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