SeaVeg USAID Presentation - World Vegetable Center

IMPLEMENTATION AND IMPACT OF AN INTEGRATED

NUTRITION PACKAGE WITH HOMESTEAD FOOD

PRODUCTION AS A PLATFORM TO IMPROVE FOOD

SECURITY AND NUTRITION

SEAVEG 2016, USAID Horticulture Open Presentation Session

Nancy J Haselow, Helen Keller International

ESTIMATES OF THE PROBLEM/ REASONS FOR THE APPROACH

159 million children under 5 (24%) are stunted, 96 million are in Asia

50 million children under 5 are wasted

20% of stunting by 24 months is due to being born Small for Gestational Age

Undernutrition is responsible for 45% of all under 5 child deaths

842 million people do not have enough to eat, 550 million in Asia

PROPOSED INTERVENTIONS FOR ADDRESSING UNDERNUTRITION– LANCET SERIES 2013

NUTRITION SPECIFIC

• Promote appropriate

breastfeeding and

complementary feeding

• Micronutrient supplementation

• Management of acute malnutrition (including screening and referral)

• Balanced energy and protein supplements to women

NUTRITION SENSITIVE

• Agriculture & food

security

• Social safety nets

• Women’s empowerment

• Water, sanitation &

hygiene

• Health and family planning

services

• Early child development &

child protection programs

THE DETERMINANTS OF MALNUTRITION

Nutrition specific

Nutrition sensitive

Photo © HKI / Keang Khim

HELEN KELLER INTERNATIONAL’S MODEL

HOME GARDENING PROJECT

INITIATED IN BANGLADESH

• Initiated the first pilot gardening

project in 1988 to improve dietary

diversity and micronutrient status,

particularly vitamin A status

Increased availability of vitamin A and other MN rich foods and their consumption – Talukder et al, Food Nutr Bull 2000;21:165-172

Diversification is important for increasing consumption and possibilities to increase varieties of food - Bloem et al, Eur J Clin Nutr 1996;50:s62-s67

Ensures year round availability - Talukder et al, Food Nutr Bull 2000;21:165-172

Increased family income and women’s participation in decision making – Bushamuka et al, Food Nutr Bull 2005;26:17-25

0

0.5

1

1.5

2

2.5

3

3.5

No HG, No Poultry Poultry HG HG & Poultry

Pre

va

len

ce

of

XN

(%

)

Night blindness decreased

VITAMIN A DEFICIENCY

Prevalenece of nightblindness among underfives (12-59 mo)

that had not received VAC by home garden and poultry

ownership (n=4296) (Kiess et al)

HKI’S ENHANCED HOMESTEAD FOOD

PRODUCTION (EHFP) PROGRAM MODEL IN FOOD

INSECURE AREAS

Year round production of

plant and animal source

foods at household

Nutrition/hygiene education

and communication for

behavior change

•Home gardens (1988)

•Animal raising (1990s)

•Village model farms for

ongoing support

Essential Nutrition/Hygiene

Actions (ENA/EHA), including

optimal breastfeeding and

complementary feeding

with gender transformation

training

9

Farmer’s Groups

(primarily women)

FOOD

CARE

HEALTH

HKI’s EHFP-Linking Agriculture and Health

FOOD-CARE-HEALTH components…

MAJORITY OF POOR GROWTH OCCURS

BEFORE FIRST 2 YEARS OF LIFE

Weight for age, by region

Need to also focus on nutrition

of women and children < 2

years old

CHARACTERISTICS OF HFP • Women with children under 2 years from poor HHs in food insecure

areas as primary agriculture and nutrition/hygiene education/BCC beneficiaries

• Work through and build capacity of local partners (communities, NGOs, GOs)

• Establish model farms as private enterprise /community resource for ongoing support and build linkages to the local health, WASH & agriculture systems

• Promote optimal nutrition, hygiene and feeding practices through education/ behavior change communication

• Improved local farming practices and initial agriculture inputs and training for up to 2 years to ensure year round production of micronutrient rich crops and animal source products

• Facilitate income generation through training and links to market

BASIC CHARACTERISTICS OF EHFP

IMPACT

Nutrition-sensitive agriculture interventions have

shown consistent improvement in the :

• volume and diversity of vegetables and fruits

produced

• diversity of foods consumed

• women’s involvement in family decision making

• But inconsistent impact on nutritional status of

children

SUMMARY OF REVIEW STUDIES ON IMPACT OF

AGRICULTURE INTERVENTIONS OF NUTRITION

Masset, BMJ 2012

There are synergistic pathways that lead

to improved nutrition including:

• Production-consumption pathway

• Production-income pathway

• Knowledge - adoption of optimal health,

nutrition and hygien-related practices

pathway

• Women’s empowerment pathway

IMPACT PATHWAYS

IMPACT OF HKI’S ENHANCED

HOMESTEAD FOOD PRODUCTION

HKI’s HFP programs in Asia (Bangladesh, Nepal,

Cambodia, Indonesia, the Philippines and Vietnam) have

reached over 1.2 million families and have resulted in:

• improved home gardens & animal husbandry practices

• increased production and consumption of MN rich foods

• increased dietary diversification for children and women

•improved household food security

• Increased women's level of influence in household

decision-making

• increased household income, controlled by women

•Reduced anemia prevalence among targeted children

aged 6-59 months and non-pregnant women

• Reduced prevalence of night blindness among children

aged 12-59 months

PRODUCTION AND CONSUMPTION OF

VEGETABLES BY TYPE OF GARDEN

(N=10,107), BANGLADESH

0

1

2

3

4

5

6

7

None Traditional Improved Developed

Garden type

Ch

ild

co

nsu

mp

tio

n/

# v

ari

eti

es

0

10

20

30

40

50

60

Pro

duction (

kg)

Child consumption

Number of varieties

Production in last 2 mo (kg)Crop diversity, production and consumption increased

Source: Talukder et al. Food Nutr Bull 2000;21:165-172

PLB, BANGLADESH: MONTHLY

VEGETABLE PRODUCTION INCREASED

17

Baseline = 10 Kg

Year 1 = 17 Kg

Year 2 = 24 Kg

Year 3 = 33 Kg

Year 4 = 40 Kg 400%

increase

DIETARY IMPROVEMENTS IN PLB,

BANGLADESH

18

• Baseline - female beneficiaries with

inadequate diet

reduced to at end line!

compared to 54% nationally (FSNSP)

• Women’s mean dietary diversity pattern has shown remarkable improvement over the middle of project period. Mean dietary diversity score from 3.7 to 5.02 increased in two years

35.6

79.4

37.7 44.1

0

10

20

30

40

50

60

70

80

90

100

Baseline Follow - up*

Pe

rce

nt

of

child

ren

Survey period

EHFP

Control

AAMA, NEPAL RESULTS - EFHP IMPROVED

COMPLEMENTARY FEEDING PRACTICES

Proportion of children 12- 23 months fed

recommended minimum acceptable diet

* p<0.05

WOMEN’S INDIVIDUAL DIETARY DIVERSITY,

FISH ON FARMS, CAMBODIA

Control

n (%)

HFP

n (%)

HFP + F

n (%)

Baseline

Low (≤ 3 food groups) 97 (32.3) 83 (27.7) 90 (30.0)

Medium (4 - 5 food groups) 175 (58.3) 194 (64.7) 177 (59.0)

High (≥6 food groups) 28 (9.3) 23 (7.7) 33 (11.0)

Endline

Low (≤ 3 food groups) 37 (20.7) 21 (11.4) 19 (10.1)

Medium (4-5 food groups) 100 (55.9) 96 (51.9) 115 (61.2)

High (≥6 food groups) 42 (23.5) 68 (36.8) 54 (28.7)

79.7

53.6

87.4 78.3

0

10

20

30

40

50

60

70

80

90

100

Baseline Follow - up

Pe

rce

nt

of

ho

use

ho

lds

Survey period

EHFP

Control

RESULTS FROM AAMA, NEPAL- EFHP

IMPROVED HOUSEHOLD FOOD SECURITY

* p<0.05

Proportion of food insecure households

HOUSEHOLDS GENERATED INCOME FROM SALE

OF HFP AND FISH PRODUCTS, FISH ON FARMS

CAMBODIA

22

Item

EHFP EHFP + Fish Control

Baseli

ne

Endlin

e

P-

value

Baseli

ne

Endlin

e

P-

value

Baseli

ne

Endli

ne P-

value

Sell home garden (vegetables and fruit) products in last 2 months [n (%)]:

Yes 9.3 47.0 0.000 9.7 45.2 0.000

5.7 11.7

0.01

7

No 90.7 53.0 90.3 54.8 94.3 88.3

Income amount from sale of

garden products in last 2 months

(US$) [x̅±SD]

0.69±

3.75

8.23±

17.65 0.000

1.95±

14.06

12.05

±39.6

6

0.000

0.28±

1.77

1.1±6

.31 0.34

Sell home fish products in last 2 months [n (%)]:

Yes 0.3 4.3 0.002 1.3 29.3 0.00

0 1.3 3.4

0.13

5

No 99.7 95.7 98.7 70.7 98.7 96.6

Income amount from sale of fish

products in last 2 months (US$)

[x̅±SD]

0.3±5.

19

1.37±

7.99 .074

0.51±

5.13

13.02

±58.4 .000

0.9±

14.44

0.46±

2.89 .687

USE OF INCOME EARNED FROM HFP AND FISH

PRODUCTS, FISH ON FARMS CAMBODIA

Item

HFP n (%) HFP + Fish n (%) Control n (%)

Baselin

e Endline

P. Value Baselin

e Endline

P. Value Baselin

e Endline P. Value

Chicken/duck 0.0 5.1 0.268 8.0 10.0 0.769 13.3 5.9 0.471

Beef/pork/buffalo/goat 43.5 73.1 0.008 36.0 82.9 0.000 46.7 58.8 0.492

Fish 87.0 74.4 0.205 56.0 61.4 0.634 73.3 82.4 0.538

Eggs 13.0 42.3 0.010 20.0 50.0 0.009 6.7 17.6 0.349

Fruits & Vegetables 4.3 3.8 0.914 12.0 10.0 0.780 6.7 29.4 0.100

Fruits 8.7 15.4 0.415 12.0 15.7 0.653 6.7 17.6 0.349

Rice 13.0 3.8 0.101 20.0 5.7 0.036 6.7 5.9 0.927

Iodized salt

26.1 64.1 0.001

52.0 80.0 0.007

.007 33.3 64.7 0.077

Sugary foods 47.8 69.2 0.060 64.0 78.6 0.150 60.0 52.9 0.688

Fat/oil 56.5 70.5 0.209 56.0 74.3 0.088 60.0 52.9 0.688

Summary of findings from past evaluations of HKI’s EHFP

Programs

IFPRI’s Millions Fed Report, Bangladesh. Iannotti et al. 2009

HKI’s EHFP programs:

•increased diversity and quantities of food produced and consumed

•increased women’s involvement in household decision making

“…there is sufficient evidence to conclude that HFP is improving

household food security, and in some cases nutrition and other

intermediary outcomes”

• EHFP intervention roll-out

– Home gardens and poultry

– BCC strategy led by Female Community Health Volunteers

– Covered

• ~11000 families with children < 2 years /pregnant

women

• 21 Village Development Committees (VDCs), each

consist of 9– 11 villages

• Evaluation research design

– Cluster randomized controlled trial (14 EHFP VDCs vs. 14

Controls VDCs)

– Baseline and follow up surveys, each involved > 2000

families with children 12 – 48 months in EFHP and control

villages

– Process evaluations/monitoring conducted every six

months

FINDINGS FROM RANDOMIZED CONTROLLED TRIALS ON HKI’S EHFP : AAMA NEPAL STUDY, 2009 - 2012

AAMA, NEPAL RESULTS – EHFP IMPROVED

ANEMIA AMONG CHILDREN AND WOMEN

0.76

1

0

0.2

0.4

0.6

0.8

1

1.2

EHFP * Control

Children 12 – 48 months

0.62

1

0

0.2

0.4

0.6

0.8

1

1.2

EHFP * Control

Mothers

Adjusted odds ratio, with 95% CI

*P < 0.05

And non-pregnant mothers were 39% less likely to be

underweight (BMI < 18.5 kg/m2)

Baitadi District

• HKI’s Enhance Homestead Food Production program can

reduce anemia among children and women

• EHFP can reduce underweight among women

• There is still no demonstrated impact of EHFP on child growth

(child stunting, underweight and wasting)

• However, there was significant improvements in a range of

maternal practices that are known to impact child growth Note: Duration of the intervention may have been too short to realize impact on child

growth, broad targeting, cross-sectional design, and inadequate WASH component

Kailali District was not a RCT, used an intervention-comparison

evaluation design. Difference in difference analysis found

a10.25 (P value0.008) in stunting between baseline and endline.

SUMMARY OF FINDINGS FROM AAMA

DECREASE IN STUNTED CHILDREN FROM BASELINE TO

ENDLINE (54% TO36%), MAKING MARKETS WORK FOR

WOMEN, HKI BANGLADESH, HKI, 2012

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58

Pro

po

rtio

n o

f ch

ildre

n s

tun

ted

Child age in months

Baseline - February/March 2010 Endline - May/June 2012

Twenty-two month cluster randomized control design with

three arms

Intervention groups received horticulture and/or aquaculture

inputs, training and support, nutrition education and gender

BCC via trained Village Model Farmers

Conducted baseline and endline after 22 months

Anthropometry measured, 24-hours recalls done

FANTA’s Household Food Insecurity Access Scale (HFIAS)

FAO Individual and Household Dietary Diversity Score (IDDS)

Hemoglobin for mother-child pair via Hemocue

Venous blood sub-samples collected from 450 women for

hemoglobin concentration, serum ferritin and RBP, serum

zinc, CRP, B12 and folate, etc

IMPACT ON NUTRITION: FISH ON FARMS

CAMBODIA METHODS

CHILDREN’S ANTHROPOMETRY

Children’s anthropometry

Control

n (%)

HFP

n (%)

HFP+F

Stunting (HAZ<-2SD)

Baseline 88 (29.3) 68 (22.7) 83 (27.9)

22-months 73 (32.0) 72 (28.9) 72 (29.9)

Wasting (WHZ<-2SD)

Baseline 25 (8.3) 25 (8.4) 20 (6.7)

22-months 17 (8.9) 27 (13.0) 20 (10.2)

Underweight (WAZ<-2SD)

Baseline 69 (23.0) 78 (26.1) 70 (23.5)

22-months 66 (28.8) 72 (28.8) 77 (32.0)

HEMOGLOBIN, FERRITIN, SOLUBLE TRANSFERRIN RECEPTOR, RETINOL

BINDING PROTEIN, C-REACTIVE PROTEIN, AND Α-1 ACID GLYCOPROTEIN

CONCENTRATIONS AT BASELINE AND 22 MONTHS AMONG ENROLLED NON-

PREGNANT CAMBODIAN WOMEN, BY TREATMENT GROUP

Control

mean ± SD

HFP

mean ± SD

HFP+F

mean ± SD

Hb2, g/L

Baseline 123.6 ± 10.9 124.6 ± 9.9 124.9 ± 11.4

Endline 122.7 ± 11.3 126.3 ± 9.6 126.9 ± 11.5

Serum ferritin, g/L

Baseline 99.6 ± 56.6 97.1 ± 52.5 88.9 ± 62.1

Endline 109.0 ± 68.5 97.8 ± 52.1 100.1 ± 57.2

sTfR, mg/L

Baseline 6.9 ± 2.5 6.9 ± 7.9 7.2 ± 2.8

Endline 6.7 ± 2.2 6.7 ± 2.3 7.3 ± 3.4

RBP, mg/L

Baseline 2.5 ± 0.7 2.6 ± 0.7 2.5 ± 0.7

Endline 2.1 ± 0.7 2.3 ± 0.9 2.5 ± 1.0

CONCLUSION OF FISH ON FARMS

Enhanced Homestead Food production in both the HFP

and HFP + Fish groups:

Improved production of micronutrient-rich foods by

participating households

Increased dietary diversify among women

Increase household income - mostly spent on buying

quality food

Improved women empowerment in decision making in

the households

Overall, HFP contributes to household food security and

dietary diversity. However, no impact on anthropometry

and other nutrition indicators were seen.

CHALLENGES AND LESSONS

• Flow of quality inputs

• Continuous engagement

of input seller/private

sectors locally

• Continuous engagement

of government agriculture

extension, capacity

• Adopt appropriate climate

smart agricultural practices

• Water management

• Post-harvest processing

and storage

CHALLENGES

• Aggregating small

quantities of produce for

market

• Ensuring food safety

• Financing for expansion

• Management

• Models for urban and

peri-urban food insecure

households

• Sustainability and

enrollment of new

mothers

1. Collaborate with local partners across sectors to ensure all food,

health and care determinants of undernutrition are addressed

2. Target interventions to pregnant women and women with children

under two years of age to best address child growth

3. Implement in food insecure areas among disadvantaged HHs

4. Ensure the program design empowers women

5. Base program design and adaptation to local context on evidence

6. Have a programmatic entry and exit strategy in communities

7. Ensure there is a local source for continued agriculture inputs

and support

8. Work to build multi-sector collaboration at all levels

9. Provide continuous learning through an effective monitoring and

evaluation system

10. Document, publish and disseminate findings to advocate for

policy and resource support

KEY LEARNING TO LEVERAGE IMPACT OF

NUTRITION-FOCUSED AGRICULTURE PROGRAMS

NJ Haselow, A Stormer, A Pries,

Evidence-based evolution of an

integrated nutrition-focused

agriculture approach to address

the underlying determinants of

stunting. Maternal and Child

Nutrition (2016), 12 (Suppl. 1),

pp155-168

http://onlinelibrary.wiley.com/doi/

10.1111/mcn.12260/epdf

www.hki.org

Photo © HKI / George Pigdor

THANK YOU

Alone we can do so little,

together we can do so

much…more.

Helen Keller