Tips for integrating human nutrition into research on the interaction between livestock/agricultural production and climate change; overview of the Global Livestock CRSP's ENAM project in Ghana. Presentation given by G. Marquis (McGill University) at the Livestock-Climate Change CRSP Annual Meeting, Golden, CO, April 26-27, 2011.

1. Integrating human nutrition in CRSP programs Grace S Marquis McGill University/Iowa State University

2. LCC & nutrition frameworks reflect multiple layers of determinants that contribute to human well-being & livelihoods UNICEF. Global Framework for Action. 2006 LCC-CRSP Technical Approach.

3. Cognitive development Reproductive success Work capacity/efficiency Adult-onset chronic diseases Environmental Health Production Animal & Human Health Climate change Training, management Policies, laws, markets

4. Take-home messages Prevalence of malnutrition remains unacceptably high, especially in SSA and Asia, and urban/rural disparities continue Maternal and young child nutritional status matters for society and should be the focus of interventions There are interventions that have been proven effective (SUN) Nutrition lends itself to being integrated (relatively easily) into diverse projects There is a growing recognition of the need and desire for integrated approaches

5. In Sept., 2000,Millennium Declaration was signed by 189 countries “to create an environment – at the national and global levels alike – which is conducive to development and the elimination of poverty” Improving nutrition is key to achieving the majority of the MDGs Nutrition interventions should 1st focus on vulnerable populations - women of reproductive age - children < 2 y

6. ~ 25% reduction in mortality for every 1 g/dL increase in hemoglobin Stoltzfus www.who.int/publications/cra/chapters/volume1/0163-0210.pdf

7. Low maternal prepregancy BMI and inadequate weight gain are primary predictors of low birth weight. Low birth weight is ~ at least 30% of deaths among children < 5 y (75% of neonatal deaths) MDG Report 2010

8. Underweight in < 5 y as an indicator of Goal 1 Will not meet 2015 goal (i) Starts at birth: birth weights & lengths in LMC are below WHO growth standards (ii) Early growth faltering is faster than currently assumed. (iii) Nutrition interventions needed before birth & in 1st 2 y of life. Victora et al. 2010

9. “Unfortunately, there has been little appreciable change over the last two decades in the high worldwide prevalence of iron deficiency anaemia. Few active programmes in both developed and developing countries have succeeded in reducing iron deficiency and anaemia. Important factors contributing to the lack of progress include failure to recognize the causes of iron deficiency and anaemia, lack of political commitment to control it, inadequate planning of control programmes, insufficient mobilization and training of health staff, and insufficient community involvement in solving the problem.” (WHO 2000)

10. Maternal & young child nutrition matters – Lancet 2008 series Short-term consequences Significant increased risk before classified as underweight Black et al. Lancet. 2008

12. Scaling Up Nutrition (SUN) Cost of scaling up a minimal package of 13 proven nutrition interventions to full coverage in 36 countries with highest burden (90% of stunting). World Bank 2010

14. Traditional complementary foods fed by West African mothers

15. Example of successful community-based nutrition education intervention on complementary feeding (where common 1st foods were soups & porridges) Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomised controlled trial ME Penny et al. Lancet 2005;365:1863-72

16. General Objectives To implement and evaluate an educational intervention to improve breastfeeding and complementary feeding of infants in Trujillo 2. To implement the intervention through existing and feasibily enhanced resources in health facilities and the community.

17. Study Design Randomized controlled effectiveness trial 6 pairs of matched health facilities with their communities in peri-urban Trujillo, a town on the northern coast of Peru

18. Rationale for Health Services The health service in Peru is well organized, extensively used by poorer families and there is a clear policy facilitating community outreach activities. In urban shanty towns there is easy access to government health facilities which offer a comprehensive service. The health service is the most sustainable institution in these poor areas.

19. Formative Research Methods Community Motivations Interviews with mothers of development Perception and Perception of CRED Focus Groups Feeding practices of micronutrient Attributes rich foods Household Trials Difficulties with feeding Interviews with community agents : midwives , presidents of community kitchens glass of milk program , health promoters

21. Household Trials Mothers of children 6 - 18 months

22. 4 5 3 2 1 5 4 3 2 1 Feasibility Specialingredient (liver, fish, egg) Thick puree Puree first 5 times a day Love,patience and good humour Avoid sweets before lunch Eat with dad Repeat serving Different flavours Imitation Finger pieces Impact Eat with hands Portion mid afternoon Give own plate Small servings Have child sit Results: “Teach your child to eat with love, patience, and good humour” High acceptability, High impact factor, lasting

24. Allhealthstaffweretrained

25. Accreditation of clinic

26. Well-babyclinicactivities

27. Evaluation of nutritional status

29. HEALTH FACILITY

30. Evaluation of Exposure to Intervention: Structured observations 197 children 6-24 months Exit interviews, 216 children, 6-24 months Midterm survey, 9 months after starting 476 children 6-14 months Evaluation of exposure to “How” questions Spontaneous recall Recognition of educational material Prompted recall

31. 100 90 80 70 60 50 40 30 20 10 Intervention center Control center Intervention center Control center Intervention center Control center Intervention center Control center Intervention center Control center Intervention center Control center Intervention center Control center Intervention center Control center N=6 N=39 N=55 N=8 N=39 N=6 N=8 N=39 N=3 N=56 N=37 N=9 N=56 N=3 N=9 N=56 Example: Exit Interviews with messages reported received Any “how” message Any nutrition message Any “how” message Any nutrition message Any “how” message Any nutrition message Key message Key message Key message Nutrition Well Baby Clinic Doctor Vaccines Well Baby Clinic Doctor Vaccines Well Baby Clinic Doctor Vaccines % caretakers reporting message % caretakers reporting message % caretakers reporting message

32. Intervention improved dietary outcomes P<0.05 Penny et al. Lancet 2006;365

33. Education alone improved nutrition outcomes Penny et al. Lancet 2006;365

34. The importance of animal source foods for young child growth The ENAM project

35. Iowa State U Co-PIs U of Ghana Co-PIs Grace Marquis US PI Owuraku Sakyi-Dawson Ghana PI Lorna Butler Manju Reddy Helen Jensen Elizabeth Lonergan Anna Lartey Ben Ahunu Emmanuel Canacoo Esi Colecraft Project manager Richard Tweneboah-Kodua, Aaron Christian Field supervisors / data management Selasie Agamah, Gymfiwah Nikoi Administrative officer Mawunyo Timbo, Gifty Nyarko Data entry 24 sponsored students (Ghana, USA, Canada) Felix Boadu Driver William Quarmine, Clifford Marquaye Data analysis assistants Temporary region-based data collection team Staff from: Women in Agricultural Development/MoFA Ghana Health Services Heifer International-Ghana Freedom from Hunger-Ghana Rural banks Felicia Kudomor Winneba Dinah Amoah Techiman Thomas Kambonga Navrongo Regional managers

38. Meat group showed increases in indicators of physical growth, cognitive function and school performance, and physical activityGlobal Livestock CRSP (2002) Sought proposals that address the question: What are the constraints to the availability, accessibility, preparation, and allocation of ASF for children in developing countries?

42. Phase 1Participatory process to develop problem model Phase 2Implement an income-generation and education/training intervention Phase 3Transfer of activities to local agents for sustainability

43. Phase 1Participatory process to develop problem model for constraints on animal source foods (ASF)Availability (does it exist?)Accessibility (is it affordable?)Utilization (does the child get it?)

44. Selection of research communities Distinct ecological zones Upper East Region Communities chosen with ministry …1. availability or use of ASF typical to the agro-ecological zone 2. presence of community- or household-level livestock/animal-rearing activities 3. logistical accessibility to the community Brong-Ahafo Region Central Region

46. Caregivers

48. Ministry of Food and Agriculture (MOFA)/Women in Agriculture and Development (WIAD)

49. Ghana Health Services (GHS)

50. Commodity organizations

51. Non-governmental organizations

54. Provide access to micro-credit loans

55. Food processing/storage training

56. Entrepreneurship/marketing training

59. Phase 2Implement an income-generation and education/training intervention

60. Research question Does the implementation of an intervention with micro-credit,entrepreneurship training, and nutrition educationimprove household food security, use of animal source foods for children, and children’s nutritional status in rural Ghana?

61. Study communities

62. Step 1: Income-generation activities Community ENAM Team Community Develop list of IGA Consensus on IGA to support Promotion of selected IGA Reviewed IGA suitability Develop support packages for selected IGA Cash flow analysis

64. Fish selling (fishmongering)

65. Poultry egg production

67. Processing & sale of foods (shea butter, rice parboiling)

68. Organization of micro-credit for IGA Caregiver self-selection CSA leadership President Treasurer Secretary Organizer Orientation training Eligible caregivers for solidarity groups (3-5/group) Loan requirements: Group concept $50 maximum initially Loan cycle (16 wk) Repayment weekly Savings (10%) Education Future loans require: Meeting attendance Savings Group appraisal Solidarity group Solidarity group Village Credit & Savings Association (CSA) Solidarity group Solidarity group Develop group rules and by-laws Membership requirements Penalties Loan appraisal

69. Example of support for IGA: Specialized training Poultry raising Coup construction & maintenance Poultry health Feed management Marketing poultry products Technical assistance: Heifer Int’l, Ghana Veteran poultry farmers U of CA Avian Flu School

70. Operation of microcredit scheme Microcredit loans & savings Entrepreneurship education Nutrition education Weekly meeting

72. Child feeding styles

73. Malnutrition signs

74. Benefits of ASF

75. Balanced plate

78. Record keeping

79. Financial literacy Skits on lessons learned Technical assistance Women in Agriculture Development (WIAD)

80. Entrepreneurial Flipchart Nutrition Flipchart

81. Participants interviewed 179 participants open to all women with 2- 5 y old children living in community self-selected 142 non-participants living in community with 2-5 y old child matched wealth ranking 287 controls living in control community with 2-5 y old child matched wealth ranking

82. Data collection Baseline FUP1, 4 mo FUP2, 8 mo FUP3, 12 mo FUP4, 16 mo Longitudinal data collected Microcredit performance Meeting attendance Repayments Savings Cash flow for IGA (sub-sample) Household Socio-demographic Food security ASF expenditures Caregiver Child nutrition/health knowledge Child Dietary intakes FFQ Weighed food (subsample) Anthropometry Other data collected Case studies (post intervention only)

83. Baseline caregiver characteristics In bold P<0.05

84. Baseline child characteristics In bold P<0.05

85. Evidence that the intervention took place ENAM Project CSA members' weekly meeting attendance rates by loan cycle

86. Microcredit performance 100% recovery in 16-21 wk/cycle Loans Savings Savings

87. SUCCESS Previous business experiences Higher loan amount Supportive family Business commitment and vision Healthy maternal status What factors contribute to participants’ success ……. … implications for interventions

88. Research question Does the implementation of an intervention with micro-credit,entrepreneurship training, and nutrition educationimprove household food security, use of animal source foods for children, and children’s nutritional status in rural Ghana?

89. Baseline: household food insecurity in previous month 75% 54% 42% 32%

90. Food insecurity is linked to quality of diet Food secure/at risk Food insecure P<0.05 0 5 10 15 20 Percent of hh (%) 0 2 4 6 8 10 Number of ASF types consumed Food secure/at risk Food insecure (moderate & severe) * 100 * 80 * * * * 60 Percent of hh (%) * 40 20 0 1 Accounting for region, ethnicity, and child age * P<0.05 Children in moderate-severe food insecure households consumed fewer types of ASF1. They were less likely to eat individual ASF types except for fish powder. *

91. There were no differences in food insecurity among groups at baseline. After 16 months, intervention families were half as likely to report food insecurity as comparison families (OR=0.50; p<0.001).

92. ASF diversity is higher with ↑ income & ↑access Christian, 2010

93. “Before the project, I would sell all the fish because I wanted the money. But now, I make sure there is always some fish left at home for them [the children]…My other children did not benefit from what I now know and they were always falling ill…Dominic is very good in school, even the teachers say so. And I know this is because of what I feed him”.

94. Micronutrient intakes increased among children in intervention households Dietary intakes based on 2-day weighed food records (Mean ±SE) In bold P<0.05 Lartey A. 2008

95. Intervention effect on child weight-for-age * * * Wt-for-age Z-score Baseline and Follow-up time points 1-4 Mixed linear regression hierarchical model Includes district, lives with partner, income, caregiver occupation, time Intervention effect overall: + 0.26 Z-score P< 0.001

96. Intervention effect on child height-for-age * Ht-for-age Z-score Baseline and Follow-up time points 1-4 Mixed linear regression hierarchical model Includes district, lives with partner, income, caregiver occupation, time Intervention effect + 0.11 z-score P= 0.12

97. Phase 3Transfer of activities to local agents for sustainability

98. Partnership framework for sustainability Freedom from Hunger, Ghana Institutionalization Rural Banks MOU signed ENAM Project Adoption and scale-up Logistical support Rural Women’s Credit & Savings Associations

99. Sustainability – (i) Access to credit Enabling institutions Freedom from Hunger, Ghana MOU ENAM, FFH, banks “Credit with Education” program for private banks Permanent institutions Rural banks (private) Akyimpem Rural Bank (Central) Fiagya Rural Bank (Techiman) Naara Rural Bank (Navrongo) Mechanism of sustainability 15% interest / 4 month cycle Offer 1st to ENAM mothers, then expand

101. “We must say that at the end of the Credit with Education loan cycle we had 100% recovery which is Unprecedented in the history of any loan product of the bank “ Microfinance coordinator, participating rural bank, Northern Ghana

102. Sustainability – (ii) access to education (a) Enabling institutions Freedom from Hunger, Ghana “Credit with Education” program Permanent institutions Three rural banks Mechanism of sustainability Sessions with loan payment & savings

103. Sustainability – (ii) access to education (b) Enabling institutions University of Ghana Permanent institutions Communities Mechanism of sustainability Peer educators Peer educator manuals

104. Sustainability – (ii) access to education (c) Enabling institutions University of Ghana Permanent institutions University of Ghana NGO Ghana Health Services Mechanism of sustainability Undergraduate course Continuing education short course

106. Expanding the LCC-CRSP overall vision... To reduce vulnerability, increase adaptive capacity, and augment the income of livestock producers in regions where agricultural systems are rapidly changing, available resources are shrinking, and climate change is having an impact, to assure the physical and cognitive development of at-risk populations so that society reaches its full potential.

107. The ENAM Project is funded through the Global Livestock -CRSP funded in part by US-AID Grant No. PCE-G-00-98-00036-00; Women in Development, US-AID; and the Jim Ellis Graduate Mentorship Program. In addition, substantial support was provided by Iowa State University, the University of Ghana, and McGill University.