Integrating Early Childhood Development, Health and Nutrition Programs
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Integrating Early Childhood Development, Health and Nutrition Programs
- 1. ©2012 International Medical Corps Experiences With Integrating Early Childhood Development, Health And Nutrition Programs Presenters: Dr. InkaWeissbecker, PhD, MPH Global Mental Health and Psychosocial Advisor, IMC & Jennifer Burns, MSPH Senior Development Nutritionist, IMC
- 2. ©2012 International Medical Corps Agenda • IMC’s approach to ECD programming – ECD components – Guidelines & adaptation of material – Measuring outcomes • How has integration been achieved? – Three country examples: Sierra Leone, Uganda, and Lebanon.
- 3. ©2012 International Medical Corps Key Messages 1. Varying approachesforintegrating ECD, nutrition and healthprogramming 2. Integration is feasible within emergency, transitional and development contexts 3. The hands-on learning approach in group sessions and home visits is key in producing positive outcomes 4. Investing in a training of trainers approach in the community is essential for sustained ECD programming
- 4. ©2012 International Medical Corps IMC’S APPROACH TO ECD PROGRAMMING
- 5. ©2012 International Medical Corps IMC ECD Programs • Jordan, Syria, Lebanon, Gaza • Uganda, Ethiopia, Sierra Leone • Haiti
- 6. ©2012 International Medical Corps ECD Components • Settings • Staffing • Trainees • Training • Approaches
- 7. ©2012 International Medical Corps Guidelines, Resources & IMC Contribution • UNICEF Guidance Note • IASC MHPSS Guidelines in Emergency Settings • Hincks Del-Crest (HDC), Learning Through Play (LTP)
- 8. ©2012 International Medical Corps Adaptation of training materials: Ethnographic Background • Local developmental milestones • Child rearing practices
- 9. ©2012 International Medical Corps IMC ECD Materials Adapted to Local Context 9 Haiti
- 10. ©2012 International Medical CorpsPresentation Title 10 Ethiopia
- 11. ©2012 International Medical CorpsPresentation Title 11 Sierra Leone
- 12. ©2012 International Medical CorpsPresentation Title 12 Lebanon
- 13. ©2012 International Medical Corps Monitoring and Evaluation ① Caregiver Knowledge, Attitudes and Practices ① Mother-child Interaction ② Mental Health & Psychosocial Wellbeing of Caregivers, including Maternal Mood ③ Health, Nutrition and Feeding practices ④ Behavior Change (Parenting)
- 14. ©2012 International Medical Corps UGANDA EMERGENCY/RELIEF CONTEXT Case Studies A Controlled Evaluation From Northern Uganda “Does Combining Infant Stimulation With Emergency Nutrition Improve Psychosocial Outcomes for Displaced Mothers and Babies? “ Reference: (Jones 2012. American Journal of Orthopsychiatry 2012, Vol. 82, No. 3, 349–357)
- 15. ©2012 International Medical Corps Context • Community-based management of acute malnutrition (CMAM) program for severe and moderately malnourished children. • Integrated with health and nutrition education (e.g. IYCF, HIV, family planning, WASH, and child health).
- 16. ©2012 International Medical Corps Objective • Assessing the impact of combining a group-based psychosocial intervention with an existing emergency nutrition program for internally displaced mothers in Northern Uganda.
- 17. ©2012 International Medical Corps Program Design: The Psychosocial Intervention Two components: • Six weekly mother and baby group sessions: knowledge, discussion and practice (ECD education, play, toy making, challenges) • Follow-up home visits by psychosocial facilitator and nutrition counselor *Training materials were adapted from the Learning through Play program.
- 18. ©2012 International Medical Corps Study Design and Selection of Participants • Five centers in the Kitgumdistrict: – Attending mothers received nutritional support plus the psychosocial intervention – Control group received the therapeutic and supplementary feeding support alone.* * These mothers were wait-listed for the psychosocial intervention, which they received after the research was complete.
- 19. ©2012 International Medical Corps Outcomes Investigated (a)The Acholi Home Observation for Measurement of the Environment (HOME) was used to assess the impact of the intervention on mother’s ability to stimulate her child (b) The Kitgum maternal mood scale to assess changes in maternal mood, and (c) KAP test to assess changes in maternal knowledge of ECD.
- 20. ©2012 International Medical Corps Results and Discussion
- 21. ©2012 International Medical Corps Way Forward • Mothers established new mother-to-mother groups • Integration of ECD psychosocial interventions via group and home visits as part of nutrition programs
- 22. ©2012 International Medical Corps SIERRA LEONE DEVELOPMENT CONTEXT Case Studies A Comprehensive And Integrated Approach To Reducing Food Insecurity And Chronic Malnutrition In Sierra Leone A USAID Food for Peace Multi-Year Assistance Program
- 23. ©2012 International Medical Corps Context • Sierra Leone: 11-year civil war, highest child morality rate, 180 out of 187 on the HDI, 36% stunted, 21% underweight, 10% wasted • IMC, in partnership with ACDI/VOCA and OIC, implements the health, nutrition and SBCC activities of a USAID MYAP
- 24. ©2012 International Medical Corps Program Design Using the Care Groupmodel, project staff, health promoters, and peer educators (LM) trained on WASH, IYCF and family planning 1O LMs 150 PLWS 1 HP 43 HPs 1 LM 50 LMs 15 PLWs 2200 750 PLWs 43671 PLWs 220 5 CGs 1 CG
- 25. ©2012 International Medical Corps Pilot Study: Structure & Approach 1. Community mapping/ethnographic background study 2. Development of culturally appropriate ECD curriculum and study tools 3. Cascade training for District Supervisors, Health Promoters, Care Group Volunteers on ECD modules 4. 10-weekgroup educational sessions or home visits integrated into existing MCGs • Positive caregiver-child interaction • Safe play • Supporting child development- relationships, communication, understanding, physical, and sense of self
- 26. ©2012 International Medical Corps Pilot Study: Structure & Approach • Research: – impact [maternal knowledge of early child development, quality of mother and child interaction, and maternal mood] – Approach [group sessions, HH visits] • Research limitations [staff turnover, lack of technical support on-the-ground] • Ethnographic research on child-rearing practices, SBC materials, study tools
- 27. ©2012 International Medical Corps LEBANON WORKING IN TRANSITIONAL CONTEXTS Case Studies “A Comprehensive Approach to integrating Nutrition & Health within ECD Psychosocial Programming”
- 28. ©2012 International Medical Corps Context • IMC providing sessions in Early Childhood Development to refugee and vulnerable host populations since 2009. • Community Based ECD Psychosocial Program established within PHC clinics and community centers. • Emergency and Post Emergency Settings: – New Refugees (Syrian Refugees) – Refugees who have been in Lebanon for over 1 year (Iraqis) – Vulnerable host population
- 29. ©2012 International Medical Corps Objectives The objectives of the education program are: (a)Improve knowledge in ECD, health and nutrition. (b) Teach parents play activities that enhance child development; and (c) Promote active parental involvement in their child’s development.
- 30. ©2012 International Medical Corps Program Design • Caregivers with children from 0-3years and 3-6years. • IMC psychologists and social workers as ECD facilitators. • ECD facilitators paired with ECD educators from the refugee/host community. • Sessions are delivered in the presence of and active engagement of caregivers with their children.
- 31. ©2012 International Medical Corps ECD Topics The ECD program is based on 10 learning sessions. • Session 1. Early Years and the Brain • Session 2. Attachment • Session 3. Child Growth and Development • Session 4. Sense of Self and Relationships • Session 5. Understanding and Communication • Session 6. The Importance of Play • Session 7. Toys and Toy Making • Session 8. Guiding Behaviors • Session 9. Child Nutrition and Health • Session 10. Child Safety Each session discusses hygiene, nutrition, health, and the developmental milestones associated with the specific age group.
- 32. ©2012 International Medical Corps ECD Materials • Adapted from Hincks Del Crest , Learning Through Play Material – LTP material included a chapter on Nutrition. • Formative research showed a need among caregivers for nutrition and health support. • Revised Material now includes more focused and age specific nutrition and health messages and activities within ECD curriculum.
- 33. ©2012 International Medical Corps Monitoring & Evaluation Tools Pre/Post KAP Test that includes questions in line with previously described topics including Child Growth and Development, Understanding and communication, Mother/father role, etc. Pre/Post Psychosocial Wellbeing Measure with the following domains: - Daily functioning - Family dynamics - Social connectedness
- 34. ©2012 International Medical Corps Outcomes A Sample of 36 parents/caregivers with children from 0-3 years. Caregivers from the Iraqi and Syrian Refugee populations residing in Lebanon. Knowledgeincreas ed by 21.9%. Caregivers’ wellbeing improved by 16.5%
- 35. ©2012 International Medical Corps Other Reported Outcomes ① Caregivers reported a significant change in their behaviors with their children ② Caregivers reported following health, nutrition and safety messages ③ Mothers reported making friends as part of the ECD sessions and continue to meet regularly. ④ ECD educators from the refugee community now run their own ECD groups within their community.
- 36. ©2012 International Medical Corps Take Away Messages • Varying approaches to integrating ECD, nutrition and health Programming • Integration is feasible within emergency, transitional and development contexts. • The hands-on learning approach in group sessions and home visits is key in producing positive outcomes. • Investing in a training of trainers approach in the community is essential for sustained ECD programming.
- 37. ©2012 International Medical Corps Thank you!
Notas del editor
- What are donors looking at?
- Today we will share with you IMC’s approach to ECD programming, illustrating examples from 3 country examples.
- At the end, We’d like for you to walk away with 4 key messages
- Now Inka will share with you IMC’s approach to ECD programming
- Settings: Nutritional programs, PHC clinics, social community centersStaffing: ECD specialist, local counterpartsTrainees: caregivers (mothers and fathers), nutrition staff, health care providersTraining: Training of trainers and of mothersApproaches; home visits, mother-to-mother groupsAbout 10 sessionsCounterparts such as local ECD volunteers or lead mothers who teach mothers to run their own groupsHighlightsECD including children with special needs in Syria (now replicated in Lebanon)Father-only groups in SyriaIn Jordan ECD tought in homes hosted by mothers to reach Iraqi refugees about 20 per group ( impact on refugee isolation and loneliness—)TopicsUsing the Manual…………………………………………………………………………………………………..6Card 1: Child Growth and Development………………………………………………………….8Card 2: Play A: Why Is Play Important …………………………………………………….11Card 3: Play B: How to Play with Your Child………………………………………………13Card 4: Play C: Making Toys…………………………………………………………………………….16Learning and Developing Through Play (Cards 5-9)……………………………………22Card 5: Relationships……………………………………………………………………………………………28Card 6: Developing Communication……………………………………………………………………32Card 7: Physical Development……………………………………………………………………………37Card 8: Developing Understanding……………………………………………………………………41Card 9: Developing a Sense of Self………………………………………………………………45Card 10: Learning Rules, Limits and Values…………………………………………………49Card 11: Review: Principles Of Good Mother-Child Interaction……………52Mother to Mother Groups………………………………………………………………………………….58Some General Guidelines for Conveying Health Messages and Conducting Group Work……………………………………………………………………………………….60Motivating Mothers……………………………………………………………………………………………..60Some Pointers for Running Good Groups……………………………………………………….65Children with Special Needs and Difficult Children………………………………….71Advice for Home Visits……………………………………………………………………………………..73Psychosocial Assessment…………………………………………………………………………………..78Problem Solving…………………………………………………………………………………………………….81Annex 1: Activities with Toys………………………………………………………………………..83Annex 2: Optional Handout for Mothers and Care Providers……………….85Annex 3: Bringing Up Sensitive Children and Preventing Violence Among Them……………………………………………………………………………………..88
- UNICEF Guidance Note: Integrating Early Childhood Development (ECD) activities into Nutrition Programmes in Emergencies. Why, What and How IASC MHPSS Guidelines in Emergency SettingsHincks Del-Crest (HDC), Learning Through Play (LTP) MaterialRegional MOU between IMC and HDC for use and adaptation of LTP materialGood Practice GuidelinesIncorporate psychosocial components into Nutrition programs for young children, and vice versaEstablishing integrated, holistic community based services with cross cutting links with health, nutrition, psychosocial support Cross sectoral coordination, including health, nutrition, Watsan, protection, etc.
- e.g. play, feeding etc, showing love, health care, toilet training, sleep, parenting, challengesDone in Uganda, Haiti, SL (probably Eth)
- Adapted from HincksdelCrest, local artists and local languageIMC-UK will train 10 baby tent monitors with a one-week training in infant stimulation and early child development, including use of the UNICEF ECD kits theoretical training, IYCF care practices and approaches, which will be combined with 10-session trainings in mother and baby group work. Training materials include culturally adapted Early Childhood Development materials designed by Learning through Play Canada and its local partner LTP Haiti. These master trainers (baby tent monitors) will conduct further trainings with 10 mentor mothers each (total of 100 mentor mothers from IDP and host communities) in the same materials. Each mentor mother will then train additional groups of 10 mothers, and will run an average of five groups throughout the program period (50 mothers each-5000 in total). One IMC’s master trainer (baby tent supervisor) will attend the UNICEF provided baby tent training, where after this will be cascaded to all 10 master trainers (baby tent monitors).
- Somali refugee camps in EthiopiaTrained ARRA health professionals and CHWs and then ran mother to mother groups (they also received training in nutrition)
- ECD (0-3years)Target: mixed Iraqi Refugee and Lebanese host population groups , 5-10 caregivers per groupCaregiver profile: mothers, mother in laws, and fathers (latter engaged somewhat through nutritional component of the program, more committed engagement with father only groups is in the works J)Setting: PHC clinics (3) , and IMC social center (1) – 4 regions in Lebanon with high concentration of Iraqi RefugeesOutcome: Groups are ongoing, and while we have administered both KAP and wellbeing baseline, groups don’t complete the 10 sessions for another month.Material: Hinck Del Crest “Learning through Play”, adapted to local context, with added health and nutritional components.The objectives of the education program are: (a) To provide parents with information on the healthy growth and development of young children (birth to six), focusing on the physical, health, nutritional, intellectual, linguistic, and social-emotional aspects of development; (b) To teach parents play activities that enhance child development; and (c) To promote attachment through active parental involvement in their child’s development.The ECD program is based on 10 learning sessions.Session 1. Early Years and the BrainSession 2. AttachmentSession 3. Child Growth and DevelopmentSession 4. Sense of Self and RelationshipsSession 5. Understanding and CommunicationSession 6. The Importance of PlaySession 7. Toys and Toy MakingSession 8. Guiding BehaviorsSession 9. Child Nutrition and HealthSession 10. Child SafetyNote: above sessions, now include health and educational messages throughout developmental years. HOPE this helps J let me know if you need anything else.Note: We have been successful in having father-only groups in Syria – these groups were in the form of support groups rather than informal education sessions. Age group: 0-3 and 4-6 years for both Lebanon and Syria, both children with/ without special needs. Special Needs: IMC was able to adapt Hincks Del Crest Material for parents with children with special needs – material was field tested and program now being replicated in Lebanon.
- improve mothers knowledge and well-being (daily functioning, feelings, family dynamics and social connectedness). An external evaluation of IMC ECD in Jordan similarly found improved knowledge and parenting behaviors as well as impact on refugee isolation and loneliness—Ethnographic Background StudyRandomized controlled trialMother care groups vs. visits from lead mothers vs. controlOutcomes:Maternal MoodCaregiver knowledgeMother-child interactionHealth and nutrition outcomes
- In our first case study we will be looking at experience with integration in an emergency context in Uganda
- In 2007, IMC had a well-established community-based emergency nutrition program at nine centers in the neighboring districts of Kitgum and PaderThe nutrition program was combined with health education sessions on the topics of feeding practices, HIV, contraception, hygiene, and illness in the child. [Previously, there was no education on early child development or infant stimulation.]
- Six weekly mother and baby group sessions, where mothers were given culturally appropriate education on early child development, the chance to discuss and practice age-appropriate play activities with their babies, toy making, and and to share experiences and difficulties they had, (lively discussions on how to set limits and teach good behavior regarding the costs and benefits of physical punishment which had increased under the stresses of IDP life).Home visits by the psychosocial facilitator and nutrition support worker lasting 1–2 hrs, providing further opportunities to discuss and practice what they had learned in the group and to address nay behavioral or relational challenges any problems.
- The study was conducted at the five established feeding centers in the Kitgum district. It contrasted two interventions: At three sites (K1, K2, and K3), attending mothers received nutritional support plus the psychosocial intervention. A sample of these intervention mothers (132) was compared on outcome measures with a sample of 105 mothers in a contrast group at two other Kitgum feeding sites (K4 and K5), who received the nutritional intervention alone.*Mothers whose infants were so severely malnourished they required inpatient care at the stabilization centers were excluded from the evaluation. * These mothers were wait-listed for the psychosocial intervention, which they received after the research was complete.
- Three outcome measures were used to assess the impact of the psychosocial intervention: The Acholi Home Observation for Measurement of the Environment (HOME) was used to assess the impact of the intervention on mother’s ability to stimulate her child, (b) The Kitgum maternal mood scale to assess changes in maternal mood, and(c) KAP test to assess changes in maternal knowledge of ECD.
- mothers in the intervention group showed “Greater involvement with their babies”“More availability of play materials”“Less sadness and worry at follow-up”This study suggests that a low-cost intervention of relatively short duration (4-6 weeks) consisting of group sessions and home visits, conducted in addition to a nutrition intervention (CMAM program) in an IDP camp in a conflict affected area, may improve mothers’ mood, their involvement with their children and the availability of play materials.These improvements in maternal mood and maternal involvement are important. There is now a body of evidence linking low maternal mood (both clinical depression and depressive symptoms) with under nutrition and poor health outcomes in children in socially adverse environments.(Patel, Rahman, Jacob, & Hughes, 2004; Rahman, Iqbal, Bunn, Lovel, & Harrington, 2004; Rahman, Patel, Maselko, & Kirkwood, 2008).
- Some mothers established new mother-to-mother ECD groups in their neighborhoods, as a result of social connectedness and improved knowledge & skills.Given the benefits of integrated programming, IMC’semergency and developmentnutrition programs are looking at integrating ECD psychosocial interventions via group and home visits.
- Now we take you to a development context
- With the end of the war in 2002, SL had the highest child mortality rate in the world at 267 out of 1,000. Approximately 36% of surviving children under the age of 5 are stunted, 21 % are underweight and 10% are wasting in Sierra LeoneSince 2010, IMC has been implementing SNAP program.
- The care group model in the SNAP program is set up such that 15 pregnant and lactating women (or caregivers of children under 2) are supported by 1 lead mother.10 lead mother make up 1 care group1 health promoter supports 5 care groups (or 50 lead mothers)In total, 43 health promoters reach 43, 671 PLW through this community-based social and behavior change model.Every two weeks, the lead mother meets with her respective neighborhood women and they discuss a theme focusing on optimal IYCF, WASH and family planning practices. They also have cooking demonstrations using recipes using locally available nutrient rich foods and practice feeding their children. Following these group sessions, the neighborhood women receive individualized counseling from the LM who makes a home visit. This provides a chance for her to help the caregiver in addressing her individual constraints in adopting the optimal practice.The care group model presented an ideal medium through which to integrate an ECD program in an effort to promote optimal child development and follow WHO recommendations for using psychosocial strategies in addition to nutrition-based interventions.
- In 2011, a pilot study was conducted in 3 chiefdoms of Bombali District. An ethnographic study was conducted to better understand the context in which children grow up, constraints and opportunities to practicing optimal child development. Followingthe care group model already in place, a cascade training approach where CGV taught the ECD curriculum and supported neighborhood women in practicing optimal behaviors throughMCG group sessions OR group received one-on-one home visits. The ECD curriculum looked at mother-child interaction, play, and supporting child development in the 5 areas.In each two-hour session, the 1st was devoted to MCG nutrition activities, the 2nd hour focused on ECD topics. The counseling cards are available to see.
- The program aimed to consider whether a psychosocial intervention has an impact on mother-child interaction, maternal knowledge of early child development, and maternal mood, and what the best approach for delivering it is. Due to methodological and technical limitations [staff turn over, no technical expert on the ground throughout the study, poor data collection], the pilot study did not yield the information the project had hoped for.However, with the richness of the ethnographic research findings, study tools and module development, the SNAP program is planning to continue to train project staff and community members and roll out the module in other MCGs in other chiefdoms during the remainder of the project.
- Can we have exactly the same headings for each case study- e.g. context, objectives, program design, measures/results (or materials) or whatever works?The objectives of the education program are: To provide parents with information on the healthy growth and development of young children (0-3years, 3-6years), focusing on the physical, health, nutritional, intellectual, linguistic, and social-emotional aspects of development; (b) To teach parents play activities that enhance child development; and (c) To promote active parental involvement in their child’s development.
- Formative evaluations with ECD facilitators, showed a significant need voiced by caregivers about need for more focused nutrition and health messages.
- In addition, the caregivers reported a significant change in their behaviors with their children:Mothers reported that they have stopped hitting their children as a means for disciplineMothers better expressed their care for their children, and made an effort to stop comparing siblings.Caregivers are Following recommended vaccination schedules for their childrenMaintaining healthy food choices as part of their children’s diet. Implementing household safety measures to prevent accidents. Mothers have also reported making friends as part of the ECD sessions and continue to meet regularly.2 Local ECD educators from the refugee community now run their own ECD groups within their community.
- Programming ECD within Food Assistance or Nutrition Feeding ProgramsECD integrated into PHCNutrition, Health and Social Support integrated within ECD Psychosocial Programming.Integration is feasible within emergency, transitional and development contexts.The hands on approach through practice and home visits is key in producing positive outcomes.Investing in a training of trainers approach in the community is essential for sustained ECD programming.