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Would you Terminate a Pregnancy Affected by Sickle Cell Disease? Views of Doctors, Parents and Patients in Cameroon.

Author(s) Ambroise Wonkam1, Jantina de Vries2, Charmaine Royal3, Dora MBanya 4, Jeanne Ngongang 5, Fru Angrafo III6
Affiliation(s) 1Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, 2Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Institute for Genome Sciences & Policy, Duke University, Durham, United States, 4Department of Medicine, Faculty University of Yaoundé I, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon, Biochemestry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon, Surgery, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary We studied the views of 110 doctors, 130 parents with one living child with SCD (Sickle Cell Disease), and 89 adults patients suffering from SCD, regarding prenatal genetic diagnosis and termination of a SCD-affected pregnancy.
The majority accepted the principle of prenatal genetic diagnosis for SCD (78.7%, 89.8% and 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%) as opposed to doctors and patients where this group were in the minority (36.1%, and 40.9 %). Parents and patients who rejected termination of pregnancies claimed ethical reasons (69.1 and 78.1%) while those who accepted it feared having another SCD-affected child (98.1 and 88.9%) with a poor quality of life (92.6% and 81.5%).
Background Patients with Sickle Cell Disease (SCD) can suffer from anemia, painful episodes, susceptibility to infection, stroke, and chronic organ damage (kidneys, lungs, heart, brain). There is currently no cure available for SCD, but the condition can be managed using a variety of therapies. When the condition is not managed patients tend to die in early childhood as occurs in many African countries.
In Cameroon it is possible to test for sickle cell homozygosity before birth, and in fact Prenatal Genetic Diagnosis (PND) represents one type of preventive strategy, as it is offered as a reproductive option to at-risk parents. PND provides parents with a reproductive option to test at-risk pregnancies and make decisions regarding medical abortion.
However, legal bans on abortion exist in virtually all African countries and when allowed medical abortion is often restricted to direct threats to maternal health. This raises important ethical questions regarding the desirability of terminating affected pregnancies.
Many parents currently caring for a child with SCD opt to abort a fetus that is also suffering from SCD. What has not yet been investigated is the comparative views of parents to those of health care providers and patients living with SCD.
Objectives We examined the attitudes of a sample of Cameroonian medical doctors, parents with at least one SCD-affected child, adult SCD patients towards PND and TAP. There were two major research questions: (1) their agreement with prenatal genetic diagnosis and pregnancy termination in general (2) their agreement with prenatal genetic diagnosis for SCD, and pregnancy termination for SCD, and the reasons for their attitudes.
Methodology Design
This research was a quantitative social science study administered by structured questionnaires.
Sample Population and Eligibility Criteria.
The sampling methods used included both purposeful and convenience sampling.
Medical doctors were recruited from a National Medical Conference for continue medical education. In an attempt to ensure inclusion of parents and adult SCD-affected patients and incorporate the entire spectrum of this illness, we issued a call for participation using the national Cameroonian media. We also approached two SCD Patients’ Associations in Cameroon. Participants needed to be at least 18 years old with a diagnosis of SCD that was confirmed by a laboratory documentation of their hemoglobin electrophoresis.
Questionnaire Format.
The data were collected by means of a structured questionnaire consisting of three sections of closed-ended questions. These were (1) Socio-demographic characteristics; (2) Attitudes towards SCD screening policies; and (3) Attitudes about principles of SCD- prenatal diagnosis and termination of an affected pregnancy if the participant’s unborn child were proven to be affected. Response options were “Yes,” “No” or “Undecided”.
Research Setting and Data Collection.
The study was conducted at the Yaoundé Central Hospital where face-to-face questionnaires interviews were conducted. Informed consent was also obtained at this stage. In addition to the introductory explanation, each patient was given full non-directive genetic counseling with neutral information concerning PND and its reproductive options. Images were used to explain the obstetric procedure of PND and risks (specifically 1% induced miscarriages). Information on the available therapeutic options and follow up for patients with SCD was reviewed and the participants were given an opportunity to ask questions. The information provided during this counseling session was equivalent to the information that prospective parents would have received had they been seeking PND for SCD.
Data Analysis.
Data were analyzed using SPSS (Statistical Package for Social Sciences, Chicago). A comparison between two or more variables was evaluated by non-parametric tests (H test of Kruskal-Wallis or Z test of Kolmogorov-Smirnov, when applicable). The p values were considered significant if they reached 95%.
Results The majority of parents participants lived in urban areas (89%), were female (80%), Christian (93%), married (60.2%) in monogamous households (81.1%), were employed (61.7%), and had at least a secondary or tertiary education (82%). Similarly, the majority of the patient participants were urban dwellers (84.3%), female (57.3%), Christian (95.5%), single (90.9%), with a secondary/tertiary education (79.5%).
The clinical profile of participant children and patient participants indicated that they suffered from (relatively) severe forms of SCD. The majority of research participants received poor treatment for their SCD. Only 4.4% of participants received hydroxyurea treatment, the only treatment currently available to manage SCD. Nearly 90% (89.7%) had received traditional medicine for their conditions on at least one occasion in the past.
The majority accepted the principle of prenatal genetic diagnosis for SCD (doctors: 78.7%; parents: 89.8% and patients: 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%), but doctors and adults patients were less comfortable with this principle (36.1%, and 40.9 % acceptance, respectively). The acceptance of the principle of medical termination for SCD increased with unemployment status. (missing data here)
Conclusion Differential views regarding medical abortion for SCD in Cameroon could lead to societal, ethical and legal conflicts. Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon.
The patient participants in this study indicated a surprisingly high (40.9%) rate of acceptability of TAP. This is surprising as one could argue that a decision to terminate a pregnancy where the future child would suffer from the same condition that is affecting the parent seems to imply a value judgment about the individuals’ quality of life. Patients who participated in this study presented with severe forms of SCD. We wonder whether our results mean that approximately 4 out of 10 of the patients included in this study did not find their quality of life worth living and did not want to allow a child to experience it. This is a disturbing finding that requires the further attention of policy makers and medical professionals in Cameroon.
Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon. For instance, the average late diagnosis of the condition in our participants leads to greater clinical severity. In addition, the very low number of people who receive adequate medical care to manage their condition, as well as the large number of people who received traditional medicine, may also indicate the failure of medical professionals in Cameroon to adequately manage SCD. Many patients with SCD require the expertise of specialized centers. Lifelong medical care and surveillance are not yet available in Cameroon where provision of healthcare services is hampered by major economic, organizational and infrastructural difficulties.These differential views of patients, physicians and parents also indicate potential ethical conflicts between various components of the Cameroonian society regarding TAP for SCD. Additional studies among various groups may provide detailed insight into the range of moral, legal and social perspectives held by the public and the healthcare community regarding genetic technology and prenatal diagnosis in Cameroon.

Creating Healthy Work Environments by training Medical and Nursing Students: Nigeria

Author(s) Ezinna Enwereji1.
Affiliation(s) 1Community Medicine and Nursing Sciences, Abia State University, Uturu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Advocacy and Communication
Summary There is mounting evidence that unhealthy work environments contribute to medical errors,
ineffective delivery of care, and conflict and stress among health professionals. This report describes steps taken to encourage good interprofessional and interpersonal relationships to reduce unhealthy work environments in hospitals. To guarantee this, a two day seminar which emphasised advocacy and effective communication as a panacea for quality services was held for medical and nursing students on clinical posting. The novelty of this procedure is that students approached each professional personally to evaluate difficulties and constraints in professional collaboration.
What challenges does your project address and why is it of importance? Exposing medical and nursing students to general practice and community healthcare services is common practice in health care training curricula. When students are posted for clinical experiences, particularly in community settings, non-academic staff also teach some procedures like laboratory and midwifery. But proponents of the hospital and biotechnology based paradigm, which is dominant in most academic environments, question both the scope and quality of training covered by non-academic staff especially where incentives are not given. This doubt causes interprofessional conflicts which adversely affect the quality of health care services rendered. There is mounting evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, conflict and stress among professionals. Negative relationship issues are real obstacles to the development of work environments where patients and their families can receive safe and excellent care. Also negative relationships induce hospital-acquired infections and other complications including patient readmission. Such demoralizing and unsafe conditions in workplaces must be addressed. Establishing healthy work environments ensures patient safety, staff retention, and quality student training.
How have you addressed these challenges? Do you see a solution? Setting up sustainable medical education activities in an unfriendly environment is a difficult task that calls for wisely selected functional steps. In addressing issues of poor interprofessional and interpersonal relationships commonly reported among health workers in hospitals, lecturers in charge of students’ clinical postings organised a two day seminar to acquaint newly posted students with holistic approaches to clinical experiences that enhance professional advancement. Organizing this seminar aligns with the University’s ethical obligations of establishing, maintaining and improving healthcare environments and employment conditions favourable to the values of medical and nursing students’ professions. In this seminar students were encouraged to assess the difficulties and constraints that influenced unhealthy work environments in hospital settings so as to proffer intervention. To ensure success the University authorities funded the training seminar. This report describes the steps taken to establish and maintain good interpersonal relationship among health workers so that they were enabled to provide quality health care services to clients.
During the seminar, emphasis was placed upon effective communication skills, professionalism, teamwork, mutually respectful relationships, fostering of true collaboration, decision making, and accountability as strategies required to guarantee healthy work environment and quality services in hospitals. In this project, skilled communication was seen as a two-way dialogue in which individuals would discuss and decide together way forward. Here health care workers were encouraged to imbibe the culture of developing among themselves, irrespective of their professions, communication skills (written, spoken and non-verbal) that are at parity with expert clinical skills. In this circumstance, civility, respect, and speaking with knowledge and authority were introduced as the health workers’ veritable tools for encouraging professional collaboration.
The aim of this project was to encourage the students to promote interprofessional and interpersonal relationships through effective communication so as to ensure successful teamwork during their clinical posting. The novelty of this procedure is that the students approached each professional in the hospital personally to evaluate difficulties and constraints that affect health care professionals’ collaboration.
How do you know whether you have made a difference? Using skilled communication to support ethical obligation of the University the trained students helped to improve their professional integrity and guaranteed trust between them and other health workers in the hospital. As a result the students offered quality services to patients assigned to them as evidenced by the number of patients who said they were satisfied with the quality of services they received. By this, students assured the patients of their safety and best interests, as they provided their services with competency and mastery, which dramatically altered the conflict-laden conditions of the hospital environment. There was increased awareness among professionals on how to achieve desirable outcomes for clients. It was noted that by emphasizing skilled communication as goodwill and mutual respect encouraged common understanding on the need for teamwork and advanced collaborative relationships among health professionals.
The analysis of the students’ intervention resulted in three major positive themes: (1) improved interprofessional interactions with other students; (2) increased interprofessional interactions with other health professionals and (3) better interprofessional interactions with the hospital authorities. The students demonstrated a new level of respect for health professionals outside their disciplines, and gained insight into how their own independent roles can blend with others’ roles, to enhance each other’s expertise. A good number of the students expressed appreciation and respect for professional roles stating how their exposures to various health professionals in different contexts have enabled them to understand and appreciate other health professionals’ roles.
The project has demonstrated that students’ learning experiences can be enhanced through engaging and integrating their services with other professionals in hospital setting. Exposing students to interprofessional learning in clinical posting assignments helped to increase the students’ understanding of professionalism, teamwork and determination to improve their service delivery models. As a result, interprofessional integration was regarded as the key strategy to improve the delivery and outcomes of health care services and promotion.
Have you or the project mobilized others and if so, who, why and how? A good proportion of the students, as well as some other professionals, recognized the need to adopt interprofessional training and work practices where two or more professionals learn about one another’s roles to improve collaboration and quality care services to clients. The fact that interprofessional collaboration encouraged better health care services by optimizing the skills of healthcare teams in case management and in reducing medical errors encountered, interprofessional practice became a topical issue in the University. As a result, the University has adopted interprofessional education as a method of preparing its future students for effective health care services during clinical experiences in the hospitals.
It is evident that adopting interprofessional education for training medical and nursing students will require systemic changes in healthcare policy goals, but the University has embraced this training model for these students. To show commitment, the University has budgeted funds for lecturers who will use this model to develop the students’ competencies for collaborative practice. The argument is that graduates on entering the workforce should be made aware of roles and responsibilities of other health care disciplines to avoid workplace conflicts, inefficient use of resources and ineffective patient care delivery. A collaborative approach is therefore critical in assisting the health workers to provide better patient care and safety. The advantage is that health care professionals will be enabled to widen the scope of their knowledge and skills as well as gain experiences in working and living amicably with other professionals. This pilot project has created healthy work environments that supported and fostered excellence in patient care services especially for patients needing acute and critical care services. To increase healthy work environments that would benefit everyone including patients, the following could be enacted:
• Identify the pressing problems in work environment.
• discuss with colleagues and find solutions to challenges encountered.
• ensure that work and health care environments are safe, healing, humane, and respectful of others rights and responsibilities
• voice grave concerns about deterioration in healthcare environments and affirm that safe and respectful environments require systems that support communication, collaboration, decision making, staffing, recognition and leadership.
When your donor funding runs out how will your idea continue to live? The University, having adopted the principle of interprofessional education for training future medical and nursing students to guarantee interdisciplinary collaboration and healthy work environments, has budgeted funds for this programme. Since the University is committed to this project, there will be continuous training of the students and budgeting for the execution of the project. This means that for each academic calendar the University will ensure that the students for clinical experience are adequately trained and monitored in the hospital where they are posted. This ensures that the project will be ongoing and build over time and also with the students and other participants, become the norm in the hospital. With synchronous ongoing collaborative work among healthcare professionals, patient and family needs satisfaction, and an improved staff relationship will be optimally achieved within the complexities of the healthcare system thereby reducing the negative impact of unhealthy work environment.
The continuous training and retraining of medical and nursing students on clinical exposure will provide opportunities for health team members to develop collaboration skills that ensure knowledge and competence as well as mutual concern for quality services to patients. Team members are motivated to master skilled communication development programs by focusing on strategies that enhance collaborative decision making. Program content would necessitate mutual goal setting, negotiation, facilitation, conflict management and performance improvement in health care services.

A Gender Analysis of Access, Use and Management of Bed Nets in Tanzania.

Author(s) Flora Kessy1, Jacqueline Matoro2, Elizeus Kahigwa3, Jacques Mader.
Affiliation(s) 1Dar es Salaam Campus College, Mzumbe University, Dar es Salaam, Tanzania, Swiss Development Cooperation, Swiss Development Cooperation, Dar es Salaam, Tanzania, 3Swiss Development Cooperation, Swiss Development Cooperation, Dar es Salaam, Tanzania, Federal Department of Foreign Affairs, Swiss Development Cooperation, Dar es Salaam, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Social Determinants and Human Rights
Summary The paper explores the gendered perceptions of the access, use and management of bed nets. It looks at the extent to which the bed net distribution campaigns in Tanzania has taken account of gender issues at both the design and implementation stages. The Tanzania National Voucher Scheme was by design gender unequal because it targeted women over men and was also gender-blind as it ignored gender norms, roles and relations and differences in opportunities and resource allocation between women and men. A more gender transformative approach in social marketing programs is imperative to enable wider coverage and use of bed nets.
Background Malaria control has received major attention and increased resources in recent years due to the significant public health and economic impact of the disease. This has translated into both in national level policies and in local/sub-national government practices. There has also been significant growth of political commitment towards malaria control which has affected national policies. Major efforts have gone into implementing the National Malaria Control Strategic Plan starting with the pilot provision and social marketing of Insecticide Treated Mosquito Nets (ITNs) in 1998 through a subsidized voucher scheme to help expectant mothers access ITNs. This was followed by launching of the Tanzania National Voucher Scheme (TNVS) in 2004, the introduction of the under–five catch up campaign (2008) and most recently (2010) the universal coverage campaign.The TNVS program focused originally on pregnant women and infants—with these categories being the only groups eligible to receive a subsidy on purchase of a mosquito net. Increased availability of resources has facilitated a free bed nets distribution campaign for those under the age of five. Subsequent universal coverage campaigns provided free bed nets to households with the aim of covering every sleeping space.
Objectives The paper sets out to explore the gendered aspects of access and use of ITNs through the different mechanisms for mosquito nets distribution in Tanzania. The objectives of the study were to;
(i) Document the perceptions of men and women towards the TNVS approach.
(ii) Explore the gendered aspects of TNVS that improved/hindered access and use of ITNs.
(iii) Explore whether the change in approach to universal coverage (free distribution of LLINs through the under-five catch-up campaign, and the universal coverage campaign) enhanced the gendered aspects in access and use of mosquito nets.
Methodology The study was conducted in Dodoma Region, central Tanzania. A Multi-stage sampling method was used. First, census Enumeration Areas of Dodoma Municipal, Kondoa, and Mpwapwa districts were selected followed by sampling of wards and then households to be visited. A total of 24 Enumeration Areas were identified (8 from Dodoma Municipal, 11 from Kondoa and 5 from Mpwapwa districts). From these Enumeration Areas a total of 21 wards were sampled. The households were then sampled randomly in order to avoid bias in the results.One of the issues in the line of inquiry was the proportion of households with children below five years of age. The assumption was that if a household had children below five years of age, the women within that household had been exposed to ITN messages and would have obtained ITN (other factors remaining equal). Therefore, in addition to the projected population of the district, the proportion of under-five children (estimated by the National Census Projections at 18.4% in 2010) was used as a basis in the sample size calculation. Based on these criteria, a total of 487 households were sampled and interviewed as follows; 158 from Dodoma Municipal, 110 from Mpwapwa and 219 from Kondoa districts. In order to obtained balanced views both men and women were interviewed. A total of 243 males and 244 females were interviewed.Data from the households were collected using a semi-structured questionnaire that contained both open and closed ended questions. The questions focused on the following main thematic areas; respondents’ demographic information, household awareness, access and ownership of ITNS and the resultant gender aspects therein, the gendered perceptions of the TNVS, the under-five catch up and universal coverage approaches, the gender relations in the use and management of ITNs at the household level, and the economic status of the households.Selected men and women also participated in Focus Group Discussions (FGDs). A total of 11 FGDs (6 for women only and 5 men only) were held with participants ranging from 7-10 members. Thus, a total of 93 individuals participated in the FGDs (52 and 41 males and females respectively). Other respondents in the study were Key Informants (KI) such as Malaria and Integrated Management of Childhood Illnesses Focal Persons, Village and Ward Executive Officers, TNVS agents, and ITN retail shopkeepers.
Results Due to limited resources, TNVS had a risk group/targeted approach and hence the gender inequality was by design. However the existence of gender-blindness was due to a certain degree of oversight of the gendered aspects in planning and implementing TNVS. The approach was gender-blind in several major ways;
1. The approach ignored gender norms, roles and relations. The communication campaigns on awareness of the importance for pregnant women to sleep under ITNs only targeted women without considering the important role men play in decision making about who actually utilizes the nets within the household. Notwithstanding, it also ignored the household sleeping patterns by portraying a woman sleeping with a child in a mosquito net while in many instances the father also shares the bed with the mother and therefore sleepe under the same ITN. However, at the household level, some gender balance in the use of the mosquito nets has been maintained although more women were sleeping under mosquito nets compared to men. Where mosquito nets were in short supply, boys and girls (above 12 years but below 18 years) were the least likely to sleep under a net.
2. The approach ignored differences in opportunities and resource allocation for women and men. Women had to use their savings because men did not pay for their ITNs.
3. The approach considered pregnant women as homogenous group which is not the case. There were destitute group of women who couldn’t redeem their vouchers.Although not by design, the universal coverage campaign could be termed as gender sensitive. This is in the sense that it tried to promote equality of access (regardless of gender) by providing mosquito nets to all members of households based on sleeping spaces not yet covered. Under the program other groups, who were not eligible under the TNVS were to receive nets. Men on the other hand interpreted the universal coverage program as their opportunity to receive nets and more men collected mosquito nets distributed under this program compared to those who went to collect nets from the other two programs on behalf of their spouses.Management of mosquito nets was considered to be in women’s sphere from washing, hanging, re-treating, hanging down and tucking and to make sure that all children slept under bed nets. However, as far as collection and funding is concerned, there is a clear untapped space for men to participate in mosquito net management.
Conclusion The possibility and timing of another round of universal mosquito nets distribution is unclear, yet families keep growing by the day. In order to sustain coverage and use of LLINs, mechanism building on the TNVS should be continued in order to take care of the pregnant women and newborn children. But a more gender transformative approach is needed in social marketing programs for mosquito nets, as well as in the distribution approaches adopted. In the case of social marketing, publicity could focus on messages that illustrate spouses taking part in accessing and managing bed nets as equal partners. Messages that show either spouse taking part in redeeming/purchasing nets, washing, treating, and even hanging down and tucking the net for children to sleep under or messages portraying male involvement in decision-making on the purchase of nets, and tackling stigmas attached to men redeeming bed nets with the voucher on behalf of their wives could be particularly useful and may help address the underlying causes of gender imbalances in the access, use and management of mosquito nets. Specific messages on the benefits of investing in mosquito nets should also be prepared in order to sensitize males who often control financial resources. It is clear that men need space to contribute to the access, use and management of mosquito nets and they can play very important roles if properly sensitized and allowed the space to get involved.In order to enhance acceptance and increased exposure of these messages, the communications should be piloted (e.g. test new messages with women only or men only or mixed group of men and women) in order to ensure a gender sensitive/specific/transformative approach and thus ensure that messages are interpreted as intended.

SAFO – The Strategic Alliance for the Fortification of edible Oils and Other Staple Foods.

Author(s) Andreas Bluethner1
Affiliation(s) 1Food Fortification, BASF SE, Ludwigshafen, Germany.
Country - ies of focus Germany
Relevant to the conference tracks Women and Children
Summary SAFO (Strategic Alliance for the Fortification of edible Oils and Other Staple Foods) is a Strategic Alliance within the DeveloPPP partnership scheme of the German Government that seeks to reduce vitamin A deficiency of 100 million people at risk of undernutrition. It was implemented by the following partners: BASF, a leading supplier of high-quality, cost-effective vitamin A, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry of Economic Cooperation and Development (BMZ) and local food producers and fortification alliances, including academia, UN, NGO's and the public sector.
Background BASF has chosen food fortification as an area for partnership engagement because it has been ranked by the Copenhagen Consensus as a top developmental priority due to its outstanding cost-benefit ratio.
For BASF, food fortification is part of the company's commitment to the Global Compact LEAD initiative of the United Nations. BASF's activities in food fortification is a strategic Shared value project, as the company becomes part of the solution to the global malnutrition challenge. Through effective communications this results in measured gains for branding (employer), sustainability reporting, serving as a partnership model for other divisions, and last but not least access to future markets.
Objectives The aim of the Strategic Alliance is to reduce vitamin A deficiency of 100 million people at risk of undernutrition in 8 Target countries within Latin America, Africa and Asia. In order to achieve this, SAFO builds local capacity in the food industry to deliver cost-effective interventions in food fortification which is the addition of essential nutrients to staple foods that are affordable for those groups with limited purchasing power and risk of micronutrient deficiencies.
Methodology National fortification programmes are typically based upon four components: policy advice and
advocacy, legislation, economic and technical implementation and testing arrangements. SAFO supports local partners to build upon these components. SAFO demonstrates that food fortification is a cost efficient and effective way of reducing hidden hunger and, to that end, brings all relevant actors together in the partner countries. Within SAFO, BASF empowers local food producers through technical training, analytical support, mobile laboratory equipment (with the German SME BioAnalyt as the partner for mobile analytics) and other in-kind start-up support that enables the cost-effective fortification of staple foods with essential micronutrients. Moreover, BASF assists local producers in the development of business plans that affordably supply enriched foods to low-income populations at high risk of micronutrient deficiencies.
GIZ supports capacity development by facilitating multi-stakeholder dialogues, advising government authorities, and supporting locally embedded food fortification NGOs. GIZ advises the public sector on the development of industry standards for fortification and credible labeling schemes that inform consumers about the health benefits of nutrient-rich foods and also supports M&E trainings of food and drug authorities.
This objective is not always a strictly linear process as local partners work in different countries at the same time with the support of BASF and GIZ.
Results SAFO has obtained its goal to reach about 150 million people at risk of malnutrition with fortified staple foods thereby contributing to reduce the prevalence of vitamin A deficiency in vulnerable populations.
Conclusion SAFO has reached its goal to reduce the prevalence of vitamin A deficiency in a self-sustainable and scalable way through a transformational public-private partnership approach. In terms of population reach one may assume, that the SAFO program, in conjunction with 150+ Mio. beneficiaries, is among the largest partnership and ‘shared value’ project that addresses an essential need.
Based on a ‘shared value’ business model, BASF's food-fortification engagement grew significantly over the 10 years of experience. Within BASF as a whole the overall turnover appears marginal, but the business model receives growing interest and support, including R&D efforts, on the basis of its needs-oriented engagement with  low income nutrition populations.

Linking Health And Educations Measures To Improve Early Childhood Development Programmes: Kyrgyzstan.

Author(s) Anara Doolotova1, Jypara Ergeshbaeva2
Affiliation(s) 1Health department, Aga Khan Foundation, Bishkek, Kyrgyzstan, 2Health, Mountain Society Development Support Program, Osh, Kyrgyzstan.
Country - ies of focus Kyrgyzstan
Relevant to the conference tracks Women and Children
Summary Since 2005 AKF has been implementing an early childhood development (ECD) program targeting caregivers and preschool age children in three districts of Osh province. The focus of the programme has been to provide different models of preschool education, from government kindergartens to private, home-based care facilities and even yurt-based kindergartens in high pastures during the summer (jailoo). This programme develops cognitive, social and intellectual skills of children 0 to 8 but mainly focuses on the older age group, from 4 to 8. Beginning in 2013 the Health Program introduced health components in the education formats to protect and promote the health of pregnant women and children under 5.
What challenges does your project address and why is it of importance? According to DHS-KG (2012), only 56% of infants are exclusively breastfed, more than 18 % of children under 5 are stunted, and 33 percent of women of reproductive age and 39% of children age 6 to 59 months have some level of anemia. The integration of health elements with the cognitive components of education is designed to increase health promoting practices and to reduce the prevalence of poor health practices. The Kyrgyz Republic has not recognized a formal ECD agenda for children 0 to 3 years old. Policy-makers and caregivers/parents are not fully aware that promoting the health of the mother and investing in the early years of a child’s development generate a substantial return later in life. While such an investment is a rational for a low-income country like the Kyrgyz Republic, most communities believe that children do not need to be educated in the early years because they are too young to learn. Also, while women generally support measures to promote the development of the young child through health and education initiatives, most men do not understand and are not involved in the care and development of the young child.
How have you addressed these challenges? Do you see a solution? AKF implements programs in 35 pilot villages of three districts. It is a community based approach and relies on involving volunteers of parent support groups and health providers. Integrating the health initiatives in the existing early child development programmes enables women and their families to have full knowledge of the care needed during pregnancy, delivery and the postpartum period, and promotes practices such as exclusive breastfeeding, proper nutrition, parenting and nurturing that promote the development of the young child. To address these challenges AKF, KR has adapted an integrated health and education model that uses a multi-partner approach based on community involvement and innovative implementation techniques such as home-visits of parent support groups, involving instructors of mothers schools to work with young parents, addressing ECD and health issues to men and partners, developing IEC materials on ECD and other initiatives which were not presented in the country.
How do you know whether you have made a difference? The study will measure the project implementation results between ECD indicators of integrated health and education programs in 35 pilot village communities and non-pilot villages where only the education component is being implemented.
Annual M&E data will be compared against the baseline. The following indicators will be tracked to monitor progress and impact: % of caregivers practicing at least five responsive parenting techniques; % of families with access to Parent Resource Centers (PRC) services; % of M/F children 0-6 months who are exclusively breastfed in project areas; and % of mothers with children under 5 who know at least 3 ways to prevent enteric infections which includes the % of M/F community members who know that breastfeeding should be initiated at birth.
Have you or the project mobilized others and if so, who, why and how? To reach mothers-to-be, new mothers and very young children, AKF KR works through Mother Schools. These are ‘sessions’ that take place largely in health facilities where the ’pregnancy to parenting approach’ is provided for pregnant women and family members during antenatal visit at birth preparedness schools (Mother schools) which are a part of primary health care facilities. Mothers Schools teach couples about antenatal, childbirth and postpartum care but also the early needs of the young child during the first days of life. Mother schools instructors will be trained on measures to ensure proper growth and development in the earliest years of a Child’s life. Parents will be educated by trained physicians to take proper care of the young child, not only physical development but cognitive and social development as well. Trained health providers provide sessions to young parents. Parental Resource Centres address the developmental needs of somewhat older children, i.e., 0 to 8 years. The families of these children are encouraged to visit a village-based centre in village or school libraries where trained facilitators, e.g. librarians and facilitators, provide special learning sessions for parents. Health messages and other interventions are incorporated. These measures inform parents about good health and nutrition practices and contribute to the healthy development of children between 4 to 8 years old. The material developed reaches parents with children aged 0 to 8 and a wide range of topics are included as breastfeeding and complementary feeding, danger signs during first years of childhood, immunization, how to take properly care of children in addition to ECD day to day development. To improve the health status of WRA the following topics are presented: postpartum nutrition, contraception and depression, danger signs of postpartum period and the role of family members. Finally, all parents with children 0-8 are informed of methods to prevent anemia and micronutrient deficiency, which is very common among local communities, how to adopt good nutrition habits, how to use safe water and maintain proper hygiene and sanitation in the family. The libraries of the PRCs have a space where parents and children can have access to information and can adopt/adapt practical lessons and plays, read IEC materials and watch DVDs. The health unit will provide health IEC materials to complement Education program. Home Visits will be carried out to reach families who cannot attend the PRCs.
When your donor funding runs out how will your idea continue to live? When the AKF program ends, the community will continue to implement the activities because the local personnel of the parent resource centers, mother schools, community leaders, district authorities will have already built their capacity and will continue their duties in order to benefit families.