ECD, the most important equalizer: supporting child well-being at the household level

1. 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

2. “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 interventions at household level?

3. 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

4. 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)

5. Maximal growth in brain function: the critical time is first 2-3 yrs.

6. 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

7. 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

8. 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

9. 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

10. 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

11. The pathways of development of inequality

12. 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

13. ..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 Parents play a crucial role

14. Parental role is based on interaction The “Serve and return” effect • Brain requires responses for synaptic growth • 1-way stimulation is not enough

15. What is Parental Responsivity? Prompt, developmentally appropriate response to infant cues Sensitive to infant cues

16. Interaction and play: ancient models

17. 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

18. 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

19. 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

20. How to promote responsive and interactive parenting Example 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

21. 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

22. HW Gave significantly more Care for Development recommendations in all 3 countries.

23. More intervention mothers than control tried out “new activities” with the child in all 3 countries * * * Kyrgyzstan question is “how often”; others are “last week”

24. Tajikistan: intervention children scored significantly higher at 0-12 and 13-37 months.

25. Differences in Child Scores by Intervention Group in Kyrgyzstan for children 4-36 months *

26. leaflets examples nutritional supplements books Supporting home visits with materials for parents

27. Communication materials combined ECD and sprinkles

28. Materials for community volunteers

29. Materials for parents – 10 recommendations from Care for Development

31. Each child received a book

32. 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 Offering services is not sufficient!

33. Underlying determinants: barrier to accessPercentage 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

34. Barriers to access. Women not assisted by a skilled attendant skilled attendant at delivery: those left out (MICS Database)‏

35. Beyond averages: disadvantaged and discriminated population groups Reasons for not visiting a doctor in spite of feeling sick among the Roma Supply factors Demand factors Source: EDIS S.S., European Survey on Health and the Roma Community, 2009

36. MDG 3, 4 and 5: the crucial links Adolescent health MDG 6 HIV/AIDS MDG 5 Maternal health MDG 4 Child Health MDG 3 Gender equality and women’s empowerment Reproductive health MDG 1 and 2 SE status and education

37. 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

38. 3. Action to implement effective service delivery and interventions at family and community level and health facility level along the continuum of care Health facilities Family and community • 2. Action on health systems functions: • Governance • Creating Resources • Service Delivery • Information System Health systems • 1. Cross sectoral action to address the main determinants of MCH: • Nutrition • Gender equality • WASH and safe environments Government policies and plans 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 The challenges: action at three levels

39. 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

40. 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