Multi-sectoral interventions for healthy growth
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Correspondence: Ma del Carmen Casanovas, Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, Geneva 1211 27, Switzerland. E-mail: email@example.com
The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.
It has been argued that government health-related objectives are best achieved when all sectors include health and well-being as a key component of their policy development, acknowledging that many influences of health and well-being lie outside the health sector (WHO & Government of South Australia 2010).
Malnutrition is a complex problem related to various factors. To protect nutrition and address malnutrition, there is need for nutrition-specific interventions as well as nutrition-sensitive programmes, the latter through a multi-sectoral approach (Ruel et al. 2013; WHO 2013). For example, Scaling Up Nutrition is a global movement that unites governments, civil society, businesses and citizens in a worldwide effort to end undernutrition. In 2010, it released an action framework proposing a multi-sectoral approach to effectively address this problem (Bezanson & Isenman 2010).
The World Health Organization (WHO) conceptual framework on Childhood Stunting: Context, causes and consequences presented by Stewart et al. in this supplement outlines the elements associated with different causal categories (Stewart et al. 2013). It shows that stunted growth and development, a manifestation of undernutrition with long- and short-term consequences, is attributable to a combination of household and family factors, inadequate complementary feeding, inadequate breastfeeding practices and infection. The risk of stunted growth and development is influenced by the context in which a child is born and grows. This context is multi-sectoral, and includes the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. These influences are interdependent. For example, during the latest food crises (2007–2008 and 2010), global food production was at a record high. However, because of high prices (which depend on political and marketing regulations) worldwide, almost 870 million people went hungry during the period 2010–2012 (FAO 2012) and the gains in food security made in preceding decades were erased. In this article, we briefly review how factors linked with the context-related sectors mentioned above can contribute to healthy growth and a reduction of childhood stunting.
- Women's education and empowerment are essential for the key roles they play in food consumption, income generation and ultimately the growth and development of children.
- The factors that cause stunted growth and development require interventions from multiple sectors.
- It is important that all concerned sectors and actors equally appreciate the severity of stunting and what each can contribute to its reduction.
Agriculture/food security and healthy growth
Food production and agriculture are key pillars of food security and the right to food. Links between the agricultural sector and nutrition include environmental management, water resources and their management, agrochemicals, food safety, farming-related infections (e.g. diarrhoeal and fungal infections), and the diversity of available foods and production systems. Agricultural policies have important consequences for the health and nutritional status of individuals and communities. The health and nutritional status of agricultural workers in turn directly affects food production (Hawkes & Ruel 2006). Focusing only on food production does not guarantee availability of and access to food and adequate nutrition. Factors such as hygiene and consumption of a variety of nutrient-rich foods need to be taken into account, particularly for young children if they are to grow and develop appropriately (PAHO 2003; Rah et al. 2010).
According to the World Bank, 3 billion people live in rural areas and their main occupations are in agriculture and related activities (livestock production, aquaculture and forestry) (World Bank 2007). These activities are the main source of family incomes for the rural communities as well as contributing nearly 70% of global basic food production (Agriculture and Food Commission of Coordination SUD 2008). This form of agriculture, also referred to as family farming, is characterized by structural linkages between economic activities and family organization. Family farms are generally flexible enough to have a diversified production of crops and animal breeding and emphasize sustainable use of natural resources (Agriculture and Food Commission of Coordination SUD 2008). Besides the market, family farming production is directed towards household consumption, potentially providing a variety of quality foods like meat, fruits, vegetables and eggs. Most of these foods, if they were to be bought, would be unaffordable or unavailable for many families (Salcedo 2010). Family farming contributes to income generation, stabilizes populations in their places of origin thereby curtailing internal migrations, develops local economies, strengthens institutions and public structures, provides occupational labour, conserves natural resources and supports poverty alleviation (Salcedo 2010). Additionally, it is the foundation of a sustainable production of food that sustains biodiversity while ensuring food security and preserving the important cultural heritage of rural communities and nations (FAO 2013).
Paradoxically, despite being the main food producers, family farmers, including pastoralists, experience high rates of malnutrition, especially among young children. A recent review of the links between agriculture and nutrition focusing on homestead food production systems and biofortification of staple crops found little evidence of effectiveness of either programme type on maternal or child nutrition (Ruel et al. 2013).
Half of the more than 1 billion hungry are small-scale farmers and their families, another 20% are landless families that depend on farming, 10% live in communities whose livelihoods depend on herding, fishing or forest resources, and the remaining 20% are poor people living in cities (WFP 2012). There is enormous potential for substantially reducing stunted growth among young children in farming communities. In addition to increasing their production, families need to improve feeding practices, with special attention to children and women. Within the family, women should be given priority in terms of educational interventions given the key role they play in translating food production into food consumption. Women's income generation and their capability to take decisions have a greater impact on health and nutrition than men's income generation and control (FAO 2012; FAO 2013; World Bank 2013).
Education and healthy growth
Education is a human right which influences the well-being of the people, either directly or indirectly (WHO 2011a). In analysing the relationship between education and children's healthy growth is important to consider the effect of parental formal education. Parental, and especially maternal, schooling is an important determinant of child health and nutritional status. Children of less-educated mothers have a lower chance of survival and a higher risk of undernutrition in utero, during infancy and in childhood, compared with children of educated mothers. Even a little education, it appears, makes a difference to a child's welfare (Cochrane et al. 1982; Bicego & Boerma 1990). In fact, the highest marginal benefits of a mother's education in resource-poor settings have been associated with primary education (Burchi 2010). Children of mothers with no schooling are generally the most disadvantaged with regard to stunting, regardless of their economic situation or whether living in urban or rural areas (Pongou et al. 2006; Subramanyam et al. 2011).
There are multiple pathways for maternal education to influence child nutrition. Educated mothers are more likely to take leadership positions in community structures and influence child care practices in their homes and communities; and they have the confidence needed to adopt new technologies – e.g. improved hand-washing facilities – and make appropriate choices with respect to care, health seeking, and infant and young child feeding (Burchi 2010). On the other hand, cultures or traditions, especially those affecting women's empowerment and the community's social infrastructure, reduce the impact of mothers' formal education or the lack of it on child health and nutrition. For example, it has been reported that good child care and feeding practices in poor remote communities could compensate for the negative effects of poverty and low maternal education (Ruel et al. 1999). Mothers with nutrition knowledge acquired in the community are reported to choose a more diversified diet for their children and utilize food more effectively (Burchi 2010). This type of knowledge could also increase responsive feeding/care that improves child health and nutrition (Shieh et al. 2010).
In terms of multi-sectoral linkages, nutrition education programmes rather than just providing abstract knowledge of nutrition practices are likely to be effective if they are coupled with support that increases demand for services and technologies (e.g. using soap for washing hands, using multiple micronutrient powders, oral rehydration salts, etc.) and improved food production skills (how to prepare composite flours, how to produce fast-growing fruit trees, how to improve food flavour, etc.). It has been argued that strategies to increase coverage and guide nutrition interventions may not yield the same level of long-term payoffs in terms of childhood nutrition as investment in women's education (World Bank 1993; Deaton 2002).
Given how important women's education is for child nutrition, it should be enhanced for women throughout the lifecycle. In utero and early childhood nutrition are essential facilitators of human development with a significant impact on a future generation's cognitive development, school enrolment, learning capacity and productivity (Hoddinott et al. 2008). Improved nutrition for girls in early childhood increases the number of years of schooling completed by women later in life and their academic achievement (Maluccio et al. 2009).
Political economy and healthy growth
Political economy is understood as the study of how a country – the public's household – is managed or governed, taking into account both political and economic factors. The relationship between economics and health is well documented and strengthening the synergy of policies for both results in more efficient use of resources (Figueroa-Lara 2013).
Early childhood nutrition interventions that prevent stunting can be viewed as investments in human capital leading to large gains in adult health, education and productivity (Hoddinott et al. 2008; Victora et al. 2008). There is also evidence that improved early childhood nutrition carries intergenerational benefits. Guatemalan infants born to women who were supplemented during early childhood had higher birth weights (Ramakirshnan et al. 1999). An analysis of socio-economic differentials conducted by Barros et al. found that children from poor households were at higher risk of exposure to inadequate water and sanitation, crowding and indoor pollution than children from wealthier families. There were also differences between both groups with regard to behaviours such as hand-washing. All these differences resulted in a higher likelihood of malnutrition among children from poor families than those of families in the highest quintile (Barros et al. 2010).
The above-mentioned findings support the recommendation of investing in maternal and early childhood health and nutrition as drivers of individual productivity and the long-term economic growth of countries. They also highlight the fact that to improve growth and nutrition there is a need not only to aim for economic growth but also to reduce inequalities (World Bank 2013). A detailed analysis of the economic rationale for investing in stunting prevention is presented by Hoddinott et al. (2013) in this supplement.
One of the elements of political economy related with the healthy growth and development of children relates to the commercial sector. The Global Strategy for Infant and Young Child Feeding (IYCF) acknowledges this sector's potential constructive role (WHO & UNICEF 2003) in improving IYCF. However, its contribution has to be carefully balanced against the risk of marketing foods that could displace nutritious, locally available, affordable and more sustainable alternatives. Improving the diets of infants and young children should primarily target the consumption of locally available and culturally appropriate foods, combined with improving feeding behaviours. Various tools are available to help countries determine the most appropriate product/s in specific contexts, and an example of such tools is described by Daelmans et al. (2013) in this supplement.
Some country programmes are currently coordinating activities with the for-profit sector to provide commercially prepared complementary feeding products using local foods to cover nutrient gaps in regions where typical diets do not cover infants' and young children's nutrient needs (Ministerio de Salud y Deportes, Estado Plurinacional de Bolivia 2009; Lartey et al. 1999).
The Codex Alimentarius provides standards for labelling and hygiene practices for processed cereal-based foods for infants and young children (Codex Alimentarius 2006) and guidelines for formulated supplementary foods (Codex Alimentarius 1991), the guidelines have been revised by the Codex and recently adapted by the Commission. In addition, WHO has published guidelines on the ideal composition of multiple micronutrient powders for home fortification of complementary foods (WHO 2011b). Adherence to these standards and guidelines by product developers and promoters is important in the interest of placing children's health ahead of commercial interests (Piwoz et al. 2003).
Water, sanitation and hygiene and healthy growth
Frequent illness and inadequate food intake are immediate causes of child undernutrition as illustrated in the United Nations Children's Fund (UNICEF) Conceptual Framework (UNICEF 1990) and its adaptations by others, including the Lancet Nutrition Series (Black et al. 2008, 2013) and the WHO's conceptual framework on childhood stunting (Stewart et al. 2013). Associations between water, sanitation and hygiene (WaSH) and growth were documented by various authors in the 1990s (Lutter et al. 1989; Lunn et al. 1991; Esrey et al. 1992; Solomons et al. 1993, Esrey 1996). Since then several studies have linked stunting to poor water supplies, sanitation and hygiene mediated through frequent episodes of diarrhoea (Moore et al. 2001; Checkley et al. 2004, 2008; Humphrey 2009). Evidence also shows that improvements in hygiene and sanitation and access to clean water have a high potential for improving growth and reducing stunting rates, for example by reducing the risk of environmental enteropathy as well as the risk of exposure to environmental contaminants (Esrey et al. 1992; Esrey 1996; Abidoye & Ihebuzor 2001; Merchant et al. 2003; Korpe & Petri 2012; Smith et al. 2012). There are reports of reduction in diarrhoea morbidity related with hygiene education (27%), point-of-use water quality (29%), sanitation (34%) and hand-washing with soap (37–42%) (Waddington et al. 2009, Liu et al. 2012). WaSH has been reported also to prevent respiratory tract illnesses, especially through hygiene measures such as hand-washing with soap (Luby et al. 2005; Rable & Curtis 2006; Fink et al. 2011). Promoting hand-washing with soap and community-wide sanitation are thus two of the five elements that UNICEF and WHO promote in their prevention package to reduce diarrhoea and pneumonia (UNICEF & WHO 2009; WHO & UNICEF 2009).
Considering the benefits above, it is especially important to ensure that not only overall community WaSH interventions are integrated in stunting reduction strategies, but also that appropriate hygiene practices are given high priority in counselling services provided to families, with emphasis on vulnerable population groups. Moreover, significant efforts are needed to improve and reach appropriate coverage levels of WaSH services. Currently, about 783 million people in the world have no access to adequate drinking-water sources, 2.5 billion lack sanitation facilities (UNICEF & WHO 2012), and only 17% of the population in low-income countries wash hands with soap after using the toilet (Curtis et al. 2009).
Social protection including cash transfers
The evidence of a correlation between poverty and stunting is overwhelming and equally applicable to environments of varying levels of economic growth. With very few exceptions, country data show significant differences in stunting rates between wealth quintiles (Black et al. 2008; UNICEF 2009). Poor families are deprived of not just access to food, but of high-quality foods of animal origin, which are especially important during the complementary feeding period (Poel et al. 2008). It has been observed that if a household is chronically poor and choices are limited, caregivers cannot achieve much even if they know what their children's nutrition needs are (Ruel et al. 1992). However, there are also arguments to the contrary, where positive deviance analysis indicates that it is possible to improve health and nutrition, even in poor communities, by encouraging people to adopt strategies used by a few individuals or families who achieved good health and nutrition (Marsh et al. 2009).
Social protection1 can play a significant role in achieving sustainable results in poverty reduction by addressing basic causes of stunting in young children. Programmes have to be based on careful consideration of the local situation and assessment of availability of quality foods (grown or produced in the community or otherwise available and affordable from the market). This assessment also needs to become a basis for interventions to make quality foods affordable and health services accessible for families with young children.
Nutrition-sensitive conditional cash transfers to the most vulnerable population groups have a high potential for improving nutritional status if they reinforce effective use of health services, increase access to food and the utilization of supplements, and raise population awareness about child care and feeding (Gaarder et al. 2010). Additionally, they can help ensure that income or food and health services are provided for the poor and that the social status and rights of vulnerable groups are protected (Devereux & Sabates 2004). Social protection can help increase access to social services, strengthen child care capacity, increase families' resilience, enhance labour market participation (Rees et al. 2012) and income-generating capacities (Devereux & Sabates 2004), thereby having a more sustainable impact.
The long history of cash transfers shows rather mixed results (Bassett 2008; Hoddinott & Weismann 2008; Fiszbein & Schady 2009; Gaarder et al. 2010; Manley et al. 2012). Success has depended on numerous factors, including linkages with the sectors that should ensure quality health and nutrition services and quality implementation of nutrition components (Bailey & Hedlund 2012). Various factors have been documented as contributing to the failure of cash transfer programmes, including low-quality health services (Fiszbein & Schady 2009) as well as problems with programme implementation, communication and targeting (Bassett 2008; Gaarder et al. 2010; Bailey & Hedlund 2012). Countries that have successfully combined poverty reduction/alleviation strategies with strong complementary programmes addressing inequity have succeeded in reducing stunting rates (Maluccio & Flores 2005; Bassett 2008; Fernald et al. 2008; Hoddinott et al. 2008) and narrowing the gap between rich and poor (Soares et al. 2009; Monteiro et al. 2010).
For conditional cash transfers to have a positive impact on maternal and child nutrition, it is important for programmes to focus on the window of opportunity (pregnancy through two years of age) targeting beneficiaries in this range and making the conditionality specific to evidence-based actions or interventions (WHO 2013).
Health and health care
As indicated by Barros et al., mainstreaming equity considerations in the health sector is essential for ensuring that users become part of the solution (Barros et al. 2010). The health sector has a key role to play in promoting healthy growth. Compared with other periods of the life course, women are most likely to access the health care system during the first 1000 days. Such contacts provide opportunities for nutrition and health interventions to improve birth outcomes, and to place and keep children on the path to healthy growth. Also, inasmuch as childhood acute illnesses, particularly clinical and subclinical diarrhoea, and tropical/environmental enteropathy negatively affect child growth (Lutter et al. 1992; Humphrey 2009), the health sector can improve child growth by preventing and treating acute and chronic illnesses associated with poor growth and by delivering interventions to improve child feeding and household hygiene. Unfortunately, the health sector's potential to improve child nutrition is often not adequately utilized, resulting in many missed opportunities (Santos et al. 2005; Arifeen 2009).
The Lancet series on Maternal and Child Nutrition identified behaviour change communication integrated in health services for improved complementary feeding (in food-secure populations) as having a positive effect on feeding practices, thus leading to a reduction in stunting (Bhutta et al. 2008, 2013). Hand-washing or hygiene interventions were also identified as having a positive effect on reducing diarrhoea and thus likely to improve nutrition and growth.
Although there are several examples of health-service-based nutrition effectiveness studies that have improved complementary feeding and child growth (Penny et al. 2005; Zhang et al. 2013), to date there are few examples of successful programmes at scale. This information is summarized in the paper by Lutter et al. in this supplement (Lutter et al. 2013).
Low coverage of nutrition interventions is likely the result of a number of factors, including little working knowledge of nutrition and counselling skills by front-line health workers. It may also result from the gap between awareness of what to do and easy-to-use tools permitting nutrition interventions to be effectively implemented (Lutter et al. 2011) or lack of integration of these tools into health service delivery protocols, such as the Integrated Management of Childhood Illness strategy (Bhutta 2008). Analysis of healthy systems shows children's health and nutrition can be improved through health financing reforms that ensure adequate health worker training and targeting of the most deprived populations (Tangcharoensathien et al. 2011; Carrera et al. 2012; Victora et al. 2012; Sunguya et al. 2013; WHO 2013). The foregoing consideration suggests a need for the health sector to mainstream the principle of equity. Using the equity lens, the health system can be structured and health workers sensitized to implement programmes and interventions in a manner that specifically attempts to reduce inequities (Barros et al. 2010).
The importance of multi-sectoral approaches for a healthy growth
As mentioned previously, careful consideration is needed to address nutrition security for appropriate complementary feeding as an important element in the prevention of stunting (Bhutta et al. 2013). This requires not only improving affordability, but also increasing availability and an intra-household distribution that ensures access to high-quality food for children 6–24 months of age. Developing agriculture, increasing livestock, market availability of necessary foods (including fortified complementary foods) are among the long-term sustainable strategies that should be based on a thorough assessment of local conditions.
Various examples of national and subnational multi-sectoral interventions for healthy growth illustrate just how critical such an approach is for stunting reduction. In Brazil, stunting dropped from 13.5% to 6.8% between 1996 and 2006/2007. Monteiro et al. analysed the probable causes associated with this decline and found that two-thirds of the reduction could be attributed to a multi-sectoral approach operationalized in increased maternal schooling, increased purchasing power of families, expansion of health care services and improvement in sanitation (Monteiro et al. 2009). An observational study on childhood stunting after exposure to multi-sectoral interventions (agriculture, income generation, improved water and sanitation, education, infrastructure) in nine sub-Saharan African countries found a significant reduction in stunting prevalence in five of them. The authors suggest that variable results may be related to interactions between several drivers of change that varied across countries (Remans et al. 2011). A case study from Bolivia (see Box 1) illustrates how improved intersectoral coordination, nationally and subnationally, resulted in a reduction of stunting rates.
Box 1. Multi-sectoral interventions for healthy growth in Bolivia
Joint Program: Infancy, food and nutrition security
The ‘Joint Program’ began in 24 food-insecure municipalities, involving 4000 families.
Interventions address the causes of undernutrition: insufficient and inappropriate food consumption; infectious diseases (mainly diarrhoea); household food insecurity; low education especially among mothers; and lack of access to water and sanitation.
The programme has four components including support to sustainable family farming, access to improved water and sanitation services, and access to education, health and nutrition services.
Family farming-related activities focus on the production of potatoes, corn, wheat, legumes, and vegetables, and raising guinea pigs and chickens to increase access to all food groups. A corollary food and nutrition education strategy was implemented to encourage participating families to consume their own production and apply the ten keys to safer foods and healthy diets (WHO 2006).
After 8 months of programme implementation, a survey on consumption and use of food produced in family farms found that 8 in 10 families consumed one or more family farm products daily, especially children under five. This was confirmed by observed daily consumption of vegetables (lettuce, chard, tomatoes, onions, parsley, cauliflower, etc.), guinea pig meat and eggs. These were important accomplishments for families that a few months earlier consumed mainly potatoes and occasionally lamb or beef.
In relation to water and sanitation, the activities included infrastructure development in communities, schools and childcare centres, with a comprehensive approach to water, sanitation, hygiene, health and institutional strengthening (training and empowerment of community development technicians and Local Water and Sanitation Committees). By this means, families, school children, teachers and others had access to improved water and sanitation services and were able to operate and maintain the systems, make appropriate use of services and apply hygiene practices.
The Municipal Council on Food and Nutrition has played a central role by giving direction to the programme and sustaining the commitment of different sectors and stakeholders.
A comprehensive analysis of the political and institutional determinants of delivering a national multi-sectoral response in six countries reported 10 key findings related to the direct involvement of the government's executive branch: (1) the usefulness of setting up a group or groups to coordinate nutrition actions and hence facilitate their implementation; (2) integrating nutrition into the national development agenda; (3) ensuring that all involved sectors and actors have a common understanding about the severity of undernutrition; (4) having a mechanism that helps ensure local delivery of nutrition services, usually through decentralization; (5) promoting and supporting local ownership of the programmes and their outcomes; (6) looking for sustainability; (7) involving civil society as a way to ensure accountability; (8) developing mechanisms for data collection using appropriate indicators and regularly analysing information; (9) centrally allocating funds for these activities to be managed by national/local authorities; and (10) transparent financial mechanisms for the management of funds given by different organizations or groups (Mejia & Fanzo 2012).
In summary, multiple sectors, by implementing nutrition-sensitive programmes play important and complementary roles to those of nutrition-specific interventions in preventing stunting and promoting healthy growth (Ruel et al. 2013). Based on country experiences, these sectors need to work together to attain better and sustainable changes.
Special thanks to Nguyen My Ha (FHI360/A&T Project), Josselyn Neukom (PSI/Vietnam) and Abel Irena (PSI/Washington DC).
Conflicts of interest
The authors declare that they have no conflicts of interest.
MCC, CKL and NM developed the outline. All authors contributed inputs to the various sections and reviewed the manuscript in preparation. MCC and AWO did the final editing of the manuscript.
MCC and AWO are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Social protection consists of policies and programmes designed to reduce poverty and vulnerability by promoting efficient labour markets, diminishing exposure to risks, and enhancing capacity to manage economic and social risks such as unemployment, exclusion, sickness, disability and old age.