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Organization of presentation. Key ideas associated with PM2AThe window of opportunity (1000 days")Prevention The UNICEF modelWhat started it all: the Haiti study (2002-2006) What next? The rationale behind the Guatemala and Burundi studies. Key idea
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1. PM2A: From Haiti to Guatemala and Burundi Gilles Bergeron
May 9, 2011
Food and Nutrition Technical Assistance II Project (FANTA-2)
Academy for Educational Development 1825 Connecticut Ave., NW Washington, DC 20009
Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fanta2@aed.org Website: www.fanta-2.org
2. Organization of presentation Key ideas associated with PM2A
The window of opportunity (“1000 days”)
Prevention
The UNICEF model
What started it all: the Haiti study (2002-2006)
What next? The rationale behind the Guatemala and Burundi studies
3. Key idea #1 of PM2A: Why up to 24 months?
Period of greatest vulnerability and of greatest opportunity.
The quality of nutrition in the first two years affects a person for a lifetime
4. 1. Chronic malnutrition begins early*
5. Intergenerational cycle of malnutrition
6. 2. First 2 years: Period of Most Rapid Growth and Vulnerability to Growth Faltering
7. 3. Period of greatest opportunity from nutrition interventions in first 2-3 years (Guatemala Oriente study)
8. 4. Long term effects of improved nutrition during early infancy (Guatemala) Body composition
Physical and reproductive performance
Cognitive development
Educational achievement
Income generation potential
(Martorell, 1995; Ruel et al. 1995; Pollitt et al. 1993; Hoddinott et al. 2008)
9. Key idea #2: Why prevention?
10. Key idea #2: Why prevention?
12. Core package of PM2A Food. Usually includes
Family ration to improve HH FS and access to foods of higher quality (FBF).
Individual ration for direct beneficiaries to increase nutrient intake.
Health: Includes:
regular visits to health centers to seek preventive/curative H/N services for:
PLW (pre- and postnatal care, assisted delivery & postnatal controls)
Children under 2 (immunization, Vit A, deworming, DD prevention/management, malaria prevention strategies, prevent/treat iron deficiency, GMP
Active case finding and referral of children with SAM
Care practices. BCC strategy to:
improve IYCF, hygiene, health seeking behaviors
stimulate adoption of recommended practices/use of available services,
teach how to use donated/local foods
ensure targeted beneficiaries access the services and donated food.
As any preventive intervention, PM2A targets ALL children -9/+24)
13. In sum: PM2A Key Elements Focus on the 1000 days
Follows public health notion of prevention (all children are covered)
Interventions are based on the UNICEF conceptual model
Those three elements are key.
The “How” can change, not the “what”
14. Summary of Haiti study findings
15. Based on a MYAP implemented by World Vision in Haiti’s Central Plateau between 2002 and 2005
Cluster randomized trial (no controls)
Study carried out by IFPRI
Goal: compare the relative merit of preventive vs recuperative programming to reduce population level of child malnutrition
Refs: Lancet paper, Propensity Score Matching paper, various documents on FANTA-2’s website
16. At final survey preventive communities had better anthropometry than recuperative ones
19. Impact on Food Security
20. Costs Both models have same direct program costs (in spite of the larger number of beneficiaries in preventive)
Food costs are higher in the preventive approach due to the larger number of beneficiary-months
Costs per beneficiary/month are lower in preventive:
direct program costs/beneficiary-mo are lower and
food costs/beneficiary are the same
21. Summary of findings from Haiti study Preventive model generated:
Lower prevalence of stunting, underweight, wasting
Higher mean HAZ, WAZ, WHZ
Results were consistent across age groups
Preventive model also improved HH food security
Cost per unit of improvement were lower in the preventive model
22. PM2A:
Preventing Malnutrition in Children under 2 Years of Age
23. FFP’s PM2A initiative Based on Haiti findings:
FFP modified its guidance, specifying PM2A as the preferred MCHN approach for its Development Programs
FFP funded additional study of PM2A in 2 countries (Burundi, Guatemala) to improve efficiency of PM2A
What makes the preventive model works?
Can the cost of PM2A be reduced?
MYAPs will receive $10M/yr for 5 years in each ($100M total); study will cost $8M total for 5 years in 2 countries
MYAPs started 2010; study enrollment started 2011
24. Specific Objectives of the PM2A study Assess the impact and cost-effectiveness of PM2A on child nutrition
Assess the importance of food ration (size/type)
Large, Reduced, or No Family Rations?
Individual Rations, Lipid-based Nutrient Supplements, or Micronutrient Sprinkles?
Assess the impact of the duration of exposure on child nutrition
Not an objective:
Assess the impact of BCC only
Assess the impact of no food at all (no individual nor FR)
25. Key outcomes examined Child nutritional status
Linear growth
Micronutrient status
Other child outcomes
Motor development
Cognition
Morbidity
Secondary outcomes
HH FS
Maternal nutrition (Hb)
26. Burundi MYAP implemented by CRS-led consortium (with participation of IMC, FH, CARITAS/Bur)
Study carried out by IFPRI
Cluster randomized controlled trial
2 cross sectional surveys (Baseline/Endline)
3 study arms
PM2A (-9 to 24mo, full FR, BCC, HS)
PM2A until child is 18 mo (instead of 24)
Control” No services from MYAP (only regular Gov’t ones)
27. Guatemala MYAP Implemented by Mercy Corps in Alta Verapaz
Study carried out by IFPRI
Cluster randomized controlled trial
2 cross sectional surveys (Baseline/Endline)
Longitudinal study repeated at 1, 4, 6, 9, 12, 18, 24 mo
Six “study arms”
PM2A: “Full” PM2A (-9 to 24mo, full FR, BCC, HS)
PM2A/.5FR: PM2A with smaller (1/2) family ration
PM2A/0FR: with no family ration
PM2A/LNS: PM2A w/LNS (no food) as individual child ration
PM2A/MNP: PM2A w/MNP (no food) as individual child ration
Control: No services from MYAP (only regular Gov’t ones)
28. Questions to study size of family rations and comparisons used
29. Questions to study the composition of individual rations and comparisons used
32. Additional studies Formative research (to develop the BCC strategy)
Operations research (throughout implementation)
Cost study to assess cost effectiveness and cost benefit of the different study arms
Special studies: tbd
Intra-HH utilization of food commodities
Side effects of food aid on production, fertility decisions
33. Next steps Studies to be finalized in 2015…
Publications in peer-reviewed journals
Revision of the FANTA-2 TRM
Development of additional tools to help programming, e.g.:
Costing tool
Ration size calculator
Meanwhile, FANTA-2 will continue to provide technical support to PVOs in PM2A implementation
34. This presentation is made possible by the generous support of the American people through the support of the Office of Health, Infectious Disease, and Nutrition, Bureau for Global Health, and of the Office of Food for Peace, Bureau for Democracy, Conflicts and Humanitarian Assistance, United States Agency for International Development (USAID) under terms of Cooperative Agreement No. GHN-A-00-08-00001-00, through the Food and Nutrition Technical Assistance II Project (FANTA-2), managed by AED. The contents are the responsibility of AED and do not necessarily reflect the views of USAID or the United States Government.