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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. - PowerPoint PPT Presentation
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ECD, the most important equalizer: supporting child well-being at the household
level
Giorgio Tamburlini MD PhDEuropean School for MNCAH
UNICEF Consultant
Supporting families for child well-being. The role of community nurses and home visiting outreach services
Ankara, 14-17 May, 2012
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 cost-efficient 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
Brain requires responses for synaptic growth
1-way stimulation is not enough
The “Serve and return” effect
Parental role is based on interaction
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 parentingExample 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 socio-
emotional 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 giving ojbects for play
0
20
40
60
80
100
Kazakhstan Tajikistan Kyrgyzstan
perc
ent Series1
Series2
% recommend colorful objects for child to see and reach for
010203040506070
kazakhstan Tajikistan Kyrgyzstan
perc
ent
intervention
Control
% recommend looking at child and smiling
0
20
40
60
80
100
Kazakhstan Tajikistan Kyrgyzstan
perc
ent
Series1
Series2
More intervention mothers than control tried out “new activities” with the child in
all 3 countries
0
10
20
30
40
50
60
Kazakhstan Tajikistan Kyrgyzstan
perc
ent
Intervention 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
42
44
46
48
50
52
54
Intervention Control
P<.008P<.006
N= 234 for Intervention, 144 for control; Ages and Stages Scales Significant differences for Communication and Personal-Social Scales (and Gross motor at 4-12 m) (Engle et al., 2010)
*
Supporting home visits with materials for parents
leafletsexamples
nutritional supplementsbooks
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 groupsReasons for not visiting a doctor in spite of feeling sick among the Roma
Source: EDIS S.S., European Survey on Health and the Roma Community, 2009
Supplyfactors
Demand factors
MDG 3, 4 and 5: the crucial links
MDG 4 Child Health
MDG 5 Maternal health
Adolescent health
MDG 3 Gender equality and women’s empowerment
MDG 1 and 2SE status and education
Reproductivehealth
MDG 6 HIV/AIDS
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.)
• Low demand: SES, women’s status, education and cultural factors
• Service delivery issues: - Barries to access - Worse quality of care
Social determinants
Health system issues
The challenges: action at three levels
1. Cross sectoral action to address the main determinants of MCH:
Nutrition Gender equality WASH and safe
environments
2. Action on health systems functions: Governance Creating Resources Service Delivery Information System
3. Action to implement effective service delivery and interventions at family and community level and health facility level along the continuum of care
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
Family and community
Government policies and plans
Health systems
Health facilities
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