INTEGRATING EARLY CHILDHOOD DEVELOPMENT AND COMMUNITY-BASED NUTRITION

IN CENTRAL AMERICA

Synopsis of workshop report

Tegucigalpa, Honduras August 14-16, 2012

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Table of Contents Introduction ............................................................................................................................................................................... 2

The Importance of Early Childhood Development .................................................................................................... 4

Why Focus on Early Childhood Development? ...................................................................................................... 4

A Comprehensive Approach to Early Childhood Development Policies ...................................................... 7

The Way Forward ............................................................................................................................................................... 8

ECD Policies in Central America ................................................................................................................................... 9

Case Study: Integration of Early Stimulation in Honduras’ Community-Based Growth Promotion Program, AIN-C ....................................................................................................................................................................... 12

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Introduction

It is well established that a child’s ability to develop and learn is related to the synergistic interplay

of good health, good nutrition, and appropriate stimulation and interaction with others. Many of the

Central American countries have put in place programs to improve child nutrition using

community-based approach. These community-based growth promotion (CBGP) programs support

children’s growth through regular growth measurement and individualized counseling to parents

about caring practices, feeding, disease treatment, and appropriate use of health services. Given the

vital synergy between nutrition and other Early Childhood Development (ECD) activities (e.g. early

stimulation, parenting skills), and the importance of counseling and follow-up with caregivers,

incorporating ECD activities into CBGP programs is a promising approach to integrated child

development.

In an effort to share experiences related to the integration of ECD and

community-based nutrition programs, the Bank, along with the Ministry of

Health, organized a regional workshop held in Tegucigalpa, Honduras, on

August 14-16, 2012. The workshop, “Integrating Early Childhood

Development and Nutrition in Central America,” built on interest

expressed in the regional workshop “Promoting Healthy Child Growth and

Development: Advances and Opportunities for Community-Based

Nutrition Programs in Central America,” held in the city of Panama

October 26-28, 2011.1

The primary objectives of the ECD and nutrition workshop were to

exchange experiences on the development of ECD policies, especially the

integration of CBGP programs and ECD activities, and to prepare a road

map to ensure that the lessons learned from the exchange contribute to

optimal early childhood development in Central America.

The specific objectives of the workshop were:

1. To present a rational for integrated approaches to early childhood

development.

2. To present and practice a methodology for designing services based on beneficiary needs

3. Discuss how different nutrition programs incorporate an ECD approach during early

childhood.

4. Learn about a community-based child nutrition program (Atención Integral a la Niñez

Comunitaria, AIN-C), which integrates early stimulation and nutrition.

5. Agree on actions to strengthen and align nutrition interventions with early stimulation, care

guidelines, health care services and other comprehensive early childhood development

practices.

1 Workshop report: http://siteresources.worldbank.org/INTLACREGTOPNUT/Resources/EnglishfinalReport.pdf

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Workshop participants included representatives of the Ministry of Health, including those responsible for AIN-C and PAIN (Proyecto de Atención Integral al Niño y la Niña), the Ministry of Social Development, the Honduran Children and Family Institute (Instituto Hondureño de la Niñez y la Familia, IHNFA), as well as representatives of various Honduran organizations implementing early childhood development and nutrition programs (e.g. Red Cross, ChildFund). Government officials from El Salvador, Guatemala, and Panama also participated.

The workshop made use of a variety of methodologies, including

presentations by experts, exhibitions of materials from the

various countries, a group activity to learn about and apply the

Human Centered Design methodology, and a field visit.

The meeting emphasized the importance of strengthening efforts

focusing on early childhood development and nutrition during

the first one thousand days of life and collaborating across

countries to identify joint solutions.

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The Importance of Early Childhood Development

This section presents strategic guidelines and actions being implemented in Central America

related to social protection and early childhood development.2 Policies aimed at children are not

always targeted at early childhood, the most critical period for development, and often these

policies are not sufficiently coordinated so as to provide an integrated set of services from different

sectors to each individual child.

Why Focus on Early Childhood Development?

Scientific Arguments

Scientific studies show that the foundations of a successful society

are built on the first few years of life. Investing in early childhood

health, nutrition and cognitive development increases the potential

that children will achieve optimal development and grow up to be

engaged and intelligent adults. This investment not only helps

individual children to develop, but also acts as the foundation for a

healthy and productive society.

Scientific evidence shows that during the first 6 years of life, 700 synapses in the brain are formed

every second. After age 14 the number declines significantly (see Figure 1). Children’s brains are

like a machine that observes and processes everything, especially within the first 2 years of life. If

this observation and learning is not stimulated, it will be lost and cannot be regained at a later time.

Figure 1: Formation of synapses in the brain

2 This section is based on a presentation by Veronica Silva, Social Protection Specialist at the World Bank.

At birth Age 6 Age 14

Experience shapes the brain’s architecture in the first years of life. Source: Shonkoff, 2010

“A strong foundation lays the groundwork for responsible citizenship, economic prosperity, healthy communities, and successful parenting of the next generation.” (Shonkoff, 2010)

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Data show that the first year of life is critical for child development. Sensory development, including

sight and hearing, language, and higher cognitive function attain their highest level of development

in the first two years of life (see Figure 2). The development of sight and hearing is highest within

the first 3 months and language between 6 and 7 months. This implies that if children are not

spoken to during the first 6 months, they cannot achieve the same level of language development

and the damage has to be repaired. Higher cognitive function peaks within the first 2 years of life,

so complementary early stimulation actions should be included in child growth and development

programs. Also, because the window of opportunity for intervention starts during pregnancy, it is

important to begin programming with parents-to-be at that stage. Prenatal check-ups are not

merely a health investment to ensure a healthy delivery and baby, but also can facilitate optimal

brain development.

Figure 2: Timing of brain development

Studies have shown that extreme neglect reduces the power of the brain. Neglect, defined as lack of

attention or indifference, but not abuse, occurs when a baby is not spoken to, touched, or cared for –

conditions necessary to develop electrical connections in the brain and, in turn, healthy

development (see Figure 3).

Figure 3: Influence of stress on development

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Normal brain plasticity, i.e. the flexibility required to assimilate information and adapt to new

stimuli and situations, declines with time. In contrast, the physiological effort required to enhance

neuronal connections increases over time. The two intersect around age 30. Given the timing of

each of these kinds of brain change, the most crucial period for investing in brain development is

prior to age 10 (see Figure 4).

Figure 4: Brain changes over time

As the brain matures and becomes more specialized and able to assume more complex functions, it

is less able to reorganize and adapt. For example, at the end of the first year of life, the parts of the

brain that differentiate vocal sounds specialize in the language to which the child has been exposed

and the ability to recognize important sound distinctions with the other languages begins to be lost.

The brain “trims” the circuits that are not used and those that are used are strengthened and

become very difficult to alter through time. A decline or reduction in brain plasticity means that it is

more effective to influence the development of the brain architecture of a baby than to “retrain”

brain circuits in adults. Failure to invest early to ensure positive conditions for healthy child

development, means paying more later in terms of health care, mental health services, etc.

Preventive interventions are more efficient and generate better outcomes than remedial actions. It

has been demonstrated that the rate of return of human capital investment is higher during the first

three years of life. The earlier the investment is made, the more profitable for society. Later the

cost becomes very high and does not provide the required returns.

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Other arguments in favor of ECD policies

1. ECD efforts have an important impact on children’s brain and physical development,

providing benefits for their whole life.

2. ECD programs improve children’s mental and physical health, reducing their dependency

on health care services.

3. ECD improves children’s readiness for school, as well as educational outcomes.

4. ECD interventions reduce participation in high risk behaviors, including crime, drugs,

violence, etc.

5. ECD interventions are a key strategy to promote equity and fight against poverty.

A Comprehensive Approach to Early Childhood Development Policies

When conceptualizing ECD interventions and policies, there is a tendency to think of the material

things that children may need. However, at the core of children’s development are not things, but

rather their own needs. Public policies have to address not only children’s material or biological

needs, but also their cultural, social and psychological ones. Both the child’s own attributes

(biological and psychological) as well as the conditions that surround the child (cultural and social

attributes) affect each child’s development (see Figure 5). For example, something like mother-

child bonding, which has much to do with the biological and psychological conditions of the mother

and child, is also influenced by hospital policies about whether to keep babies with mothers, the

absence of treatment and counseling for post-partum depression in many places, and the duration

and timing of maternity leave.

Figure 5: Influences on child development

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Children develop in the context of family, community, and public policies, all of which affect their development—in positive and negative ways. For example, in many places there are no safe public spaces for children under age three to be and watch what is going on in their community and in many places waiting rooms at health posts have no activities for children. A pro-child community or space is aware of young children’s needs and adjusts to the needs of the youngest children.

To have a comprehensive policy it is necessary to provide different kinds of support for the same

child, family and community, including:

Integrated care services: This is not equivalent to having

many services; instead it is about ensuring that all of the

necessary services reach the same child.

Personalized follow-up: This involves not only checking in

on children and families, but also defining clear referral

protocols for difficult cases. The referral protocol should

ensure that the child will be received and cared for in time,

and not put on a waiting list so that the window of opportunity is lost.

Effective intersectoral arrangements and actions: This is important to ensure that services

provided by different sectors are coordinated.

Information systems: A system to capture and track data on child development services and

outcomes is critical to determine which services reach a child and which are needed. Since

the family is the entry point for children’s development, it is important to keep records of

the families with young children.

The Way Forward Implementing a comprehensive set of ECD policies does not require starting from scratch, but rather should build on and coordinate with existing ECD actions already being implemented, whether these be in health, nutrition, education, parenting, poverty-alleviation, other another area.

In terms of education, it is important to think beyond teachers and classrooms because children

under age three often do better in a family-like environment. Conditional cash transfers have great

potential to make a significant contribution to ECD, but this has not been capitalized upon. There is

a captive population of beneficiaries, usually with young children, but parental and early

stimulation components have not been developed.

Whatever the intervention, it is critical to be able to measure the impact on child development. This

should be measured with tests based on a set of indicators that can be reported to various actors

and stakeholders. Ideally, a country’s public policies should be focused according to the indicators

(see Figure 6).

Probably each child has

the support of an ECD

program, but none has the

support of all the

programs they need.

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Figure 6: Set of Indicators for ECD

ECD Policies in Central America

Here is a very general assessment of ECD policies in the region:

There are multiple programs targeting early childhood, most of which operate without

coordination, therefore, resulting in duplication.

Some have a broad coverage and others are very small.

Some are present throughout a country or region and others are only present in a specific

territory.

In cases where there are multiple programs, it is not known if the different types programs

reach the same children.

Generally, programs are demand-driven more than supply-driven: people are expected to

go to get services themselves, but often those who need the program the most is least likely

to seek them out. This demand-focused approach means that many children are being

missed and once a child passes the early years, much of the opportunity for development

has passed.

Maternal care Child health Early education/ Social Protection and nutrition stimulation Prenatal care (at least 1 Infants with low birthweight Public programs Children registered at visit) focusing on children at birth under 5 Prenatal care (at least Under 5 underweight Access to pre-primary Child abuse (physical, 4 visits) education psychological, neglect) Birth attended by trained Under 5 stunting Estimated duration of Child labor staff pre-primary education Institutional delivery Child mortality Pre-school attendance rate (x 1,000) Repetition rate in first Extreme poverty Under 5 mortality rate cycle of primary Maternal Mortality Rate (x 1,000) (x 100,000) School dropout in first Vaccination cycle of primary Children affected by displacement Exclusive breastfeeding (6 months) Pre-primary trained teachers Learning outcomes

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A World Bank report analyzed Central American countries based on the following four policy

dimensions, using several established indicators:

1. Enabling environment

2. Policy focus

3. Degree of implementation

4. Monitoring and quality assurance

In each of these dimensions, the countries have been classified using the scale latent, emerging,

established or mature, reflecting a process towards reaching a mature policy (see Figure 7).

According to this study, there are mature policies for the dimension of “enabling environment” only

in Costa Rica and El Salvador. On the other hand, there are latent policies in the dimension of

“monitoring and quality assurance” in four countries: El Salvador, Guatemala, Honduras and

Panama.

Figure 7: Classification of Central American ECD policies

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The Central American Social Integration Council (Consejo de la Integración Social Centroamericana,

CIS) has established four strategic lines within the Early Childhood Regional Comprehensive Care

Plan, 2012-2021. They are:

1. Intersectoral coordination to improve access to early childhood comprehensive care

services.

2. Improving the quality of early childhood comprehensive care services.

3. Training and capacity building in early childhood care.

4. Institutional, national, and regional institutional capacity building for early childhood

comprehensive care.

At the presidential summits these four regional actions were agreed upon among the targets and

actions for each country; and they are specifically time-bound. However, there is a lack of sufficient

knowledge, tools, and skills, which makes it necessary to support training in these fields.

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Case Study: Integration of Early Stimulation in Honduras’ Community-Based Growth Promotion Program, AIN-C The AIN-C Program is a community-based growth promotion (CBGP) Program. CBGP programs support children’s growth through regular growth measurement and individualized counseling to parents about caring practices, feeding, disease treatment, and appropriate use of health services. A common program feature is the use of a team of community volunteers (called monitoras) for counseling, monitoring children’s growth, and helping families and communities overcome obstacles to healthy growth. Given the vital synergy between nutrition and ECD, and the importance of counseling and follow-up with caregivers, incorporating ECD activities into CBGP programs is a promising approach to integrated child development. Using the CBGP platform has the advantage of reaching children at the community level during their most important developmental years—the first two years of life—and having regular contact with parents/caregivers. In 2007, a component on early stimulation was integrated into the AIN-C strategy (called AIN-C+ES) in 17 communities in the municipality of Chinacla in the Department of La Paz. 3 This began as a pilot strategy and later the Ministry of Health’s Integrated Care for Children program (PAIN in Spanish) made the decision to include the early stimulation component in the AIN-C strategy under the Nutrition and Social Protection Project financed by the World Bank. Project implementers include the Ministry of Health, the Nutrition Program of the Regional Health Directorate in La Paz, and ChildFund, an NGO with almost 25 years of experience in ECD. The AIN-C+ES model consists of adding a development assessment, activities, and counseling on early stimulation to existing AIN-C activities. First, a development scale designed by ChildFund and validated in several countries is applied to measure child development levels. The result indicates what kind of stimulation the child needs to receive.

3 Information in this section comes from: Gutiérrez, Tesla. 2012. “Informe de implementación de la estrategia de Atención Integral a la Niñez en la Comunidad (AIN-C) con el componente de estimulación temprana en el Municipio de Chinacla del departamento de La Paz, Honduras.”

“As a mother I have learned to care and treat my children better and stimulate them from the womb. Now I am a better mother and a friend to my children. I have learned to do new things such as make toys from bottles and plates. It is better to learn to make toys in our home. Our children are superstimulated.” - A mother from Arenales, Chinacla, La Paz

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Children are classified into four development levels: Advanced: the child’s developmental age exceeds his or her biological age. Expected: the child’s developmental age coincides with his or her biological age. At risk: the child’s developmental age is less than the biological age. At high risk: the child’s development age is one or more years behind the biological age.

The first two levels (advanced and expected) are considered to represent adequate development. Children identified as at risk and at high risk become the intervention priority, with home visits and referrals to additional kinds of care, such as the La Paz Hospital, in this case. The AIN-C+ES monthly meetings operate in an integrated manner. One monitora measures the child’s weight and then the child and the mother/father move on to the second monitora who charts growth on a chart and shows the trend to the caretakers. The third monitora assesses the child’s development and provides individualized counseling on the child’s feeding and care practices as well as healthy age-appropriate development (see Figure 8). At the end of the meeting, the information is recorded and entered into the Ministry of Health’s Information, Monitoring and Evaluation System (Sistema de Información, Monitoreo y Evaluación, SIME). Figure 8: AIN-C+ES Activities

Attention and counseling is personalized for each mother and child and there are also support groups that meet twice a month to work on specific community issues. During the month, the monitora and ChildFund promoter make follow-up visits to children identified as needing additional attention (e.g. persistent lack of weight gain, development level at risk or high risk, illness, etc.). If any child is determined to be at high risk, he or she is referred to the Hospital Center.

MONTHLY

AIN-C MEETING

Monitora 1 Measures weight

Monitora 2 Plots graphics, builds trend and fills in list

Monitora 3 Provides individual counseling on feeding and checks progress in the child’s development

Development of community report and home visit plan

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Monitora 1 Monitora 2 Monitora 3 To help stimulate the development of their children’s skills and abilities, parents receive a brochure corresponding to the child’s age. This is used to begin stimulating the skills and abilities that the child has not yet acquired and the outcomes are tracked as follows:

Children with advanced and expected development level: Follow up provided during monthly AIN-C meetings.

Children with at risk development level: Follow up provided through home visits, during which the parents will be shown how to conduct the activities described in the early stimulation brochures.

Children with high-risk development level and/or special needs: These children are referred to a hospital or specialized center for the relevant evaluation and diagnosis. Those diagnosed with a disability are referred to a specialized center. In both cases, the monitora’s role is to provide follow-up through home visits to verify compliance with the recommendations from the specialized services.

Although there has not been an impact evaluation of the AIN-C+ES strategy and there is no evidence of causal effects, the analysis of data on child growth and development shows some important progress among the children participating. For example, at baseline, 55 percent of the children were measured as having the “expected” development level and two years later 78 percent had achieved this level. Also, the number of children identified as having problems with fine or gross motor skills, communication and language, emotional and cognitive skills declined as follows:

Gross motor skills problems: 8 children in 2009 vs. 3 children in 2011 Fine motor skills problems: 22 children in 2009 vs. 2 children in 2011 Communication/language skills problems: 19 children in 2009 vs. 6 children in 2011 Emotional problems: 32 children in 2009 vs. 8 children in 2011 Cognitive problems: 39 children in 2009 vs. 3 children in 2011

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The AIN-C+ES strategy in Honduras presents a promising model for providing support for child growth and development in a community-based and integrated manner. At the same time, it is important to consider the tradeoffs of assigning ECD-related responsibilities to monitoras, such as higher turnover due to greater workloads. Given that the ECD activities linked to a community-based nutrition program have not yet been implemented at scale, nor rigorously evaluated, it would be valuable to learn more about the impacts on child development, nutrition outcomes, and other outcomes of interest resulting from larger efforts and, possibly, additional models of intervention amd to document synergies to use for advocacy and knowledge-exchange.