day 1 session 1 causes and interventions
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The document discusses malnutrition in India and strategies to address it. It notes that malnutrition takes multiple forms and has various underlying causes requiring interventions across several sectors. While India has made progress, there remains significant variability in malnutrition across states and districts. Effective strategies must involve delivering evidence-based nutrition-specific interventions through existing public programs and private providers to reach women and children in the first 1000 days, but coverage of interventions remains highly variable across areas. Addressing the context-specific drivers of malnutrition in each location is key to effectively tackling this challenge in India.
![Understanding causes of malnutrition: four
things to keep in mind!
1. Malnutrition takes many forms but the risk factors
for poor nutrition are often similar
2. Timing matters [the first 1000 days matter for
most forms of malnutrition!]
3. Multiple causal factors, and therefore,
interventions needed in multiple sectors
4. Effective convergence means “reaching every
household, every woman, every child in the first
1000 days with ALL interventions”](https://image.slidesharecdn.com/2-190305031553/85/day-1-session-1-causes-and-interventions-2-320.jpg)
day 1 session 1 causes and interventions
- 1. Tackling malnutrition in all its forms by acting on its multiple determinants Purnima Menon Mussoorie | February 13, 2019
- 2. Understanding causes of malnutrition: four things to keep in mind! 1. Malnutrition takes many forms but the risk factors for poor nutrition are often similar 2. Timing matters [the first 1000 days matter for most forms of malnutrition!] 3. Multiple causal factors, and therefore, interventions needed in multiple sectors 4. Effective convergence means “reaching every household, every woman, every child in the first 1000 days with ALL interventions”
- 3. Scope of the challenge: India’s nutrition challenge has taken a different shape in the last decade; despite many improvements, the new challenge is one of variability across India Districts with no data Districts with 10⎼20% Districts with 20⎼30% Districts with 30⎼40% Districts with >40% 1 29 170 202 239 Anemia among women of reproductive age, 2016 Districts with no data Districts with 0 - <20% Districts with 20 - <40% Districts with 40 - <60% Districts with ≥60% 0 7 122 360 151 Overweight or obesity among men, 2016 Districts with no data Districts with 0 - <10% Districts with 10 - <20% Districts with 20 - <30% Districts with ≥30% 0 141 288 149 62 Stunting among children < 5 years, 2016 What forms of malnutrition are challenges in your district?
- 4. -2 -1,75 -1,5 -1,25 -1 -0,75 -0,5 -0,25 0 0,25 0,5 0,75 1 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 Age (months) Z-scores(WHO) Weight for age (WAZ) Weight for length (WHZ) Height for age (HAZ) Source: Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print) 2. Timing matters (the first few years are really important) 4
- 5. Fig 3. Categories of length-for-age stratified by exact month of age and site. MAL-ED Network Investigators (2017) Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study. PLOS Medicine 14(10): e1002408. https://doi.org/10.1371/journal.pmed.1002408 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002408
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- 7. Immediate causes of malnutrition (especially for children) Food • Breastfeeding • Complementary feeding • Limiting non- nutritive foods Care • All activities that assure that family food, health and other resources reach the child • Attention to the child, care arrangements • Responsive feeding • Psychosocial stimulation Health • Maternal health and well-being • Preventive and curative health care • Assurance of a healthy and clean environment
- 8. Underlying causes of poor nutrition for children Food-related resources • Household food security • Household food diversity • Healthy/unhealthy food environment Care-related resources • Support available to parents • Time • Stress • Workload Health-related resources • Access to and availability of health care • Access to clean environments Poverty, social exclusion and lack of agency and opportunity are underpinnings of these causes Causes of the causes!
- 9. Stunting: Factors related to gender, poverty and health services account for much of the difference between high and low stunting districts. Half the difference is tied to women’s wellbeing Districts with no data Districts with 10⎼20% Districts with 20⎼30% Districts with 30⎼40% Districts with >40% 1 29 170 202 239 Stunting among children < 5 years, 2016 Source: P Menon, D Headey, P Nguyen, R. Avula. 2018. Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from 2015–16. Maternal & Child Nutrition Stunting differences between high and low stunting districts Menon et al., Maternal and Child Nutrition 2018
- 10. Anemia: Factors related to gender, poverty and health services account for changes in anemia over time – both for women and for children Decomposition analysis for factors contributing to change in hemoglobin among children and pregnant women in India from 2006 to 2016 Source: Nguyen et al., 2018 Factors contributing to changes in anemia over time • Changes in women’s anemia: Schooling, diet, socioeconomic status, sanitation and nutrition interventions • Changes in children’s anemia: maternal schooling, SES, health and nutrition interventions and other factors (majority related to maternal wellbeing)
- 11. How these determinants play out differs from place to place: your response must tackle the most important causes first Indicator Nuapada (Odisha) Bongaigaon (Assam) Outcome: Stunting 37.6% 39.1% Immediate determinants Women BMI<18.5 kg/m2 34% 19.2% Exclusive breastfeeding 49.2% 68.3% Adequate diet 2.6% 13.7% Coverage of interventions >=4 ANC 75.5% 24.2% Institutional delivery 84.7% 67% Newborn check-up 35.7% 14.2% Full immunization 83.8% 42.4% Underlying and basic determinants Women literate 49.9% 71.4% Girls married before 18 years 19.1% 42.6% Households with an improved drinking water source 95% 74% Households using improved sanitation facility 20.2% 45.9% Open defecation 84.6% 42.2% Households below poverty line 60.5% 31.9% Source: NFHS 4
- 12. Do a little diagnosis for your district! • What does the burden of malnutrition look like in your district? What forms does it take? • What do major risk factors/causes for malnutrition look like in the district? • Start off a causal map of the components and their interactions – on paper
- 13. Lancet 2013 conceptual framework: linking interventions to determinants 13
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- 16. Nutrition-specific interventions: What are they? What’s the evidence base? Where do they site in India’s policy response? 16
- 17. Global evidence on nutrition-specific interventions in the first 1000 days 17 Bhutta et al. 2013
- 18. Most of these evidence-informed nutrition interventions exist in the Indian policy framework Preconception Pregnancy Delivery & Postnatal Early childhood •Iron and folic acid (IFA) supplementation •Deworming •Fortification (Iodized salt) •IFA supplementation •Calcium supplementation •Food supplementation •Counseling on nutrition during pregnancy •Counseling on EIBF •Malaria prevention •Deworming •Maternity benefits •Conditional cash transfer •Institutional birth •Birth conducted by skill health personnel •Delayed cord clamping •Counseling- EIBF •Counseling on kangaroo mother care •IFA supplementation •Calcium supplementation •Food supplementation •Counseling- EBF •Counseling- Complementary feeding •Immunization •Vitamin A suppl • IFA supplementation •ORS with zinc during diarrhea •Growth monitoring •Food supplementation •Management of SAM •Management of MAM •Deworming in children •Sanitation 90% coverage 20% reduction in stunting (Bhutta et al. 2008) * Preventive zinc supplementation in early childhood – Not in the Indian policy framework
- 19. Birthspacing-pregnancycare AntenatalCare Immunization Home Based Newborn Care Feeding counseling: breast feeding and complementary feeding Birth Institutional Deliveries 6 weeks Facility Based Newborn Care Integrated Management of Neonatal and Childhood Illnesses Home-based Young Child Care (Nutrition and health counseling, early stimulation 6 months 1 year 2 years Swachh: Safe water, hand washing, toilet use, safe disposal of feces Supplementary nutrition: mother >>> baby Growth monitoring; stimulation and care of the malnourished child HEALTH*ICDS* Not to scale Pregnancy Pre- pregna ncy *predominant role Care for severe acute malnutrition Program packages of Interventions for first 1000 days: for health, nutrition and development 19 BetiBachao,betipadhao Adolescentcare Iron-folic acid; Vitamin A; Deworming All Enablers: Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Janani Suraksha Yojana (JSY) Pradhan Mantri Maatru Vandana Yojana (PMMVY), Janani Shishu Suraksha Yojana (JSSY), Rashtriya Bal Suraksha Karyakram (RBSK)
- 20. Delivery platforms to help achieve scale are also in place Delivery platforms • Public sector programs • ICDS • NHM • Private sector providers • Self-help groups • Mass media • Jan Andolan Service providers/Events • Anganwadi workers • ASHAs • ANMs • Doctors • Nurses • Group facilitators • Public service announcements • Campaigns/Celebrations 20
- 21. And yet - coverage of interventions remains highly variable: by life-stage, by intervention, by the delivery channel … 21 93.3 51 77.7 30.2 83 18 75.4 40.1 52.6 35.1 43.8 81 83.3 36.7 65.1 27.1 47.8 35.137.1 62.6 59.3 26.5 32.2 79.1 50.5 20.2 51.7 42.744.6 28.55 0 10 20 30 40 50 60 70 80 90 100 PREGNANCY DELIVERY & POSTNATAL EARLY CHILDHOOD Health ICDS Health ICDS Health ICDS
- 22. ….and among states and… 22 0 10 20 30 40 50 60 70 80 90 100 DemandforFPsatisfied Iodizedsalt ≥4ANCvisits Consumed100+IFAduring… Neonataltetanusprotection Dewormingduringpregnancy Weighingduringpregnancy Breastfeedingcounselingduring… Supplementaryfood-pregnancy Healthandnutritioneducation‐… Healthcheckup-pregnancy Institutionaldelivery Skilledbirthattendant JSY Postnatalcareformothers Postnatalcareforbabies Supplementaryfood-lactation Healthandnutritioneducation‐… Healthcheckup-lactation Fullimmunization ReceivedvitaminAinthelast6… PediatricIFA Dewormingforchildren Careseekingforpneumonia ORSduringdiarrhea Zincduringdiarrhea Supplementaryfood-children Healthcheckup-children Weighing-children Cousellingonchildgrowth Prepregnancy Pregnancy Delivery and early postnatal Early childhood % Source: National Family Health Survey -4
- 23. Proportion of mothers receiving any ANC …among the districts 23 Proportion of mothers receiving 4 or more ANC Source: National Family Health Survey -4 Take a look at your district for ANC 490 districts ≥75% women received any ANC 156 districts ≥75% women received 4 or more ANC
- 24. 24 Proportion of women who received food supplements during their pregnancy Proportion of children (6-35 mo) who received food supplements 172 districts ≥75% children received food supplements An example of coverage variability – Food supplementation Source: National Family Health Survey -4 144 districts - ≥75% women who received food supplements during pregnancy Take a look at your district for food supplementation coverage
- 25. Exercise time! • 5 mins (individual exercise) • Take a look at your state coverage note and focus on the district dashboard • Which interventions are consistently high? • Which ones are low for all districts? • 5 mins - table buzz – what are you finding • As you think forward to your district action plans – think of how you will achieve C2IQ • Coverage • Consistency • Intensity • Quality
- 26. Nutrition-sensitive interventions What are they? What is India’s policy landscape? What opportunities exist to strengthen them?
- 27. Many underlying determinants contribute to difference in stunting between very high‐burden & low-burden districts, 2016 Source: Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from 2015–16; Authors: Purnima Menon, Derek Headey, Rasmi Avula, and Phuong Hong Nguyen
- 28. Lancet 2013 conceptual framework 28
- 29. How to think about maximizing nutrition sensitivity of other sectors Three ways that programs in other sectors can have a greater impact on nutrition, i.e. be more ‘nutrition-sensitive’. 1. addressing the underlying determinants of fetal and childhood nutrition and development 2. incorporate specific nutrition goals and actions 3. serve as delivery platforms for nutrition- specific interventions Ruel, Marie T., and Harold Alderman. "Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?." The Lancet (2013).g Agriculture and food systems Social protection Sanitation Gender
- 30. Beyond agriculture, to food systems for better nutrition Global Panel Foresight Report 2016 30
- 31. Social safety net programs and nutrition: mixed evidence 31 Lack of impact due to: • Short duration of transfers • Lack of linkages to nutrition interventions • Poor quality of health and nutrition services • Lack of consideration of caregivers’ time constraints Ruel & Alderman 2013; Alderman 2014 Pathways for nutrition- sensitive social protection: 1) Increasing incomes through cash 2) Providing subsidies and price supports 3) Addressing preferences and behaviours Alderman 2015
- 32. What is the current state of evidence in India? Approach one Approach two Approach three Address the underlying determinants Incorporate specific nutrition goals and actions Delivery platforms for nutrition- specific interventions | | | Public distribution system (PDS) ___ Strong (numerous studies) Weak (7 studies) None | | | Mid-day meal scheme (MDMS) ___ Weak (4 studies) Weak (6 studies) Weak (1 study) | | | Mahatma Gandhi national rural employment guarantee scheme (act) (MGNREGA) ___ Weak (7 studies) None None Raghunathan et al. Economic and Political Weekly, 2017
- 33. Stopping transmission of fecal matter into the mouths of human beings is the primary goal of WASH interventions! FIVE F’s Source: Perez et al., 2012 33
- 34. Recent evidence on WASH intervention impact on malnutrition NOT promising • 3 large randomized controlled trials published in 2018/19 • Combinations of nutritional supplements, behaviour change communication and WASH (pit latrines, Tippy taps, promotion) • None of the trials found an ADDED benefit of the WASH interventions for child growth over the nutritional supplement and behaviour change • Stunting/growth retardation remained high • Requires re-thinking WASH solutions! 34
- 35. Gender & patriarchy are major contributors to malnutrition in India (recognized in 1996!) and how girls and women are invested in and supported throughout their lives. 35 Girls • Education • Age at marriage • Nutrition Women • Health • Nutrition • Economic opportunities Pregnant women/mothers • Care during and after pregnancy • Support
- 36. Underweight women in India vs. Sub Saharan Africa 36 Coffey, PNAS 2015 INDIA SUB-SAHARAN AFRICA
- 37. The challenge for multisectoral action is to bring sectoral interventions together for effective convergence on the household, woman, child) Basic causes/enabling environment •Leadership •Commitment •Financing •Knowledge systems/learning Underlying causes •Economic growth/jobs •PDS •Livelihoods programs •Sanitation mission •Gender/women’s programs •Girls education/MDM Immediate causes •Health •ICDS •SHGs •Media
- 38. Effective convergence: reaching all households, all women, all children with all interventions during the entire 1000- day window • Data from a cross-sectional survey of 1644 mothers with children 6-24 months of age in 5 states, IFPRI WINGS study 2017 Nutrition-sensitiveNutrition-specific 0 10 20 30 40 50 60 70 80 90 100 1 ≥4ANC Received MCP card Received IFA tablets /syrup Food supplementation (preg) Institutional birth Visited by health worker within 2 days of delivery Food supplementation (lactation) Vitamin A (in the last 6 months) Paediatric IFA (in the last 6 months) Deworming (in the last 6 months) Food supplementation (child) Weighing (in the last 3 months) JSY-enrolled PDS - has ration card MNREGA - has job card SHG member Drinking water safe Aware of Swachh Bharat HH has an improved toilet facility
- 39. What do you think effective convergence looks like for these people? 100% • Received at least ONE intervention of the 19 interventions • 12.6 on average, range 4 to 19 1.9% • Received ALL 13 nutrition-specific interventions • Average number of nutrition-specific interventions = 8.8 6.9% • Received ALL 6 nutrition-sensitive interventions • Average number of nutrition-specific interventions = 3.9 2 households out of ~ 1600 got all 19 interventions Data from a cross-sectional survey of 1644 mothers with children 6-24 months of age in 5 states, IFPRI WINGS study 2017
- 40. Let’s discuss how to make convergence of interventions happen? • How can YOU know the extent of effective convergence in your geographic areas? • What can do you to focus on effective convergence?
- 41. SUMMARY Malnutrition burden in India remains high despite some progress, with tremendous inter-state and inter-district variability and multiple drivers of disparity Stunting differences are not explained by any single factor, but rather by a multitude of economic, health, hygiene and demographic factors. Many success stories across India! Several states (Chhattisgarh, Arunachal Pradesh, Gujarat) are among high performers on stunting reduction Multiple forms of malnutrition – with several common drivers – health, food and physical environments
- 42. Children < 5 years of age • Stunting: child <5 years of age is too short for their age—a result of chronic undernutrition (more than 2 standard deviations below median in a healthy population) • Wasting: child <5 years of age has weight too low for their height—a result of acute undernutrition (more than 2 standard deviations below median in a healthy population) • Underweight: child <5 years of age has weight too low for their age—from either chronic or acute undernutrition (more than 2 standard deviations below median in a healthy population) • Overweight: child < 5 years of age has weight too high for height (more than 2 standard deviations above median in a healthy population) The ways malnutrition is most frequently referred to in major reports 42
- 43. Stunting: an index of child growth based on attained height for age Wasting: an index of child growth based on weight proportional to height 43 38.4% children (<5y) in India are stunted 21 % of children (<5y) in India are wasted
Editor's Notes
- #2: Delhi pollution
- #19: -Product-based interventions -Information-based interventions -Incentive-based interventions
- #20: Earlier I had shown a slide on the interventions in the Indian Policy Framework. These are the interventions featuring the package of interventions in the first 1000 days under the POSHAN Abhiyaan. So there are no new nutrition-specific interventions.
- #21: -Delivery platforms are key to achieving scale. In India what are the delivery platforms that we have: These could be public sector programs or private sector providesr. It could be through the SHGs, mass media or Jan Andolans.
- #22: Coverage of our nutrition-specific interventions remains variable- A cursory look at the graph makes this quite evident. Not all the bars are at the same level nor are they touching the 100% mark Zooming in a bit, le us look athe graph by the life-stage. We have divided the graph by three life stages. In pregnancy, the coverage ranges from 18-83%.
- #23: - >4ANC - Range:12% (Bihar)to 90% (Kerala)
- #34: F-diagramme highlights pathways of transmission of faecal pathogens from the environment to humans
- #40: Variable Proportion of respondents who recd … N Mean no. of interventions recd Std Dev Min Max Received/Covered by atleast one of the 19 intervention 100.00 1114 - - - - Received/Covered by all the 19 interventions 0.18 1114 12.75 2.62 4 19 Received/Covered by all the 13 nutrition specific interventions 1.89 1114 8.84 2.07 2 13 Received/Covered by all the 6 nutrition sensitive interventions 6.91 1114 3.91 1.17 0 6