Integrated solutions for healthy birth, growth, and development in Lao PDR

Wasting (low weight-for-height), which increases the risk of child mortality eightfold, affects 6% of children under 5; however, 13% of infants 6–11 months of age are wasted. Moreover, 15% of Lao newborns have a low birth weight (<2,500gm), which is a strong predictor of poor child nutrition outcomes(1).

Our previous work showed that food taboos for mothers characterised by inappropriate dietary intake during pregnancy and after birth, along with delayed and non-exclusive breastfeeding and poor complementary feeding practices in infants, are key determinants of child undernutrition in Lao PDR(2,3). Reducing the burden of undernutrition during the 1,000-day window from pregnancy to the age of two years using mixed multi-sectoral nutrition interventions has been recognised as a priority in the Post-2015 Sustainable Development Goals(4).

Burnet’s approach over the last two decades has been to combine the best evidence for approaches to PHC, health systems strengthening and behaviour change communication to tackle health issues, strengthen health services and improve health seeking behaviour among vulnerable groups around the world. In addressing undernutrition in Lao PDR, Burnet has drawn on extensive BCC activities among at-risk populations for HIV and early nutrition work in Houaphanh and Phongsali that provided one of the first comprehensive accounts of the contribution of food taboos and feeding behaviours to child undernutrition to develop a nutrition implementation model embedded within a PHC strengthening approach. Two Burnet projects in Savannkhet have employed this model: (i) 2006-2009 ‘Safer mines: HIV intervention for Lane Xang Minerals Ltd and Vilabouly communities’ (Southern Laos); and (ii) 2008-2011 ANCP Maternal and Child Health project. A peer-reviewed paper evaluating the first of these projects concluded that “the combination of strengthening PHC services and community based nutritional interventions using the existing structure of health services and health actors (including community volunteers) was successful in addressing acute malnutrition in this food insecure area of Laos.”

These data have been used to develop Burnet’s current randomised controlled trial in Vientiane province in partnership with TPHI that will rigorously assess the effectiveness and cost-effectiveness of this model.

This research is funded through a highly competitive National Health and Medical Research Council project grant. This series of nutrition work in Lao PDR illustrates how we pursue evidence to translate into effective public health policy and practice.

The cluster-randomised controlled trial will include catchment villages of health centres in six Districts in Vientiane Province (Kasy, Vangvieng, Feuang, Mad, Hinherb and Muen). The 38 health centres involved in the study serve 256 villages with a total population of 224,200 residents.

References:

1. Ministry of Health and Lao Statistics Bureau. Lao PDR, Social Indicator Survey 2011-12. Vientiane 2012.
2. Holmes W, Hoy D, Lockley A, et al. Influences on maternal and child nutrition in the highlands of the northern Lao PDR. Asia Pacific journal of clinical nutrition. 2007;16(3):537-545.
3. Coghlan B, Toole MJ, Chanlivong N, Kounnavong S, Vongsaiya K, Renzaho A. The impact on child wasting of a capacity building project implemented by community and district health staff in rural Lao PDR. Asia Pacific journal of clinical nutrition. 2014;23(1):105-111.
4. Lateef AT, J. Call to Action: Nutrition in the Post-2015 Development Agenda. CORE Group, Bread for the World Institute, Helen Keller International & Concern Worldwide,;2014.

This study aims to evaluate the clinical and cost effectiveness of a synergised model of nutrition-specific and nutrition-sensitive interventions that is integrated into existing community structures, building in essential capacity building of beneficiary communities to maximise sustainability.

Nutrition specific interventions address the immediate determinants of foetal and child nutrition: (i) adequate food and nutrient intake and (ii) control of infectious diseases. They encompass exclusive breastfeeding promotion, complementary feeding, micronutrient supplementation and food fortification, maternal health and nutrition, dietary diversification, deworming, treatment of severe wasting, and the management of infectious diseases(1).

In contrast, nutrition-sensitive interventions address the underlying determinants: (i) food security; (ii) social and care behaviours at maternal, household and community levels; and (iii) health environment and health services.

The trial has two arms:
1. A control arm, which will receive the standard primary health care (PHC) services mandated by the Ministry of Health.

2. An intervention arm, which will receive the standard PHC services plus a package of nutrition-specific interventions.

References:

1. United Nations SuN. SUN movement progress report 2011-2012. 2012.