LAO PDR EARLY CHILDHOOD EDUCATION PROJECT SNAPSHOT TWO: CHILD HEALTH AND NUTRITION This snapshot summarizes preliminary findings related to child health and nutrition from the Early Childhood Education (ECE) Study in Lao PDR. The ECE Study was initiated to evaluate the Early Childhood Education Project. The results presented here represent data collected on the status of child health and nutrition prior to the implementation of the project. Data will be collected again after the project has finished to see if the project has improved outcomes for children. This snapshot highlights that child undernutrition is a serious public health issue in Northern Laos PDR. Good health and nutrition are essential not only for children’s survival, but for healthy development and growth. Health and nutrition lay the foundation for development throughout childhood, in turn impacting on later learning, educational achievement and adult productivity. To promote holistic child development, a basis of good health and nutrition for the country’s children is critical. THE EARLY CHILDHOOD EDUCATION PROJECT The ECE Project seeks to support the expansion of quality ECE services with the objective of improving the overall development and school readiness of children aged 3-5 years in disadvantaged villages across the country (for further information, refer to Snapshot One: Project Background and Baseline Data Demographics). Good health is essential in promoting development, and as such the ECE Project incorporates interventions designed to improve child health and nutrition to better support overall child development. Community awareness campaigning and parental education will aim to improve knowledge and understanding of what is needed for good child health, while the provision of school lunches aims not only to promote healthy eating and better nutrition, but to improve school attendance and children’s concentration. Baseline data were collected to provide information on the current status of child outcomes, including indicators of child health and nutrition. Here we present findings on breastfeeding, undernutrition and vaccination coverage. LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION 1 The results are based on data collected from 7,520 had to work (23%), was either pregnant or wanted to be children and their caretakers in the Northern provinces of pregnant (12%), or because the child did not want their Lao PDR: Phongsaly, Oudomxay, Houaphanh, Xaiyabouly mother’s milk anymore (6%). and Borlikhamxay. Of all children assessed, 53% were exclusively fed breastmilk until at least 6 months of age, 68% were BREASTFEEDING breastfed beyond 12 months of age, and just 8% were Not only does breastfeeding provide infants with breastfed up until two years old and beyond. Worldwide, nutrition for healthy growth and development, it also about 36% of infants are exclusively breastfed until 6 reduces infant mortality and provides protection against months of age, and WHO has set a global target to disease and infection. It is recommended by the World increase this rate to at least 50% by 2025. Encouragingly, Health Organization (WHO) that children be exclusively the children in the baseline sample have already breastfed for the first six months of life. Thereafter, children exceeded this target. should receive complementary foods with continued Figure 1 shows that when looking at breastfeeding rates breastfeeding up to two years of age or beyond. more closely, there are disparities across ethnicity and Almost all children in the survey (99%) had been breastfed. family background. In particular, more Lao-Tai children For the small number of children that had not been were exclusively breastfed until at least 6 months of age breastfed, this was mainly due to their mother not having than Khmun and Hmong children. Further, educated enough milk (<1%), or because they had been adopted by parents were more likely to exclusively breastfeed their another family (<1%). For children who had been breastfed, children for at least six months than parents who had the majority were breastfed until they were 7–12 months never been to school. old (27%) or 13–24 months old (62%). The remainder were breastfed from 1–6 months old (4%), 25–36 months old (7%) and 37–60 months old (1%). Overall, 89% of children were breastfed beyond 6 months of age. The most common reasons mothers stopped breastfeeding were due to the child reaching an age when they felt that they should no longer be breastfed (50%), because the mother FIGURE 1. CHILDREN WHO WERE EXCLUSIVELY BREASTFED UNTIL AT LEAST 6 MONTHS OF AGE 70 66% 60 56% 57% 58% 53% 53% 54% 53% 55% 48% 49% 49% 48% 50 47% % of Children 40 30 20 10 0 Male Female 2 Years 3 Years 4 Years 5 Years Lao-Tai Khmun Hmong Other No school Did not Completed Completed complete Primary Secondary Primary School School or School above GENDER AGE ETHNICITY CARETAKER'S EDUCATION 2 LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION UNDERNUTRITION Children’s height and weight was measured to calculate of public health significance according to the WHO the presence of stunting, wasting and underweight. classification system. Stunting refers to a child being too short for his/her age; it is the failure to grow both physically and cognitively TABLE 1. PREVALENCE OF UNDERNUTRITION and is the result of chronic or recurrent undernutrition. AND PUBLIC HEALTH SIGNIFICANCE Wasting refers to a child who is too thin for his/her FORM OF % OF WHO CLASSIFICATION height, reflecting recent sudden weight loss or acute UNDERNUTRITION CHILDREN Stunting 50 40+ = ‘very high’ undernutrition, usually as a result of starvation or severe public health significance disease. Underweight can imply stunting, wasting or Wasting 9 5-9 = ‘medium’ public health significance both. Table 1 presents the overall prevalence of these Underweight 27 20-29 = ‘high’ three forms of undernutrition alongside the degree public health significance FIGURE 2. CHILDREN WHO WERE STUNTED 70 60 57% 54% 53% 54% 51% 50% 49% 49% 50 48% 48% 48% 46% 42% % of Children 40 30 20 10 0 Male Female 2–3 3–4 4–5 Lao-Tai Khmun Hmong Other No school Did not Completed Completed Years Years Years complete Primary Secondary Primary School School or School above GENDER AGE ETHNICITY CARETAKER'S EDUCATION LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION 3 reported in Snapshot One of this series of reports, which indicated that only 2% of households reported food shortages for more than two consecutive days over the last 12 months. Either households were unwilling to admit to their level of food insecurity, or there is a lack of variation and quantity of food being provided to young children, resulting in such high rates of stunting. When examining stunting in greater detail, disparities across age, gender, ethnicity and family background emerge, as shown in Figure 2. More children from Khmun, Hmong and other ethnicities were stunted than Lao-Tai children, and children whose parents had some form of education were less likely to be stunted than children whose parents had never gone to school. Wasting at the level found in this study would be considered a medium public health concern according to the WHO universal growth standards. If wasting goes unidentified and untreated, the condition progresses severely, requires specialized nutritional rehabilitation and greatly increases the risk of child mortality. As Figure 3 shows, when examining wasting more closely, while there were no gender differences there were differences across age, ethnicity and family background. Children from other ethnicities (a combination of Prai, Child stunting is classified as a very high public health Phong, Akha, Lao, Leu, Yang, Cingmoon, Kmer, Toum, concern in Northern Lao PDR. Stunting is largely Singsili, Hor and Ilmain – please refer to Snapshot One for irreversible and can have detrimental consequences further details) were most likely to be wasting. Slightly in later life, such as poor motor and cognitive skills, more Lao-Tai children were found to be wasting than leading to reduced adult productivity. These findings Khmun and Hmong children. Finally, while fewer children are interesting to reflect on when considering the results whose parents had completed secondary school or FIGURE 3. CHILDREN WHO WERE WASTED 35 32% 33% 30 28% 28% 27% 27% 27% 26% 27% 26% 25% 25% 25 22% % of Children 20 15 10 5 0 Male Female 2–3 3–4 4–5 Lao-Tai Khmun Hmong Other No school Did not Completed Completed Years Years Years complete Primary Secondary Primary School School or School above GENDER AGE ETHNICITY CARETAKER'S EDUCATION 4 LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION above were wasting, there was very little variation in the proportion of children wasting among those whose parents had not gone to school, had gone to school but not completed primary school, or had completed primary school. VACCINATIONS More than half of caretakers reported they had their child’s vaccination card (56%); 29% were able to present their child's vaccination card but without the details recorded on it, and 28% presented a vaccination card that did have information recorded on it. Examining only the responses from caretakers who were able to present their child’s vaccination card, we are able to estimate that up to 24% of children had their BCG vaccine for tuberculosis, 20% had been vaccinated against Measles, 22% had been fully vaccinated against both Polio and DPT (three doses of each), and while 12% of children had received two doses of the Hepatitis B vaccine, no children had received all three doses and were therefore not fully vaccinated against the infection. It is likely that children of families who did not have, or who were unable to provide, an immunization card have had no immunizations at all, or likely at a LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION 5 lower coverage than those families who were able to were much less likely to be vaccinated against Polio than present an immunization card. Table 2 below presents Lao-Tai, Khmun and children of other ethnicities. Further, vaccination results by age with an upper and lower children of parents who did not go to school were estimate of the coverage. This information is then much less likely to have had their Polio vaccinations than presented against the WHO recommended routine children whose parents had some form of education. vaccinations for all children. Polio immunization largely varied by age, with more than double the amount of 2 year olds vaccinated than Figure 4 shows large variations in vaccination coverage 5 year olds. Hopefully this is a reflection that programs across child age, ethnicity and family background. designed to increase immunization coverage are gaining These differences were much bigger than those of more traction. breastfeeding and undernutrition rates. Hmong children TABLE 2. VACCINATION COVERAGE BY CHILD AGE AND WHO VACCINATION RECOMMENDATIONS VACCINATION AGE LOWER ESTIMATE OF UPPER ESTIMATE OF WHO CHILDREN VACCINATED CHILDREN VACCINATED RECOMMENDATION BCG 2 10% 34% Age of first and only dose 3 8% 27% as soon as possible after birth. 4 6% 20% 5 5% 19% Measles 2 8% 18% Age of first and only dose, 3 6% 21% 9 or 12 months. 4 5% 17% 5 4% 15% Polio 2 9% 31% Minimum 6 weeks old at (3 dosages) 3 7% 24% first dose, then 4–8 week intervals between second 4 5% 18% and third dosages. 5 5% 16% DPT 2 9% 31% Minimum 6 months old at (3 dosages) first dose, then minimum 3 7% 24% 4–week intervals between 4 5% 19% second and third dosages. 5 5% 17% Hepatitis B 2 5% 13% First dose as soon as possible (2 dosages only) 3 4% 17% after birth, then minimum 4–week intervals between 4 3% 9% second and third dosages. 5 3% 9% Note: The upper and lower bounds are estimated taking into account the families that were unable to provide an immunization card. FIGURE 4. CHILDREN WHO WERE FULLY VACCINATED AGAINST POLIO 35 33% 33% 31% 30 28% 27% 25 24% 22% 21% % of Children 20 18% 19% 19% 16% 15 14% 10 7% 5 0 Male Female 2 Years 3 Years 4 Years 5 Years Lao-Tai Khmun Hmong Other No school Did not Completed Completed complete Primary Secondary School Primary School or School above GENDER AGE ETHNICITY CARETAKER'S EDUCATION 6 LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION KEY FINDINGS AND RECOMMENDATIONS This study finds that children in the northern parts of Lao PDR are not receiving the health services and nutrition that they should be. Despite meeting the WHO global target for exclusive breastfeeding until 6 months of age, there is still room for improvement in the breastfeeding rates in Northern Lao. The rates of stunting and children being underweight are of high public health significance. Additionally, the rates of immunization are well below international standards. These figures are consistent with previous research studies conducted by non-government organizations and the World Bank in Lao PDR. The ECE Project has the potential to support improvements in child health and development through the community awareness campaign. The campaign includes a focus on the importance of the first 1,000 days of life, immunization and good nutrition. It will be extremely important that the community awareness campaign is effectively implemented and that the key messages are delivered clearly and successfully to families living in the communities of Northern Lao PDR. LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION 7 FUNDING FOR THIS INITIATIVE: Funding for the ECE Project is provided by the World Bank Group through an International Development Association (IDA) Grant and Credit under the Early Childhood Education Project (P145544). Further funding to support the production of this series of snapshot reports has been provided through a partnership between the World Bank, Plan International and Save the Children International as part of the Lao Educational Access, Research and Networking (LEARN) Project, with funding from Dubai Cares under Externally Financed Output (EFO) Agreement EFO 990. The findings, interpretations and conclusions expressed in this brief do not necessarily represent the views of the Government of Lao PDR or the World Bank Group. Prepared by: Dr Sally Brinkman, Ms Alanna Sincovich, Mr Pedro Cerdan-Infantes, Mr Plamen Nikolov Danchev For more information about the ECE Project, visit: http://www.worldbank.org/projects/P145544/lao-prd-early-childhood-development- project?lang=en For more information about the study results, please contact Sally Brinkman: sally.brinkman@telethonkids.org.au For more information about the ECE Project, please contact Plamen Nikolov Danchev: pdanchev@worldbank.org The World Bank Country Office Education Global Practice Patouxay Nehru Road The World Bank P.O. Box: 345 1818 H Street, NW Vientiane, Lao PDR Washington D.C. 20433, USA Tel: (856-21) 266 200 Tel: (202) 4731000 Fax: (856-21) 266 299 Fax: (202) 4776391 www.worldbank.org/lao www.worldbank.org 8 LAO PDR EARLY CHILDHOOD EDUCATION PROJECT  SNAPSHOT TWO: CHILD HEALTH AND NUTRITION