Wash, Nutrition and ECD Matter_Julia Rosenbaum_4.25.13

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  • WE know that Nutritional and developmental insults in the first few years of life have profound public health implications
  • Almost 7 million children under age five died in 2010 largely due to pneumonia, diarrhea, and birth complications. Globally diarrhea is a leading cause of death in children under five years of age, accounting for approximately 760,000 deaths (10 percent) each year. Diarrhea is a leading cause of malnutrition in children under five, and about one-third to one-half of child mortality cases are linked to malnutrition. , Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Liu, et al. The Lancet (May 11, 2012). Black et al. 2008. Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences. The Lancet 371: 243–60. Black et al. 2003. Where and Why are 10 million Children Dying Every Year? The Lancet 361:2226–34. Bryce et.al and the WHO Child Health Epidemiology Reference Group. 2005. WHO estimates of the causes of death in children .  The Lancet 365: 1147–52. UNICEF. 2012. Children and Water: Global Statistics . New York: United Nations Children’s Fund. http://www.unicef.org/wash/index_31600.html ISSUES Survival is an enormous challenge for children younger than one year of age and especially those younger than one month, the neonates. In Bangladesh, 14 babies under one month of age die every hour and 120,000 every year. Three quarters of these newborn babies die within their first week of life and almost fifty per cent die within the first 24 hours of birth, with most of these deaths occurring at home. The 1 BDHS 2007
  • 156 million children below the age of five are stunted.1 While these numbers represent 28% of all children under five in the developing world, the prevalence is even higher in Sub-Sahara Africa and South Asia (i.e., 61% and 52% of children, respectively).
  • 2 Worldwide, there are 200 million children under the age of five that fail to reach their cognitive developmental potential due to a variety of factors, including poor infant and child nutrition and sub-optimal caregiver-child interactions. 3 Nutritional and developmental insults in the first few years of life have profound public health implications Shortfalls in micronutrient intakes during the time period of birth to two years of age are considered to lead to lasting deficits in cognitive development, 24 morbidity and mortality in infants. 25
  • Optimal development that can lead to the attainment of the individual’s fullest potential requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. 20
  • A lack of sanitation, poor hygiene practices and contaminated drinking water cause 88 percent of diarrhea deaths. Source: WHO/UNICEF, State of the World’s Children 2008 It is serious, common, and costly, but it is also preventable! With known interventions and with known delivery mechanisms… UNICEF estimates that more than 90 percent of deaths from diarrheal illnesses in children under five can be attributed to unsafe water and inadequate sanitation and hygiene practices. UNICEF. 2012. State of the World’s Children : Children in an Urban World. New York: United Nations Children’s Fund.
  • What is Scale? 04/25/13 Overview Complete Process Improving hygiene and sanitation practices can have a dramatic effecting on reducing both diarrheal disease and ARI…. POU water treatment: 30-50% reduction in child DD prevalence – twice as effective as interventions at water source Safe storage: covered, narrow neck container, … serving water by pouring or dipping a ladle not the hand… 21% reduction Proper handwashing: 43% reduction Sanitation: basic, low-cost systems can reduce DD by 30% or more
  • What is Scale? 04/25/13 Overview Complete Process Improving hygiene and sanitation practices can have a dramatic effecting on reducing both diarrheal disease and ARI…. POU water treatment: 30-50% reduction in child DD prevalence – twice as effective as interventions at water source Safe storage: covered, narrow neck container, … serving water by pouring or dipping a ladle not the hand… 21% reduction Proper handwashing: 43% reduction Sanitation: basic, low-cost systems can reduce DD by 30% or more
  • Despite the recognition of this synchrony in both the literature 6-10 and the policy arena, 11-13 only a handful of efficacy trials have tested the effects of integrated child growth and development interventions, 14-17
  • a five-year effectiveness trial of an integrated intervention through existing community-based programs in two countries: the ASHA and Angawadi workers in India and the Lady Health Worker Program in Pakistan. 30 Key elements include promoting key newborn and child survival interventions; enhancing care-giving skills; support for optimal infant and young child feeding practices; and the use of a problem solving/supportive counseling approach to help mothers play with their children.
  • a five-year effectiveness trial of an integrated intervention through existing community-based programs in two countries: the ASHA and Angawadi workers in India and the Lady Health Worker Program in Pakistan. 30 Key elements include promoting key newborn and child survival interventions; enhancing care-giving skills; support for optimal infant and young child feeding practices; and the use of a problem solving/supportive counseling approach to help mothers play with their children.
  • Survival is an enormous challenge for children younger than one year of age and especially those younger than one month, the neonates. In Bangladesh, 14 babies under one month of age die every hour and 120,000 every year. Three quarters of these newborn babies die within their first week of life and almost fifty per cent die within the first 24 hours of birth, with most of these deaths occurring at home. The 1 BDHS 2007
  • [this next bit would be in my discussion] Households receiving free safe water kits were also more likely to be purchasing WaterGuard one year after receiving the free kit, using water treatment products regularly, and their neighbors were more likely to do the same. Studies show that ANC visits also increased by 10-15 percent. This type of incentive program may be helpful in bringing new clients into PMTCT who might not generally get there (Sheth et al. Am J of Trop Med, 2010).
  • In addition to keeping food safe, there is a set of evidence-based nutrition actions to prevent undernutrition and keep babies healthy 1) Exclusive breastfeeding for six months; 2) Adequate complementary feeding starting at about six months with continued breastfeeding for two years; 3) Appropriate nutritional care of sick and severely malnourished children; 4) Maternal nutrition and health greatly influence children’s nutritional status. A woman’s low weight for height or anemia during pregnancy can lead to low low birthweight and continued undernutrition in her children. 5) Adequate intake of vitamin A for women and children; 5) Adequate intake of iron for women and children; 6) Adequate intake of iodine by all members of the household.
  • Wash, Nutrition and ECD Matter_Julia Rosenbaum_4.25.13

    1. 1. Why WASH, Nutrition and ECD Matterfor health, thriving infants and childrenJulia Rosenbaum, FHI360USAID WASHplus Project
    2. 2. Building the Casefor Integration:The 3 Legged Stool
    3. 3. Source: State of the World’s Children, UNICEF 2008What Kills More Children Each Year?Pneumonia18%Malaria 7%Diarrhea 11%OtherNeonatal40%All Other 24%Causes of Mortality for ChildrenUnder 5Diarrhea: 11% of all childdeathsDiarrhea leading cause ofmalnutritionUndernutritioncontributed 1/3 to ½ ofall mortality
    4. 4. A Viscious CycleUndernutritionDiarrhea• Children with diarrhea tend to eat less• With diarrhea, nutrients from food are not well-absorbed• Undernourished children are more susceptible to diarrhea
    5. 5. Scope of Undernutrition & StuntingPrevalence of stunting (height/age) >-2SD (HAZ)Source: Black et al, 2008
    6. 6. Not just about child survival… and not just about more / better food• Adequate nutrition for pregnant women and infants is necessary for‘normal’ brain development• Key period for formation of the brain, laying the foundation fordevelopment of cognitive, motor and socio-emotional skills• Lack of micronutrients especially critical to optimal infant cognitiveand motor development• Children with restricted development in early life are at risk– later neuropsychological problems,– poor school achievement,– early school drop out,– low-skilled employment and lower wage earnings,– poor care of their own children• Some of damage is irreparable if not addressed before age 2**• Contributes to the intergenerational transmission of poverty
    7. 7. What supports child nutrition,growth and development?Access towater/sanitation/hygieneand basichealthservicesImprovedmaternaland child-carepracticesAccessto food– quantityand quality
    8. 8. 1. What percentage of child deathscaused by diarrhea are preventablethrough WASH related interventions?a. 0%-30%b. 31%-60%c. 61%-80%d. over 80%POP QUIZ!!!!!!!!
    9. 9. Safe Storage & Treatment ofWaterHandwashingSafe Feces DisposalFocus on WASH behaviorsfor Diarrhea DiseaseReduction….Food hygiene
    10. 10. Safe Storage & Treatment ofWaterHandwashingSafe Feces DisposalFocus on WASH behaviorsfor Diarrhea DiseaseReduction….21%30% ++43%30-50%
    11. 11. The Case for the 3 Legged StoolIntegrating WASH, Nutrition & ECD• Recognition of the synchronicity of the dyads– WASH and nutrition– Nutrition and ECD• Abundant research has demonstrated that nurturing andresponsive interactions between caregivers and infantspromote optimal growth and development• Maybe a handful of efficacy trials for even the ‘pairs’,none??/few?? for the triad• Limited intervention experience• Little though promising programming guidance
    12. 12. A few program examples• Integrated nutrition and child development efficacy trial inAndhra Pradesh, India• SPRING** 5-year effectiveness trial in India and Pakistan• Alive & Thrive (FHI360/Gates)/ Bangladesh• MAMA reaches over 25 million moms in 22 marketsaround the globe through text messages -- with a uniqueblend of stage-based advice and mom-to-mom wisdom.• The Essential Package Frameworks: Holistically Addressingthe Needs of Young Vulnerable Children (Save, CARE,more)
    13. 13. Mobile Alliance for Maternal ActionReaches over 25 million moms in 22 markets•stage-based advice•mom-to-mom wisdomWhen they need it: timed for each weekWhere they need it: on their mobile phoneHow they need it: as SMS (text) messages
    14. 14. A few program examples• Integrated nutrition and child development efficacy trial inAndhra Pradesh, India• Alive & Thrive (FHI360/Gates)/ Bangladesh• SPRING** 5-year effectiveness trial in India and Pakistan• MAMA reaches over 25 million moms in 22 marketsaround the globe through text messages -- with a uniqueblend of stage-based advice and mom-to-mom wisdom.• The Essential Package Frameworks: Holistically Addressingthe Needs of Young Vulnerable Children (Save, CARE,more)
    15. 15. Alive and Thrive BangladeshBehavioral Objectives• Handwashing with soap & water before food preparationand feeding the child– Maintaining handwashing station- Soap & water near to foodpreparation & child feeding area• Complementary feeding : Correct quantity & frequency• Complementary feeding: Four varieties including oneanimal food daily
    16. 16. WASH Behavior Reduces Neonatal Deaths• Study in Nepal– Maternal and birth attendant handwashingleads to a 41% reduction in neonatal deaths• Programming implications– Handwashing training for birth attendants– Including soap in clean birthing kits– Including handwashing messages andpractice in birth counseling– Promoting fixed handwashing stations or“tippy taps”
    17. 17. Integrating WASH is an incentive forearlier and more frequent prenatal careDistributing a “safe water kit”that includes a water treatmentproduct, water storagecontainer and soap• Earlier enrollment• Increased ANC visits• More HIV testing of women andpartners• More attended/facility delivery
    18. 18. Adding Handwashing and ResponsiveFeeding as Essential Nutrition Actions
    19. 19. Contact InformationJulia Rosenbaumjrosenbaum@fhi360.orgContact InformationJulia Rosenbaumjrosenbaum@fhi360.org

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