviews examining the potential for agriculture programs and food-based strategies to improve nutrition have highlighted the importance of explicit nutritional objectives and nutrition education activities—specifically as behavior change communication (BCC)—to affect positive nutrition outcomes (Ruel 2001; Berti et al. 2004; World Bank 2007). “There are millions of good materials out there, and improved sharing among organizations within countries. It takes time to develop quality materials, so sharing helps get consistent messages.What is more critical is the investment in the facilitation skills that enable staff to lead these type of BCC activities, or counseling skills. “Messaging” persists because it is easier to deliver, and requires less training investment—even though behavior change science tells us that knowledge does not translate to action. The question about scale-up is that it often dilutes the quality and duration of the training. Where and through what channels to invest the intensive training within the ag sector is a question, but it is unequivocal that increased production of nutritious foods will not translated into improved consumption practices without a BCC strategy. With IYCF practices in particular, counseling is critical. Not likely to be delivered through ag channels or staff, but have used cooking demonstrations, which can be combined with agricultural fairs. Above, a group of grandmothers have a ball playing a game of ludo modified to teach helpful /harmful behaviors around antenatal and breastfeeding care. It emphasizes mother-in-law support of household work for the mother, so that she can breastfeed.
  • One year, $100,000. Heavy investment in training—Master trainers, then trainers of the project, then every cadre of worker coming into contact with pregnant women or mothers. Duration of training depended on the level of contact with the mothers—those who had more direct contact got longer days of training; those with less direct contact, a 1-day training. Did re-training and incorporated supervisory tools and supervision training. Used a participatory curriculum that included games, role-plays, talked intra-household issues. Etc. Growth impacts accelerated after completion of the training period. Obviously, don’t expect a nutrition extension worker to be delivering breastfeeding counseling, but when we consider costs of intervention, also have to consider the intensity of the benefit. And when we scale up, we often water-down—and may lose the impact.
  • The ag community thinks that BCC—and certainly breastfeeding—as a public-health intervention, but would like to share the process of developing an integrated, community-level BCC strategy, which illustrates how we identify entry points and channels for practical integration of nutrition and agriculture and gender. A participatory process initiated at the start of a new agriculture-based project in Indonesia. Here, the problems were very high seasonal food insecurity, very un-diverse diet (corn-based, many food taboos), lack of water, and very poor exclusive breastfeeding practices, especially after 3 months. Working with the field staff (both agriculture and nutrition specialists, from the partner NGO and from HKI) at the outset, we designed a two-week integrated gender /livelihoods analysis, with the purpose of developing an integrated gender-ag-nutrition communications strategy that would include the whole family. Staff had one week training staff (on communications, PRA tools, and nutrition), and two weeks in the field. The main behavior that we wanted to focus on were Exclusive breastfeeding and dietary diversity, but the tools used were: Seasonal calendar (to understand agricultural year and time constraints); body maps to explore perceptions of health and nutrition; we used food card sorting to understand food taboos and find acceptable alternatives; used drawings to explore good fatherhood and motherhood perceptions and how they viewed proper child development (see above).Project: Kraft (donor) and WFP (partner); four-year aims to improve dietary diversity and IYCF practices.
  • What we found is that in this communities, the breastfeeding practices had a lot to do with the agriculture calendar. Women were pressured to return to the fields at three months, so we strove to build a strategy that would also more directly integrated nutrition practices and agriculture production practices. There was very strong support from family members (including husbands) around the birth period, but at around three months, women were expected to return to the fields, which were far from the homes, and left the babies with the grandmothers. Most women wanted to continue breastfeeding but couldn’t; and it was particularly difficult during the harvest period, when they had to do regular work, plus harvest work, plus cooking for the neighborhood families who came to help with the harvest work.And grandmothers (both sides) werevery influential and saw the grandchild as their own responsibility—but had never received any information from the health services, which targeted women only. Also, there was a very punitive approach to breastfeeding here—women were actually being fined for not breastfeeding or not delivering in the hospital, which was very discouraging.On the other side, there were very strong support groups through the church systems, and there were was an ethic of “laismanekat,’ or ‘let’s all care for each other,” which explains how help is organized during disasters—and during the harvest period. Neighborhood committees organize labor support during this period, so that all families get enough labor.So the strategy here was to build off these positive support systems, but to reposition breastfeeding as a valuable caring labor, and as a family investment in the future. Build off that good-fatherhood image, and the workload sharing that goes on during the first months of birth, but help extend it through six months. And to establish special support systems during that harvest period, when pressures are greatest.Developed new parent support groups (mothers, fathers, AND grandmothers) through the church groups; developed a tool—birthing calendar—where they could track the child’s development AND the family members’ workload-sharing contributions. And rather than punishing them for not breastfeeding, through the support groups, the calendars would be used to track all the days when they had succeeded and to identify when they needed further help. For the harvest period, the strategy is to work with the neighborhood committees, to make sure that when allocating support for this period, there’s also support for child-feeding, and that women who are exclusively breastfeeding get time to do that.Rewards and celebrations: To build incentives, the strategy is to work with the community leaders, to reward “most-helpful husband” at the end of the harvest season; worked with the agriculture fair system to establish joint nutrition-agriculture celebrations, where families have cooking/receipe competitions—using diverse, home produce—and also give opportunities for demonstrations on child feeding, use of iodized salt, etc. the rules were that all family members had to be involved in the preparation, had to be nutritious (use go-glow-and grow-foods), and that all ingredients had to be locally available.They seemed to love competition, so these would be scaled up to regional and District-wide competitions, which would also engage the media as a tool. The media is important, because it normalizes this practice of breastfeeding as a family commitment, and the idea of nutrition-and agriculture being interlinked. It gives an opportunity to celebrate women’s farming achievements and men’s caring contributions at the same time—and to scale them up through the publicity.
  • Which brings us to the last but one of the most important points, which is the importance of addressing the disempowering gender norms in order to empower women in agriculture and as caregivers and as self-care-givers. The evidence is solid and growing about the link between gender inequality and malnutrition –and, conversely, the link between women’s autonomy and improved nutrition outcomes. Addressing gender norms and behaviors and attitudes (around work, care, power) are crucial, because women don’t make decisions in isolation, and are often disempowered by threats of violence and power structures in the house and in the community. It takes concerted effort and long-term commitment to address the norms and structures and bring about institutional changes that build women’s autonomy. Gender inequality seems to account for “Asian enigma” of high malnutrition despite agricultural growth Violence against women (VAW), correlated with malnutrition and higher rates of child anemia Secondary education of women correlates with reduced child stunting (FSNSP)Women’s autonomy associated with positive nutrition outcomes, including reduced incidence of low birth weight agriculture program success = a pathway to transformation in the agriculture sector. There are growing regional coalitions for gender –transformative change, including research led by WorldFish, and the GAP formed at GCWA 2012. There are strong supporters in the donor community. Coalitions and collective action essential to make the structural changes required and prevent backlash. Sharing of resources and tools; longer-term/mass-media campaigns also crucial.
  • Operational ResearchThis is a twenty-two month parallel cluster design trial with three arms: plant-based HFP; plant-based HFP plus small pond aquaculture; and a comparison group. The proposed research will target women farmers and their young children from 600 vulnerable households in two districts of Prey VengProvince. Prey Veng Province is an area where food insecurity and malnutrition is higher than in other parts of Cambodia. Prey Veng province is categorized as “chronically high food insecure” based on WFP's report in 2007. As an area with low fish production it models the consequences of the impending damming of the Mekong and its potential devastation of the Tonle Sap and those who depend on it. The proposed research will be divided into three phases; the preparatory phase (4 months), theimplementation phase (22 months), and a phase out phase (4 months).One applied research program that is ongoing that will contribute to our knowledge base. It is a randomized control trial that it will provide biomarker data (Vitamin A and anemia), as well as anthropometry, economic data and applied evidence of how people make choices about consumption or sales of fish. Fish provide essential fatty acids that help absorb micronutrients; the project follows the 1000-days approach of targeting pregnant women and mothers of <2s, to see how early exposure to these foods (through the mother’s diet as well as child’s) affect development. At the same time, the study will give valuable farm systems information about how families manage a mixed-farm agriculture system and the acceptability of a nutrient-rich polyculture mix of large (presumably sales fish) and smaller fish (that presumably will be consumed); . It is an example of a partnership bringing together a diverse community of practitioners and researchers (the people on the ground (implementers), the nutritionists, fish biologists, gender people, and government) to address relevant and real-time needs of farmers, while building the evidence base for policy makers.
  • HKI brings to this coalition the practical experience and networks on the ground. As implementing partners, we know the local context, we can establish working-research models. We also have technical expertise on nutrition evaluations and surveys, and the technical expertise on nutrition training that can be useful to other organizations. We rely on partnerships with research colleagues to strengthen our evidence base, and we need collaborations with the agriculture community to strengthen the ag. side of our programs—particularly related to the value-chain approach and understanding markets. We offer a few suggestions where partnerships can be helpful.
  • Ending slide (with either logo)
  • P1.2. Pathways to household nutrition in Asia-Pacific region

    1. 1. Pathways to household nutrition in Asia-Pacific Region GCARD 2012 Punte del Este, Uruguay
    2. 2. Context: Renewed investments inagriculture, nutrition, gender equality“Fighting malnutrition should be the top priority for policy makers and philanthropists.”(Copenhagen Consensus 2012) ““There is no greater engine for driving growth…than investments in agriculture.” “Achieving gender equality… (GCARD Roadmap, 2010) is also crucial for agricultural development and food security.” (FAO SOFA, 2011)
    3. 3. HKI’s nutrition priorities in AsiaEnsure lasting capacity to Agriculture-baseddeliver effective nutrition nutritionservicesCreate a supportiveenvironment to prevent Women’sand treat malnutrition nutrition Infant and Young gender ChildDevelop Feedingreplicable, scalableevidence-based modelsBuild the evidence basefor agriculture-based Vitamin Anutrition approaches
    4. 4. HKI’s agriculture for nutrition model Goal: Increase production and consumption of micronutrient-rich foods. Evolving toward child growth focus, but limited data on impact. Core components:  Institutional linkages (health, agriculture, livestock, markets)  Community-based extension targeting poor smallholder women (demo farms)  Horticultural training (micronutrient-dense varieties)  Poultry and livestock support (animal source foods and income)  Nutrition BCC (IYCF, micronutrients, cooking, gender) Consistent evidence:  Improved dietary diversity  Greater food security  Increased income (in women’s control)  Greater participation in decision-making (small decisions)
    5. 5. Ensuring lasting capacity to deliver nutrition services:Governance model, Nepal  Partners: Government Ministries of Health, Agriculture and Local Development, the Nepali Technical Assistance Group (NTAG) and NGOs.  National and district planning workshops to define objectives, areas for integration  Food Security and Nutrition Committees formed at District and VDC level  Health workers trained as demonstration farmers
    6. 6. Outcomes: Nutrition commitments Demonstration farms Village Development Committee Funds integrated into government Contributed to nutrition initiatives: extension system at VDC level  Kailali – VDC $9800 District and VDC-level food  ENA training, seed distribution, security & nutrition working poultry distribution, vaccination, groups linked in Multi- IYCF food demonstration sectoral Nutrition Plan (MNSP)  Batadi - VDC $2500 Recognition of synergies  ENA / HFP training, seed and potential between distribution, coop improvement, Agriculture, Health, Local poultry vaccination, pol house Government construction  Bajura - VDC $36000 AAMA initiatives sustained beyond HKI withdrawal
    7. 7. More than messages: Importance of integratednutrition BCC strategies•Grounded in formativeresearch• Has specific behaviorobjectives• Uses multiple channelsand methods• Addresses gender +intra-household issues•Uses adult learningprinciples (learning-by-doing, cookingdemonstrations, games)•Invests in facilitation Grandmothers laugh at “ludo,” learn about breastfeeding-and counseling skills support
    8. 8. Investment innutrition BCC skills Child Growth in ENA Pilot Areaaccelerates child Average weight-for-age z-scores in pilot and non-pilot areasgrowth -0.85•Supplemental training -0.90and facilitation skills to -0.95existing MCHN program -1.00area -1.05•Trained TBAs, health -1.10volunteers, midwives -1.15•Used adult-learning, -1.20participatory tools -1.25•Improved counseling -1.30 A M J J A S O N D J F M A M J J A S*skills Pre-intervention Period Training Period Post-Intervention•Growth rates improvedwithin six months of Selected nearby areas Selected ENA pilot project area All children in ENA unionsimplementationSource: Training Communities on Essential Nutrition Actions. HKI Bangladesh April 2010.
    9. 9. Developing an ag-nutrition-gender strategy
    10. 10. Strategy: “Let’s all care for each other.”Problems Community strategyStrong family support at birth  Reposition breastfeeding as valuable labor and familyBreastfeeding drops at three months, women investmentreturn to fields; harvest-time workloads  Build on fathers’ caring practices Grandmothers enforce food taboos, poor IYCF around childbirth  Seasonal calendars for family workload support sharing  Work with church, agriculture, health groups (whole family)  Use neighborhood committees to allocate harvest-season work, including breastfeeding support  Train iodized salt sellers on marketing, nutrition  Organize local, district, regional agriculture-nutrition fairs and competitions
    11. 11. Creating a supportive environment: Gender- transformativepathways•Addressing intra-household powerrelations• Treating child feeding as valuablework and time investment•Engaging men, mothers-in-law inworkload-sharing strategies  Holding integrated nutrition- agriculture community events  Treating women as farmers; men as carers; establishing role models  Building women’s market skills and providing supplemental support  Measuring gender-based violence and social norms
    12. 12. Challenge: Building the evidence baseA Systematic Review of Agricultural Interventions that Aim to Improve Nutritional Status of Children found:“The studies reviewed report little or no impact on the impact of agricultural interventions on the nutritional status of children. However, we attribute this to the lack of statistical power of the studies… rather than to the efficacy.” (Masset et al, 2011)Methodological gaps in agriculture-for-nutrition studies: Absence of control groups Poor attention to determinants of participation, little socioeconomic data Inconsistent metrics of income, consumption, nutritional outcomes
    13. 13. Fish on Farms RCT, Cambodia  Partners: HKI, University British Columbia, WorldFish, Cambodian Ministry of Agriculture and Fisheries, IDRC  22-month, 3-arm RCT:  Horticulture  Horticulture + aquaculture  Control group  Target population:  600 food insecure women with <2 children  Indicators:  Anemia  Vitamin A  Anthropometry , BMI  Dietary diversity  Economic data and marketing practices  Gender and decision-making  Household livelihood strategies
    14. 14. Partnerships to build the evidence base and scalablemodels: What can agriculture research bring? Rigorous evaluation designs Food-systems thinking: integrated analysis of care, production, income, markets Better understanding of consumption-income- generation choices Building evidence of behavior-change communication channels in agriculture; what are the appropriate channels and messages for the extension sector? How can we use market actors and create demand for nutritious crops and diets? Technologies: For drudgery, efficient use of small plots, for processing and packaging foods Using common nutrition indicators and outcomes Establishing common, long-term gender- transformative goals for changes in agriculture sector (attitudes, norms, representation)