ANNALSOFTHENEWYORKACADEMYOFSCIENCES
Issue:IntegratingNutritionandEarlyChildhoodDevelopmentInterventionsPromotingequitythroughintegratedearlychilddevelopmentandnutritioninterventions
MaureenM.Black1andKathrynG.Dewey2
DepartmentofPediatrics,UniversityofMarylandSchoolofMedicine,Baltimore,Marylandand2DepartmentofNutrition,UniversityofCalifornia,Davis,Davis,California
Addressforcorrespondence:MaureenM.Black,DepartmentofPediatrics,UniversityofMarylandSchoolofMedicine,Baltimore,MD21201.mblack@peds.umaryland.edu
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Sustainabledevelopment,afoundationofthepost-2015globalagenda,dependsonhealthyandproductivecitizens.Theoriginsofadulthealthbeginearlyinlife,stemmingfromgenetic–environmentalinteractionsthatincludeade-quatenutritionandopportunitiesforresponsivelearning.Inequitiesassociatedwithinadequatenutritionandearlylearningopportunitiescanunderminechildren’shealthanddevelopment,therebycompromisingtheirproductivityandsocietalcontributions.Transactionaltheoryservesasausefulframeworkforexaminingtheassociationsthatlinkearlychilddevelopmentandnutritionbecauseitemphasizestheinterplaythatoccursbetweenchildrenandtheenvironment,mediatedthroughcaregiverinteractions.Althoughsingleinterventionstargetingearlychildde-velopmentornutritioncanbeeffective,thereislimitedevidenceonthedevelopment,implementation,evaluation,andscalingupofintegratedinterventions.Thismanuscriptintroducesaspecialeditionofpapersonsixtopicscentraltointegratedchilddevelopment/nutritioninterventions:(1)reviewofintegratedinterventions;(2)methodsandtopicsindesigningintegratedinterventions;(3)economicconsiderationsrelatedtointegratedinterventions;(4)capacity-buildingconsiderations;(5)examplesofintegratedinterventions;and(6)policyimplicationsofinte-gratedinterventions.Ensuringthehealthanddevelopmentofinfantsandyoungchildrenthroughintegratedchilddevelopment/nutritioninterventionspromotesequity,acriticalcomponentofsustainabledevelopment.Keywords:integratedinterventions;earlychilddevelopment;nutrition;equity
Sustainabledevelopment,thefocusoftheUnitedNationsSustainableDevelopmentSolutionsNet-workforthepost-2015globalagenda,dependsonhealthy,productivecitizenswiththeintellectualskills,creativity,andmotivationtolead,govern,andimplementthepoliciesandprogramsofthefuture.Thepreparationofsuchcitizensbeginsbe-forebirthandcontinuesthroughchildhood,withthewell-acceptedrecognitionthattheoriginsofadulthealthandwell-beingstemfromthegenetic–environmentalinteractionsthatbegininthefirst1000days(fromconceptionthrough24months).1,2Thus,sustainabledevelopmentdependsonensur-ingthehealthanddevelopmentofyoungchil-dren,beginningprenatallyandcontinuingatleastthroughschoolentry.3
Thehealthanddevelopmentofinfantsandyoungchildrenisalsocentraltopromotingequity.The
doi:10.1111/nyas.12351
developmentofthehumanbrainbeginsprena-tallyandcontinuesthroughadolescence.Time-sensitivegenetic–environmentalinteractionsestab-lishthebasisfortheformationandpruningofneu-ronalconnectionsthatfacilitatethedevelopmentofculture-specificskills,suchaslanguage.4Environ-mentalinteractionsandconditionscanfosterequitybyensuringthatchildrenareexposedtorespon-siveandenrichingopportunitiesforexplorationandlearning,orcanfosterinequitythroughthedenialofopportunitiesandbasicneeds,suchasinade-quatequantityorqualityoffood.Nutritionplaysacriticalroleinchildren’sdevelopment,particularlyearlyinlifeasneurodevelopmentalbuildingblocksarebeingformedandnutritionalneedsarehigh.5Thecombinationofnutritionaldeficienciesandlackofresponsivecaregivingandopportunitiestolearnunderminesthedevelopmentofindividualchildren,
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Figure1.Life-spandevelopmentofequity/inequalitymaybemodifiedbyearlyintervention.ModifiedfromRef.26.
increasesinequities,andthreatensthewell-beingofentiresocietiesandcountries.6Interventionsthatintegratenutritionandearlychilddevelopmentofferpromiseforreducinginequities.7,8Althoughthereisevidenceofeffectivesingleinterventionstar-getingearlychilddevelopment9,10andnutrition,11thereisaneedforcriticalevidenceonthedevelop-ment,implementation,andevaluationofintegratedearlychilddevelopment/nutritioninterventionsinpreparationforscalingupinterventions.9Thisvol-umeexaminestheevidenceregardingintegratedchilddevelopmentandnutritioninterventionsandaddressesstrategiestopromoteequitythroughin-tegratedinterventions.Earlychilddevelopment
Childdevelopmentisconceptualizedfromalife-spanperspective.Earlyinlife,childrenacquireanorderlyprogressionofskillsthatformtheblueprintforsubsequentdevelopment.Aschildrenmatureandadapttotheirspecificcaregivingsettings,in-dividualandculturaldifferencesemerge,andearlydisparitiesbecomemorepronounced.12Risks,suchaspoverty,nutritionaldeficiencies,andlackofresponsivecaregivingandlearningopportunities,contributetoinequitiesinchildren’sdevelopment,resultinginover200millionchildrenunder5yearsofageinlow-andmiddle-incomecountries(LMIC)notreachingtheirdevelopmentalpotential.6
Theprotectiveeffectsofsensitive/responsivecare-givingonchildren’sbehavioranddevelopmentcan
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preventearlyinequitiesandpromotedevelopmentinmultipleareas,includingcognitiveandsocioe-motionaldevelopment.13,14Earlyinterventionthatpromotesprotectivefactorscanreduceinequities,thusincreasingthelikelihoodthatchildrenreachtheirdevelopmentalpotential(Fig.1).
Earlyinlife,infantsandcaregiversestablishare-ciprocalpartnershipinwhichtheyrecognizeandin-terpretbothverbalandnonverbalcommunicationsignalsfromoneanother.Thisreciprocalprocessformsabasisfortheemotionalbondingorattach-mentbetweeninfantsandcaregiversthatisessentialtohealthysocialfunctioning.15Caregiverrespon-sivityprovidestheemotionalsupportthatchildrenneedtodevelopinternalregulatoryskills,therebyleadingtoadvancesinbehavioralanddevelopmen-talcompetence.Thus,thecaregivingcontextplaysacriticalroleinprotectingandsocializingchildrenthroughouttheirdevelopment.16
AwiderangeofprogramsforyoungchildrenhavebeendevelopedinLMIC,includingmaternalemploymentprogramsthatprovidecustodialchildcare,home/communityprograms,andcenter-basedpreschools.Programcoverageandqualityvary,basedoncurricula,resourcesandmaterials,teachertrainingandsupervision,andparentandcommu-nityinvolvement.Effectiveinterventionsthatfocusonresponsivecaregivingandearlylearningoppor-tunitiesareavailable10,17andinvestmentsininter-ventionprogramsearlyinlifearemorecosteffec-tivethaninvestmentsduringlateryears.18However,
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interventionimplementationislimitedandoftenleastavailabletochildreninthegreatestneed.10,19Arecentmeta-analysisof30early-childhoodpro-gramsprovidedoutsideofNorthAmericafoundlargereffectsoncognitiongainsandbehaviorchangeamongeducationalandmixedprograms(stimulationorcare,combinedwithnutrition)thanamongnutrition-onlyprograms.20AnunexpectedfindingwasthatprogramsinLMIChadlowereffectsizesthanprogramsinhigher-incomecountries.Othershavefoundthatchildrenwiththemostdis-advantagesoftenexperiencethegreatestbenefits,10emphasizingtheimportanceofconsideringthespe-cificcontextinwhichinterventionsoccur.20Nutrition
Thedevelopmentofmanyorgans,includingthebrain,isdependentuponadequatenutrients.De-ficienciesinmicronutrientsthathavebeenassoci-atedwithbraindevelopmentarecommoninchil-drenunderage5,withtheprevalenceofiodinede-ficiency(40%inAfricaand31.6%inAsia),zincdeficiency(23.9%inAfricaand19.4%inAsia),andanemia(hemoglobin<110g/L,mostlyduetoirondeficiency:20.2%inAfricaand19.0%inAsia).21Deficienciesinmacronutrients(energy,protein,andfat)canleadtopoorweightgainfollowedbystunting,22andcertainmacronutri-ents(e.g.,essentialfattyacids)arealsoassociatedwithbraindevelopment.23Althoughthenumberofstuntedchildrenunder5yearsofagehasdecreasedfrom253millionin1990to165millionin2011,24therearestrikinginequitiesintheprevalenceofstuntingbetweenthepoorestandrichestquintileswithincountries.21Stuntingearlyinlifehasbeenassociatedwithconsequencesthatthreatenequitythroughoutthelifespan,includingdelayedschoolentry,earlyschooltermination,andpoorschoolperformance,resultinginreducedworkcapacityandhumancapital.25–27Earlystuntinghasbeenusedasanindicator,alongwithpoverty,toestimatethenumberofchildrenworldwidewhodonotreachtheirdevelopmentalpotential.6Thereductionofnutritionaldeficienciesandthepreventionofstunt-ingduringthefirst1000daysaremajorprioritiesinpromotingchildren’sdevelopmentandpreventinginequalities.
Inadditiontogrowthfaltering,overweightandobesityhaveemergedasseriousproblemsamong
youngchildrenthroughouttheworld.InLMIC,ratesofchildhoodoverweightandobesityhavein-creasedfrom4.2%in1990to6.7%in2010(repre-sentingover35millionchildren),withanexpectedincreaseto9.1%in2020(12.7%inAfrica).28Unlikeotherhealthandnutritionalconditionsthatdiffer-entiallyaffectchildreninthelowestwealthquin-tile,inLMICobesityoftenoccursinthehighestwealthquintiles,illustratingthecomplexitiesofthenutritiontransition.29Theconsequencesofchild-hoodobesityoftenbeginwithpsychosocialprob-lemsandextendtohealth-relatedproblems.30Al-thoughthestrategiesthathelpfamiliespromotehealthygrowthamongtheiryoungchildren(topre-ventunderweightandstunting)oftenapplytothepreventionofobesity,thisissuefocusesprimarilyonthepreventionofundernutritionandstunting.Nutritionalguidelinesoftenfocusonnutrition-specificinterventionsregardingtheavailability,ac-cessibility,andacceptabilityoffoodandnutri-ents,beginningbeforeconceptionandextendingtobreastfeedingpromotion,thetimingofcom-plementaryfeeding,anddietaryadequacyduringchildhood.11
Nutrition-sensitiveinterventionshaveemergedfromtherecognitionthatnutritionalstatusisaf-fectedbyfactorsthatextendfromsocietalcon-ditions,suchaspovertyalleviationandwomen’sempowerment,tohouseholdconsiderations,suchasmealtimeorganizationandfamilyfeedinginteractions.31Sincemanyofthesenutrition-sensitivefactorsaffectnotonlynutritionalstatus,butalsochildren’sdevelopment,26,27theycouldbeincorporatedintointegratedinterventions,32therebypotentiallystrengtheningbothnutritionalstatusandchilddevelopment.
Earlychilddevelopmentasacontextfornutritionalrecommendations
Thetransactionalsystem,thetheoreticalbasisforresponsiveparentingandresponsivefeeding,em-phasizestheinterplaythatoccursbetweenchildrenandtheenvironmentandprovidesausefulframe-workforexaminingtheassociationsthatlinkearlychild-developmentandnutrition.16,33,34Throughresponsiveinteractions,caregiversprovidestructureandencouragement,whileadaptingtheirreactionstosignalsfromthechild.Inatransactionalsys-tem,childrendeterminehowmuchtoeat(often
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feedingthemselves),ascaregiversprovidenurtu-ranceandsupportwithoutforcingchildrentoeat.Specificcareisnecessaryincaseswherechildrenhavelimitedabilitytosignaltheirneeds,whichmaybeattributedtothefussinessoranorexiathatmayaccompanyseveremalnutrition,illness,orprematurity.
Caregiversmodeleatingthemselvesandlearntorespondappropriatelytochallenges,suchaschil-dren’sfoodrefusal.Childrenexploreandlearninanurturant,respectfulcontextwithfeedingandmealtimebehaviorthatisdrivenbyinternalreg-ulatoryprocessesofhungerandsatietyaccompany-inghealthygrowth.34,35Unresponsivefeedinginter-actions,characterizedbynegative,coercivestrate-giestoencouragechildrentoeatorbypermissive,overindulgentstrategies,suchasprovidingfrequentsnackfoodswithlownutritionalquality,maycom-promisechildren’sfeedingbehavior,leadingtoei-therunderweightoroverweight.36
Feedinginteractionsareanintegralpartofbothbreastfeedingandcomplementaryfeedingandillus-tratehowprinciplesfromthetransactionalsystemthatinformearlychilddevelopmentcanbeinte-gratedintonutritionalinterventions.Forexample,breastfeedingpromotionisaprimaryobjectiveofnutrition-specificinterventions,withlowratesofexclusivebreastfeedingandbreastfeedingdurationinmanyLMIC.37However,breastfeedingsuccessisdependentonreciprocalmother–infantinterac-tionsandlowratesofpressuring.38Thesebehavioralconsiderationsarecentraltotransactionaltheory,andmaybebeneficialtobreastfeedingsuccessiftheyareincludedinbreastfeedingpromotionin-terventions.Theperiodofcomplementaryfeeding,generally6–24months,39isavulnerableperiodforgrowthfalteringandexcessiveweightgain.22Thisperiodcoincideswiththechild’sacquisitionoftheoralmotor,physical,digestive,andsocialskillsnec-essarytoadvancetothefamilydiet,alongwiththecommunicationskillstosignalhungerandsatiety.Responsivefeedinginteractionscanpromoteac-ceptanceofcomplementaryfood.40However,care-giverswhomisinterprettheirchildren’ssignalsasfoodrefusalorfeedingproblemsareatriskforus-ingunresponsivefeedingstrategies(i.e.,eithercoer-civeorpermissive).41Feedingproblemsareamajorconcernamongcaregiversofinfantsandtoddlersthroughouttheworld,42withprevalenceestimatesthatrangeupto45%.43
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Althoughmanypoliciesfrominternationalagen-ciesandhigh-incomecountriesincluderesponsivefeedingrecommendations,17therehavebeenfewtrialsinLMIC,andresponsivefeedingrecommen-dationshavenotbeenroutinelyoperationalizedintonutritionalinterventions.44Theirinclusioninpoli-ciesintheabsenceofeffectivenesstrialstoguideinterventionstrategieshasbeenattributedtothepresenceofastrongtheoreticalbasisforresponsivefeeding,globalconcernsregardingthenutritionalproblemsofstuntingandobesity,andemergingev-idencethatcontrollingandindulgentfeedingbehav-iorsunderminechildren’sregulatoryprocessesandcancontributetobothunderweightandobesity.44,45Theseexamplesillustratehowprinciplesfromchilddevelopmentandtransactionaltheorycanin-formnutritionalinterventionsandthecentralrolesthatcaregiverinterpretationsofchildren’sbehavior,caregiverbeliefs,andlocalcustomsplayinfeedingbehaviorandchildren’sacceptanceoffood.Inter-ventiontrialsareneededinlow-andmiddle-incomepopulationsthatexamine(1)howfeedingpatternsrelatetochildren’sgrowth,(2)whetherresponsivefeedinginterventionspromotedietarydiversityandhealthygrowth,(3)whetherresponsivefeedingin-terventionstranslatetononfeedingsituationsandpromotechildren’scognitiveandsocioemotionaldevelopment,and(4)whetherinterventionsthatpromoteresponsiveparenting46translatetofeedingsituationsandgrowth.
Nutrition-specificandnutrition-sensitiverecom-mendationshavealsobeenincorporatedintoearlychilddevelopmentprograms,oftenthroughpro-vidingfoodtochildrenandnutritioneducationtocaregivers.Theadditionofnutritiontoearlychilddevelopmentprogramshasbeeneffectiveinpro-motingchildren’scognitionandbehaviorincom-parisontonutrition-onlyprograms,althoughavail-ableevidencehasnotshownabeneficialeffectbe-yondeducation-onlyprograms.20Integratedinterventions
Twostrategieshavebeenusedtodesignintegratedinterventions.First,afactorialdesignhasbeenusedinwhichthetwointerventions(nutritionandpro-motionofchilddevelopment)areintroducedin-dependentlyandtheeffectofeachinterventionisevaluatedindependentlyandincombination.Thisstrategyenablescomparisonsofinterventionsaswellastheadditiveandsynergisticeffectsofthe
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combinedinterventions.Synergisticeffectsoccurwhentheimpactofoneinterventionisenhancedbythepresenceoftheother.Forexample,inanin-tegratedtrialinJamaica,theimpactofzincsupple-mentationwasgreateramongthechildrenwhore-ceivedpsychosocialstimulation.47Mostintegratedinterventionshavenotformallyevaluatedthesyn-ergisticeffects.Second,interventionscanbecom-pletelyintegratedsuchthatthetwocomponentscannotbeseparatedandevaluatedindependently.Inthisstrategy,boththeinterventionteamandtheparticipatingfamiliesperceiveasingleinterventionthatincorporatesbothnutritionandchilddevelop-ment,ratherthantwointerventions.Forexample,ProPAN(ProcessforthePromotionofChildFeed-ing)isanintegratedproceduredevelopedanddis-tributedbythePanAmericanHealthOrganizationandUNICEFtodevelop,implement,andevaluateinterventionsandprogramstoimproveinfantandyoungchilddietandfeedingthatincludebothfoodandresponsivefeeding.Thisvolume
Thepapersinthisvolumededicatedtointe-gratedinterventionsrepresentsixareas:reviewofintegratedinterventions;methodsandtopicsindesigningintegratedinterventions;economicconsiderationsrelatedtointegratedinterventions;capacity-buildingconsiderations;examplesofin-tegratedinterventions;andpolicyimplicationsofintegratedinterventions.
thatfollowedchildrenintoadulthoodshowedben-eficialeffectsofearlypsychosocialstimulationoneducationalachievementandpsychologicalfunc-tioning,butnosustainedeffectsofearlynutritionalsupplementationongrowth.49,50
Thesecondpaperisareviewoftheimple-mentationprocessesusedinintegratedinterven-tions.YousafzaiandAboudsummarized31pa-pers,resultinginatableofbestpractices.51Thepracticesincludedrecommendationsoncontent,dosage,deliverystrategies,andtrainingandsupervi-sionforbothpsychosocialstimulationandnutritioninterventions.
Thethirdpaperarticulatestheadvantagesofinte-gratedinterventions,includingtheefficiencyofde-liverytothesamepopulation,sharedresources,andlessdemandonthefamily.DiGirolamo,Stansbery,andLung’ahoalsoraiseconcernsaboutchallengesofintegratedinterventionsattheimplementationlevel,includingworkloadcommitment,trainingandsupervision,andcommunication,particularlywhenprogramscrosssectors.52
ReviewofintegratedinterventionsThefirstpaperinthissectionisareviewofstud-iesthatintegratednutritionorhealthinterventionswithchilddevelopmentinterventions.Grantham-McGregoretal.foundefficacytrials(primarilyhome-visitingprograms)andprogramevaluations(primarilycenter-basedprograms),butnointe-gratedprogramsimplementedatscale.48Althoughmostefficacytrialsshowedbeneficialeffectsofcom-binedinterventionsandnonereportednegativeef-fects,onlyonestudyreportedsynergisticeffects(fewtestedforsynergisticeffects).Amongprogrameval-uations,mostshowedbeneficialeffectsonchildren’sdevelopment,buttwoshowednegativeeffectsandoneshowednoeffect.Durationoffollow-upvariedandtheauthorsprovidedrecommendationsregard-ingsubsequentevaluationsofintegratedefficacytri-als,programs,andprogramsatscale.Theonestudy
MethodsandtopicsindesigningintegratedinterventionsFivepapersaddressspecificmethodsortopicsre-latedtointegratedinterventions.Thefirstpaperex-amineshowformativeresearchisusedtodevelopintegratedinterventionsthataddressmultipletopicsinacoherentmanner.Theresultinginterventionscanbesuccessfullypresentedbyworkersandun-derstoodbyfamilies.Usingthedomainsofinfantandyoungchildfeeding,responsivefeeding,andchilddevelopment,Bentleyetal.53provideguide-linesonconductingformativeresearchanddesign-inglocallytailored,culturallyappropriateintegratedinterventions.
Thesecondpaperprovidesguidanceonthemea-suresneededtoevaluateintegratedinterventions,including:foodandnutrition,familycare,health,andchilddevelopment.54Frongilloetal.addressmeasurestoevaluateimpact,includingbenefitsandpotentialharms,aswellasthemechanismsthatcon-necttheinterventionwiththeimpact.
Thethirdpaperexaminesthetimingofnutri-tionandchilddevelopmentinterventions.55Wachsetal.describenutrient-sensitiveperiodsofage-linkeddimensionsofbraindevelopment;timingofexposurestoenvironmentalstressorsformaintain-ingneural,neuroendocrine,andimmunesystems
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integrity;andthesensitivityofcognitiveandsocial–emotionaldevelopmenttocontextualriskandpro-tectiveinfluences.Althoughtheearlyyearsoflifeareasensitiveperiodforbiologicalandpsychosocialinterventions,environmentalconditions,includinginterpersonalrelationships,haveuniqueandpoten-tiallylong-terminfluencesthroughoutlife.
Thefourthpaperfocusesonmaternalpsychoso-cialwell-being,acriticalconsiderationbecausemostnutritionandchilddevelopmentinterventionsop-eratethroughthemother.56Zafaretal.proposeacognitivebehavioraltherapy–basedinterventiondesignedtoreducematernalmentalhealthprob-lems,whichcanbeintegratedintoachildnutri-tionanddevelopmentprogram.Communityhealthworkers(CHWs)aretrainedtoincorporatefiveskillsintotheirinteractionswithmothers:empathiclistening,familyengagement,guideddiscoveryus-ingpictures,behavioralactivation,andproblemsolving.
Thefinalpaperinthissection,byNgureetal.,illustratesthepotentiallyadverseeffectsofpoorwa-ter,sanitation,andhygiene(WASH)conditionsonchilddevelopment.57Asanutrition-sensitiveexam-ple,evidencesuggeststhatenvironmentalenteropa-thy,asubclinicalconditionofthegut,maymedi-atetherelationshipbetweenpoorhygieneandde-velopmentaldeficits.FutureinterventionsshouldconsidertheintegrationofWASHandearlychild-developmentstrategies.
tiveperformance,Lopez-Booetal.concludethatthediscountedannualcostsoftheprogramperchildarelessthanthediscountedannualincreaseinbenefi-ciaryearnings.
Thefinalpaperinthissectionestimatesthecosteffectivenessofanintegratednutritionandearlychildhooddevelopmentinterventionthatwasin-tegratedintotheLadyHealthWorkersprograminPakistan.60TheanalysisbyGowanietal.suggeststhattheinclusionoftheearlychild-developmentinterventionwasmorecosteffectivethananutri-tioninterventionaloneinpromotingchildren’searlydevelopment.
EconomicconsiderationsrelatedtointegratedinterventionsEconomicimpactisacriticalconsiderationintheevaluationofintegratedinterventions.Aldermanetal.58explainthatbenefit–costanalysesfacilitatethecomparisonofalternativeinvestmentsacrossdifferentinterventions,enablingpolicymakerstoquantifyeconomicreturnsrelatedtospecificpoli-cies.Theyprovideguidelinesonconductinganaly-ses,includingafocusonthetimingofinterventions,contemporaryanddynamiccomplementarities,andthepossibilityofprogram-deliverysynergies.Twopapersprovideexamplesofcost-benefitandcost-effectivenessanalysesofintegratednutritionandchild-developmentinterventions.Onepaperestimatesthecost–benefitratioforanintegratednu-tritionandearlychildhooddevelopmentprograminNicaragua.59Onthebasisofreductionsintheprevalenceofanemiaandimprovementsincogni-6
Capacity-buildingconsiderationsThreepapersaddresscapacitybuildingandpro-gramimplementation.Inthefirstpaper,Tom-linsonetal.61discussissuesrelatedtofamilies(structure,extendedrelationships,beliefs,mentalhealth),deliverystrategies(center-basedcare,homevisiting),andthecapacityofhealthsystemsandCHWstoreachthemostvulnerablefamiliestoprovideintegratednutritionandchild-developmentinterventions.
Inthesecondpaper,Yousafzaietal.62suggestaparadigmshiftinprovidingintegratedinterven-tions.Ratherthanoperatingfromatraditionalmodelwherebyeducationalmessagesareprovidedinadidacticmannerwiththeobjectiveofchang-ingcaregiverbehavior,theyrecommendamodelinwhichfamiliesareactivepartners.Healthworkersaretrainedtorecognizefamilies’strengthsandtohelpfamiliesincorporateprinciplesofresponsivecaregivingintoongoingbehavioralpatterns.
Finally,Phukaetal.63reviewtherolesofhealthworkersinMalawi.Theyillustratethatal-thoughMalawihascomprehensivepoliciesandwell-outlinedcoordinationstructuresforintegratednutritionandearlychild-developmentapproaches,localissuessuchasworkload,logistics,andsyn-chronizedworkscheduleshavetobecoordinatedtoenablehealthworkerstobesuccessful.
ExamplesofintegratedinterventionsThreeexamplesofintegratedinterventionsareprovided.Thefirst,byHamadanietal.,presentsevaluationsofintegratedprogramsconductedinBangladesh,oneofthepoorestcountriesintheworld.64TheBangladeshgovernmenthasincor-poratedearlychilddevelopmentintothenationalplanofaction,buttherearenowell-evaluated
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programsinwhichchild-developmentactivitieswereintegratedintohealthandnutritionservicesatscale.Theevaluationsthathavebeenconductedhaveshownthatintegratedinterventionsarefeasi-bleandeffective.Recommendationsforprogramexpansionincludecurriculathatarebrief,sim-ple,andculturallyrelevant;communityawarenessofearlychild-developmentinterventions;public–privatepartnershipsthatinvolvecommunityclinics;community-basedinterventionstoenhancemater-nalself-esteem;andtrialsthatcomparetheefficacyofhomevisitingversuscenter-basedintervention.ThesecondpaperdescribestheformativephaseofSPRING(SustainableProgrammeIncorporatingNutrition&Games),anintegratedinterventiontoimprovethesurvival,growth,anddevelopmentofchildreninruralIndiaandPakistan.65Usingthreemajorthemesfromtheformativeresearch(caringformychild,feeding,andtimetoplay),Lingametal.describehowtheyusecaregiverbeliefsandpracticestodevelopaculturallyappropriateinter-ventiontobeimplementedatscalethroughexistinghealthsystems.
ThethirdpaperdescribesthedevelopmentandimplementationofGrowSmart,aninte-gratedmicronutrientsupplementationandearly-learninginterventionstudyconductedamongin-fantsandpreschoolersinruralIndia.66Thepa-per,byFernandez-Raoetal.,includesthedevel-opmentofinterdisciplinarycollaboration,researchobjectivesanddesign,managementplan,forma-tiveresearch,selectionandpilottestingofinterven-tionandevaluationmaterials,andtraining,mon-itoring,andsupervisionoftheinterventionteam.Ithighlightsthecollaborationwithstakeholders,includingvillageleadersandadministratorsoftheIntegratedChildDevelopmentServices,India’sna-tionalprogramthatprovidesearlychildnutri-tionandpreschooleducationthroughvillage-basedcenters.
andNeumandescribetwoinitiativesdevelopedandimplementedbytheWorldBank:SABER-ECD(Sys-temsApproachtoBetterEducationalResults–EarlyChildhoodDevelopment)andMNI(Main-streamNutritionInitiative).SABER-ECDcollects,analyzes,anddisseminatesdataonearlychildde-velopmentpoliciesandprograms,focusingontheirintegrationwithnutrition,health,andotherareas.Itismultisectoralinscope,withgoalsofestablishinganenablingenvironment,broadimplementation,andattentiontoquality.MNIisa3-yearprojectthatplaysasimilarroleinrelationtonutritionpro-gramsandpolicy.67Theseresearch-basedinitiativesassistgovernmentsindeveloping,supporting,andmonitoringintegratedinterventions.
Inafinalpaper,Brittoetal.68illustratehowasystemsapproachcanbeusedtoexaminevariabil-ityinprogramimplementation.Usingexamplesfromfourgeographicallydiversecountries(Cam-bodia,LaoPeople’sDemocraticRepublic,Kenya,andPeru),theyexamineearlychilddevelopmentsystems.Patternsofcoordinationandcommunica-tionarefrequentlyvertical,ratherthanhorizontalorcross-sectoral.Althoughpoliciesregardingearlychilddevelopmentprogramsareoftenfocusedatthenationallevel,localgovernanceplaysimportantrolesindecisionmakingthatcanaffectthequalityandsuccessofintegratedprograms.Conclusion
Althoughthereisstrongempiricalsupportforearlychild-developmentprograms,alongwiththeoreti-cal,empirical,andlogisticalevidencethatconfirmsthefeasibilityandeffectivenessofintegratingchild-developmentandnutritionalinterventions,9therearemultipleissuestobeconsideredduringimple-mentation.Themultisectoralnatureofintegratedinterventionsrequirescoordinationamongmulti-plestakeholders,alongwithintegratedorganiza-tional,monitoring,andcommunicationsystemstoensureprogressandavoidgapsandduplication.Asystemsscienceframework,suchasSABER-ECD,developedbytheWorldBank,67thatincorporatesthemultipleinteractingfactorsthatinfluenceearlychilddevelopmentandnutritionmaybeusefulinguidinginterventionimplementation.69Systemsscienceemphasizesthattobeeffectiveandsustain-able,interventionstopromoteequityneedtoextendbeyondthechildandfamilyfocusfamiliartomanyhealthcareproviderstoincludethephysicaland
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PolicyimplicationsofintegratedinterventionsTwopapersaddresspoliciesrelatedtointegratedinterventions.Althoughgovernmentsandinterna-tionalorganizationsareincreasinglyrecognizingthevalueofintegratingnutritionandearlychildhooddevelopmentinterventions,therehasbeenlimitedattentiontothemultisectoralaspectsofintegratedinterventionsandtothefiscal,policy,andmoni-toringaspectsofintegratedinterventions.Pelletier
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socialenvironmentandtheconnectionsandfeed-backloopswithinmultiplesectors,alongwithlocal,national,andinternationalpolicies.69
Althoughinterventionduringthefirst1000dayssupportschildren’snutritionalneedsandtheneu-rodevelopmentalbuildingblocksofbraindevelop-ment,childrenrequireongoingeducationandop-portunitiestodevelopfully.9Interventionsthatarefocusedexclusivelyduringthefirst1000dayscanprovideastrongbeginning,butareunlikelytore-sultinsustainedpromotionofequityiftheydonotextendintothepreschoolandearlyschool-ageyears.9Forexample,inarandomizedcontrolledtrial,theEarlyHeadStart(EHS)programhadben-eficialeffectsatages2and3inalltargetareasofearlychilddevelopment.However,byage5,manyofthebeneficialeffectswerenotsustained.70Al-thoughthereasonsunderlyingthelackofsustain-abilityareunknown,onepossibilityistheabsenceofongoingintervention.Halfthechildrendidnoten-rollincenter-basedpreschoolfollowingEHS,andthereisnoinformationonthecenters’abilitytohandlethechildren’sadvancedskills.Implementa-tionandprogramscalingrequireasystematicap-proach,withcarefulplanningandongoingmoni-toringandevaluation.69Werecommendthatfuturechilddevelopment/nutritioninterventionandim-plementationresearch(1)employsmultilevel,mul-tidisciplinarydesignsthatincludeanevaluationofthepotentialsynergyassociatedwithintegratedin-terventions;(2)promotescapacitybuildingamongthesectorsandworkersinvolved;(3)examineshowimplementationfactors,suchasageatenrollment,duration,andintensityofinterventionrelatetoim-pact;(4)incorporatesatheory-basedperspectivethatrecognizestheinterplayamongenvironmen-talvariablesonchildren’sdevelopment;(5)incor-porateseconomicindicatorsthroughouttheimple-mentationprocesstoaddressbenefit–costissues;(6)involveslocalandnationalstakeholdersandgover-nanceinplanningandimplementation;(7)focusesontheeffectsofearlyinterventions(first1000days),butextendsintothepreschoolyearsandexaminestheeffectsatleastthroughtheageofentryintopri-maryschool;and(8)employsrigorousdesignsthatcancontributetolong-termfollow-upandevalua-tionsoftheeffectsofearlyintervention.Integratedchilddevelopment/nutritioninterventionsearlyinlifeprovideapromisingopportunitytopromoteequityandtobuildhealthy,productivecitizens,
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therebyextendingbeyondthehealthandwell-beingofindividualstosustainabledevelopmentforfuturegenerations.Acknowledgments
WeacknowledgethesupportoftheRockefellerFoundation,BellagioCenter.Preparationofthispa-perwaspartiallysupportedbytheEuniceKennedyShriverNationalInstituteofChildHealthandHu-manDevelopment,GrantR01HD056099.Conflictsofinterest
Theauthorsdeclarenoconflictsofinterest.References
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