Clean, Fed & Nurtured: Joining Forces to Promote Child Growth and Development

"[E]arlier conversations had revealed that while the WASH sector was increasingly integrating with the nutrition sector; and that ECD research and programming experts have been coordinating with nutrition specialists, little coordination existed between the ECD and WASH sectors, or with all three integrating or collaborating in any comprehensive effort."

This Alive & Thrive report includes results of a consultative meeting, May 2-3 2013, Washington, DC, United States, that was organised as an initial step in bringing together experts in: early childhood development (ECD); nutrition, in particular infant and young child feeding (IYCF); and water, sanitation and hygiene (WASH) to discover synergies and opportunities to collaborate "to achieve the goal of thriving children with a future as productive, resilient adults." Organisers also included the Global Public-Private Partnership for Handwashing, Save the Children, and WASHplus, with support from the Bill & Melinda Gates Foundation, FHI 360, and USAID.

Evidence for collaboration included:

• WASH practices lead to diarrhoeal disease reduction. Handwashing "before food preparation and feeding is particularly effective in reducing child diarrhea at this critical time in child growth...” suggesting - though not documenting its impact on - stunting given, the cyclical relationship between diarrhoea and malnutrition. Promoting handwashing associated with children during the first 30 months of their life translates to positive developmental/school gains at 5-7 years of age.
• "[T]he first 1000 days (comprising pregnancy and a child’s first two years) were noted as the critical window of opportunity to influence a child’s growth and development, with a need to pay attention to a woman’s health status pre-conception. The case was made for combined interventions that include nutrition, infection control, and macro- and micro-nutrients." Breastfeeding is a recognised positive nutritional influence.
• In a child's early period, important factors are: "proper nutrition, nurturing parents/caregivers, adequate health services, social protection, and community and school support that can serve to counteract/buffer poverty and toxic stress."

Gaps in the research around WASH and birth outcomes, diarrhoeal disease, and intestinal worms were discussed, as well as the timing and length of interventions and the effects of maternal depression on child stunting.

Field programme descriptions focusing on the three areas included (available in a slide presentation here):

• a mobile phone/SMS intervention for pregnant women and new moms and their babies in South Africa
• a handwashing, sanitation, and food hygiene intervention in Zambia, India, Nepal, and Indonesia
• an educational intervention to improve child nutrition in Peru, and
• a nutrition and early stimulation intervention in rural Bangladesh.

Drivers for behaviour change in integrated programmes were recognised as critical to message development. The danger of overloading mothers and caregivers with multiple behaviour changes and multiple messages was discussed. "Attendees raised a number of challenges for developing a responsive communication strategy: crafting messages for multi-channel communication activities, teasing out what motivates and what works, and reaching mothers where mass communication is not accessible.” Conversations on gender inequity and cultural norms focused on “the resultant negative impact on a mother’s lack of access to money, nutritious food, and social services for her child and herself, and ultimately a child’s long-term development and growth."

A positive behavioural focus was exemplified by the most popular message of the programme in Peru - teaching responsive feeding using love, patience, and good humour. In this programme, the modelling of behaviours to form habits, e.g., the mother talking to her child from Day 1, was noted, along with sensitivity and responsiveness to a child’s cues. Fewer, more focused messages had improved feeding practices and reduced stunting. Similarly, the "small doable action" approach to changing behaviours was recognised as an Alive & Thrive and WASHplus strategy, e.g. emphasising washing prior to food preparation. Messaging to multiple family members and communities is a strategy of the MAMA programme in Bangladesh, where grandmothers and fathers sign up for SMS text messages aimed to activate cultural shifts “expected to improve family behaviors and ultimately improve outcomes for the child." Message-related comments included: "[d]esigning integrated programming addressing multiple behaviors and multiple messages should not be too complex..."

Indicators for outcome evaluation that could be shared across the three sectors include: stunting as a recognised child growth indicator and existing ECD cross-cutting behavioural indicators (with a need for developmental (cognitive) indicators, framed by age-group). Discussion to develop standardised measures for monitoring and evaluation was begun.

The Counseling Card on Caring for Newborns and Children in the Community was a tool used to expand discussion of other possible tools, e.g. a package of "Essential Hygiene Actions" parallel to the Essential Nutrition Actions "to present and prioritize behaviors and actions, and then prepare messages that are timed and targeted to the audiences, which was noted should include fathers and grandparents."

Future actions focused on 5 topics: "1. Start an integrated program or build an integrated program into an existing program; 2. Prioritize household practices and identify the touch points; 3. Develop priority research questions; 4. Identify opportunities to integrate research into programs in the next five years; and 5. Develop cross-cutting indicators." Communication components include:

• Advocate for stunting as an integrated outcome indicator.
• Identify teachable moments during transition points (e.g., at time of delivery and when the child is six months old) and touch points (opportunities to reach mothers, e.g., during home visits, vaccination days, etc.), using nurture as a motivational driver.
• Investigate the number and frequency of contacts that are needed to change single/multiple behaviours.
• Develop an international set of Essential Hygiene Actions. 
• Develop research questions that take an integrated approach and look across all three sectors to identify opportunities in current work.
• Advocate with policy makers, thought leaders, and donors, and at all levels from top down to bottom up.
• Recast the narrative to be: "Clean, Fed & Nurtured" with topline indicators:
• Clean: availability and use of a household toilet
• Fed: stunting
• Nurtured: an indicator that captures language development/school readiness
• Look at how indicators have been applied, including by looking at the Multiple Indicator Cluster Surveys (MICS)

Commitments of attendees include: champion an integrated approach; discuss with colleagues in other groups, networks, and sectors; promote the new branding and indicators; and continue work on definitions of essential behaviours and indicators.