Every Child's Potential: Integrating Nutrition, Health, and Psychosocial Interventions to Promote Early Childhood Development
Wednesday, April 3, 2013 - Thursday, April 4, 2013
The New York Academy of Sciences
Early childhood is recognized as a critical time for healthy growth and development, building the basis for future attainments of every child. Therefore, scaling up interventions to support adequate nutritional intake and appropriate care practices, and optimizing the synergistic impact of such strategies is of utmost importance. What is the global state of knowledge and experience on integrating these interventions? What are some opportunities for integration and for overcoming barriers? The objective of the conference is to investigate existing evidence about integrating early child development and nutrition interventions. Lectures and discussions will explore the relevance and effectiveness of an integrated approach from several dimensions, including the theoretical construct, timing and pathways to outcomes, indicators for achievements, and required delivery mechanisms at the community and institutional levels for implementation and scaling up. The audience will include program implementers and researchers from the nutrition and early childhood development fields that seek to better understand the science and evidence supporting integrative approaches.
*Reception to follow.
Maureen Black, PhD
University of Maryland
Kathryn Dewey, PhD
University of California at Davis
Lia Fernald, PhD, MBA
University of California at Berkeley
Sally McGregor, MBBS, MD, DPH, FRCP
University College London
Ted Wachs, PhD
Susan Walker, PhD
University of the West Indies
Aisha Yousafzai, PhD
Aga Khan University
Mandana Arabi, MD, PhD
The Sackler Institute for Nutrition Science
|By 2/1/2013||After 2/1/2013||Onsite|
|Nonmember (Student / Postdoc / Fellow)||$75||$115||$135|
* Presentation titles and times are subject to change.
Day 1: Wednesday, April 3, 2013
Registration & breakfast
Session 1: Conceptual overview, biological foundations, and review of evidence for interventions early in life
Facilitated by: Mandana Arabi, MD, PhD, The Sackler Institute for Nutrition Science
Conceptual overview of integrated interventions to address optimal child growth and development
Issues in the timing of integrated early interventions: contributions from nutrition, neuroscience and psychological research
Systematic review on the effects of combining child development with nutrition or health interventions on children's nutritional status and development
Systematic review of implementation processes to deliver integrated programs
Session 2: How to design and measure integrated interventions
Facilitated by: Kathryn Dewey, PhD , University of California at Davis
Economic perspectives on integrating early child stimulation with nutritional interventions
Measures and indicators for assessing impact of interventions integrating nutrition and early childhood development
Formative research methods for designing culturally appropriate, integrated child nutrition and development interventions: An overview
Leveraging families' strengths, paraprofessionals, and bundled services to improve child outcomes
Understanding care for early stimulation and feeding practices: The Building blocks for a sustainable and feasible intervention in India and Pakistan
Integrating Water, Sanitation and Hygiene (WASH), Nutrition and Early Childhood Development: A critical review and conceptual framework
Break in the room
Integration of a scalable maternal psychosocial well-being component into a child development intervention: challenges and opportunities
Strengthening systems for integrated early childhood development services: cross-national analyses of governance
Day 1 adjourns
Day 2: Thursday, April 4, 2013
Registration & Breakfast
Introductory remarks for Day 2
Session 3: Implementing and scaling up integrated interventions: Lessons learned
Facilitated by: Lia Fernald, PhD, MBA, University of California at Berkeley
Advantages and disadvantages of integration: Opportunities for early childhood development and nutrition programming
Integrating early child development programs into health and nutrition services in Bangladesh: Its benefits and challenges
Capacity-building for interventions to improve child development and nutrition in the health sector
A job analysis of community health workers in a context integrating nutrition and early childhood development
Session 4: Cost benefit analysis of integrated interventions at scale
Facilitated by: Theodore Wachs, PhD, Purdue University
Cost effectiveness of responsive stimulation and nutrition interventions implemented in the Pakistan Early Child Development Scale Up (PEDS) Trial
Rationale, design, methodology, and sample characteristics for an integrated child development and nutrition intervention among infants in rural India (PROJECT GROW SMART): A randomized controlled study
Effects of micronutrient provisions in PAININ III (Programa de Atención Integral a la Niñez Nicaragüense) Beneficiaries
Panel discussion: Scaling up integrated interventions
Session 5: Integration at the policy system level
Facilitated by: Aisha Yousafzai, PhD, Aga Khan University
Advancing the nutrition and early childhood development policy agenda: Indicators and guidance
Concluding Session: Strengthening knowledge for integrated interventions
Using UNICEF's Multi-Indicator Cluster Survey (MICS) Round 4 to study early childhood development outcomes
Discussion: Lessons learned for ongoing and future research and programming
Maureen Black, PhD
University of Maryland
Maureen Black, PhD is the John A Scholl MD and Mary Louise Scholl MD Endowed Professor in the Department of Pediatrics and the Department of Epidemiology and Public Health at the University of Maryland School of Medicine. She is an Adjunct Professor in the Center for Human Nutrition at the Johns Hopkins Bloomberg School of Public Health and the Department of Psychology at the University of Maryland Baltimore County. She directs the Growth and Nutrition Clinic, an interdisciplinary clinic for children with growth and/or feeding problems. Dr Black is a pediatric psychologist who conducts research examining how nutrition policies, food insecurity, maternal mental health, and feeding practices relate to children's growth and development. She has conducted intervention trials to promote parenting and child development and to promote micronutrient status and healthy growth. She is currently conducting an integrated child development/micronutrient fortification trial in India (Project Grow Smart) and an integrated parenting /obesity prevention trial in Baltimore. Dr. Black has served on committees for the World Health Organization, UNICEF, and the Institute of Medicine. She has served as chair of the Maryland WIC Advisory Board and is involved in local nutrition and child development policy initiatives through the Institute for a Healthiest Maryland, the Baltimore Food Policy Committee, and other local organizations.
Kathryn Dewey, PhD
University of California at Davis
Kathryn Dewey, PhD, is Distinguished Professor in the Department of Nutrition and Director of the Program in International and Community Nutrition at the University of California, Davis. She received her PhD in Biological Sciences in 1980 from the University of Michigan. She has conducted research on maternal and child nutrition in the U.S., Mexico, Costa Rica, Honduras, Guatemala, Peru, Ghana, Malawi and Bangladesh, resulting in more than 250 publications. Her professional service includes extensive consultation for WHO, UNICEF, NIH and the March of Dimes, and serving as President of the Society for International Nutrition Research and of the International Society for Research on Human Milk and Lactation. She has mentored more than 40 graduate students and has received several national and international awards for her research.
Lia Fernald, PhD, MBA
University of California at Berkeley
Lia Fernald, PhD, MBA is Associate Professor in Community Health and Human Development at the School of Public Health at the University of California, Berkeley. Dr. Fernald's work has focused primarily on how inequalities in socio-economic position contribute to growth and developmental outcomes in mothers, infants and children, and on how interventions can address socio-economic and health disparities. Much of her work for the past decade has centered on looking at the effects of interventions (e.g. conditional cash transfer programs, parenting programs, microcredit interventions, and community-based nutrition interventions) on child development and maternal mental health, particularly focused on low- and middle-income countries. She recently worked with a team of authors to write a review for the Lancet about strategies to address poor development among infants and children in low- and middle-income countries. Dr. Fernald has published over 70 academic articles and book chapters in journals such as the Lancet, Pediatrics, International Journal of Epidemiology, Journal of Health Economics, Social Science and Medicine, American Journal of Public Health, and Developmental Science. For the past several years, she has acted as an NIH Study Section reviewer for the Social Science and Population Studies Panel, as a reviewer for the National Science Foundation, and was selected as a member of the Canadian Institute for Advanced Research, Experience-Based Brain and Biological Development Program.
Sally Grantham-McGregor , MBBS, MD, DPH, FRCP
University College London
Sally Grantham-McGregor is Emeritus Professor of International Child Health, Centre for International Health and Development, Institute of Child Health, University College London. She trained as a physician then worked at the University of the West Indies in Jamaica, where she founded a research group to examine the development of disadvantaged children. The group focused on the effects of malnutrition and ran a series of studies evaluating the effects of low cost interventions to improve children’s development. They showed that early childhood interventions had long term benefits to children’s development. She moved to London and assisted in developing a research group in child development at the icddr,b in Bangladesh as well as continuing to collaborate with the Jamaican group. Topics studied include zinc, iodine and iron deficiency, stunting, severe clinical malnutrition, malaria, arsenic exposure, short term hunger and home stimulation and their effect on children’s development, early childhood measurements also interventions with nutritional supplementation and early childhood stimulation. She is collaborating with the Institute of Fiscal studies London on ECD interventions in Colombia and is advising the Peruvian government on a large ECD program. She has sat on several international and national committees, consulted for many international and national agencies and NGOs. She has published extensively, and with Pat Engle headed the first Lancet series on Child development in Developing Countries. She sits on the Early Childhood Board of the Open Society Foundation and the Steering Committee of the Global Child Development Group.
Theodore D. Wachs , PhD
Theodore D. Wachs is Professor of Psychological Sciences at Purdue University. He received his doctorate in psychology from George Peabody College. In 1995-1996 he was the Golestan Fellow at the Netherlands Institute for Advanced Studies, and in 2003 he was a Fulbright Distinguished Scholar at the Centre for International Child Health at the University of London. Currently he is a member of the editorial boards of the International Journal of Behavioral Development and the Journal of Applied Developmental Psychology. His research focuses on the role of chaotic family environments on child development and parenting, temperament in infancy and early childhood and the impact of micronutrient deficiencies upon infant social-emotional development. He has authored, co-authored or co-edited 11 books, and has authored or co-authored over 120 book chapters or research and review articles in scientific and professional journals.
Susan Walker, PhD
University of the West Indies
Susan Walker is Professor of Nutrition, Director of the Tropical Medicine Research Institute at The University of the West Indies, Jamaica and heads the Child Development Research Group The work of this group in developing low cost approaches to promote children’s development and the rigorous evaluations have been critical in driving global attention to the importance of early stimulation for children under 3 years and has influenced the expansion of work and commitment in this area by the Inter-American Development Bank and World Bank among others. With the support of the Inter-American Development Bank, she and her team are currently evaluating approaches to delivery of parenting programs at scale in three Caribbean countries. This research will have important implications for early child development policy. Susan was lead author in papers in the highly influential Lancet series (2007, 2011) on child development. She is a founding member of the Global Child Development Group, whose secretariat is based at UWI.
Aisha K. Yousafzai, PhD
Aga Khan University
Aisha K Yousafzai, PhD, is an Assistant Professor in Early Childhood Development and Disability in the Division of Women and Child Health, Aga Khan University, Karachi, Pakistan. Dr. Yousafzai earned a PhD in International Child Health from the Institute of Child Health, University College London. Her main research interests are the strengthening of early child development programming in health and nutrition services, and the inclusion of children with disabilities in health programmes in developing countries. Her other focus area is training and capacity development for early child development programmes and research in order to generate and disseminate local evidence and experience more widely. She has 10 years of experience in community based programmes in both South Asia and East Africa. She was the co principal investigator of the Pakistan Early Child Development Scale Up (PEDS) trial which investigates the integration of stimulation, care for development and nutrition in a government community health programme in Sindh, Pakistan. The trial has generated evidence eon how to reach the most disadvantaged children to promote early learning and equity. She is currently funded by the Saving Brains Program, Grand Challenges Canada to study the impact in later life of early intervention delivered in the first 1000 days of life to better understand implications for human development.
Mandana Arabi, MD, PhD
The Sackler Institute for Nutrition Science
Dr. Arabi is an expert in international nutrition and has facilitated nutrition programming in more than fifteen countries with high burdens of malnutrition. As Founding Director of The Sackler Institute for Nutrition Science at the New York Academy of Sciences, she is leading a global initiative to develop a research agenda for nutrition science and build public-private partnerships with corporations, nonprofits, academia and government bodies to implement the research outcomes in the field. Dr. Arabi has worked as a nutrition adviser with the Ministry of Health and the World Bank in Iran, and as a child nutrition adviser with UNICEF. She holds a medical degree and a PhD in nutrition from Cornell University.
Harold Alderman, PhD
International Food Policy Research Institute
Harold Alderman, with both a master's degree in nutrition (Cornell) and a PhD in economics (Harvard), has naturally gravitated to research on the economics of nutrition and food policy. He spent 10 years at the IFPRI prior to joining the World Bank in 1991. He rejoined IFPRI in 2012. While at the World Bank he divided his time between the Development Research Group and the Africa region where he advised on social protection policy. His current research has focused on the linkages between nutrition and early child development and the means by which nutrition and social protection programs contribute to long term economic growth.
Margaret E. Bentley, PhD
University of North Carolina
Dr. Bentley received her MA and PhD degrees in Medical Anthropology from the University of Connecticut. From 1985–98 she was on faculty in International Health at the Bloomberg School of Public Health, Johns Hopkins University. Since 1998 she has been on faculty at the University of North Carolina, where she has held several leadership roles. Dr. Bentley's research focuses on women and infant's nutrition, infant and young child feeding, behavioral research on sexually transmitted diseases, HIV, and community-based interventions for nutrition and health. She has expertise in both qualitative and quantitative research methods and the application of these for program development and evaluation. Dr. Bentley also directs a five year, longitudinal intervention study to examine risk factors for the development of pediatric obesity in North Carolina. She is also Principal Investigator of a community-based intervention to improve child growth and development in Andhra Pradesh, India. She is an Investigator on an intervention to decrease maternal to child transmission of HIV during breastfeeding in Malawi and is Principal Investigator of a Bill and Melinda Gates Foundation grant for analyses of nutrition data. The Malawi study, BAN (Breastfeeding, Antiretrovirals, and Nutrition) has enrolled nearly 2500 HIV positive mothers and their infants in a longitudinal study to assess whether ARV drugs given to mothers or infants while exclusive breastfeeding for 0–6 months reduces transmission of HIV through breastmilk.
Dr. Bentley is a member of the Advisory Board of the Indo-US Joint Working Group on Maternal and Child Health and is a member of the ASPH Global Health Committee. She also holds membership in the American Institute of Nutrition, the American Anthropological Association, the Society for Medical Anthropology, and the American Public Health Association. She is a Fellow of the Society for Applied Anthropology. In 2005 she was named Paul G. Rogers Ambassador for Global Health. She is the founding Chair of the Board of Directors of the Triangle Global Health Consortium.
Florencia Lopez Boo, PhD
Inter-American Development Bank
Florencia Lopez Boo is a senior social protection economist with the Social Protection and Health Division of the Inter-American Development Bank (IDB) and a research fellow at the Institute for the Study of Labor. Her previous positions include working at the IDB Research Department, the World Bank, the OPHI Institute in Oxford's Department of International Development, as well as teaching at University of Oxford and the University of Louvain-la-Neuve. Her work focuses on early childhood development and evaluation of the impact of social protection programs. She received a PhD in economics from the University of Oxford and a Masters from University of Namur.
Pia Rebello Britto , PhD
Yale Child Study Center
Pia Rebello Britto, PhD is known internationally for her work in the area of early childhood policy and programs in over 40 low and middle income countries for developing integrated systems and policies for early childhood. In particular, she is investigating the role of governance and finance of national systems in achieving equity, access and quality. Dr. Britto has also been involved in several early intervention program evaluations in Africa and Asia, including a six country evaluation of an innovative approach to improve school readiness. Other aspects of her international work include the conceptualization of a measurement model for quality early childhood services, and measuring and implementing the school readiness paradigm—ready children, ready families, and ready schools and understanding the best modalities to support parenting. Most recently, Dr. Britto is involved in research that is examining the relationship between early childhood and peace building. Nationally, within the United States, Dr. Britto is known for her scientific work on young children's early literacy development, and more recently on understanding issues of identity development of Muslim and Arab children. Dr. Britto obtained her doctoral degree in developmental psychology from Teachers College, Columbia University. She is the recipient of several national and international grants and awards in recognition for her work and has published numerous books, articles, chapters and reports, and has presented extensively at conferences, meetings and workshops (academic and non-academic) around the world.
Ann DiGirolamo, PhD, MPH
Ann DiGirolamo, PhD, MPH is a pediatric psychologist with training in public health and maternal and child nutrition. She is the Director of the Nutrition Plus Team with CARE USA. She also holds an Adjunct Faculty position in Global Health at Rollins School of Public Health at Emory University. Her main interests are in maternal and child health, nutrition and development, with particular emphasis on the psychosocial factors influencing child growth, development, mental health, and in the interface between nutrition and psychology. Prior to coming to CARE, she led studies in Latin America examining the role of maternal depression and child-care giving for young child growth and development, the relationship between child nutritional status and development, and the role of nutrition in mental health and school performance. Her current work at CARE involves providing technical expertise in the development, implementation and evaluation of programs in resource poor countries addressing the nutrition and developmental needs of young children in vulnerable contexts and their caregivers, with particular focus in Africa and Asia.
Edward A. Frongillo, PhD
University of North Carolina
Edward Frongillo, PhD, is Professor and Chair of the Department of Health Promotion, Education, and Behavior. He has a PhD in biometry and an MS in human nutrition and child development from Cornell University. He studies how to solve under- and over-nutrition of populations globally, especially children and families living in poverty, using qualitative and quantitative methods. His research interests are growth, development, and feeding of infants and young children and the role of family stress and parenting in these; household food insecurity; policy advancement and programs for improving nutrition and development; and design and analysis of longitudinal studies.
Ms. Gowani is a PhD Candidate in the Education Policy and Social Analysis department at Teachers College, Columbia University, focusing her educational pursuits on the intersections between early childhood education, research, and policy. Until May 2013, Ms. Gowani was also a Graduate Research Fellow at the National Center for Children and Families, Columbia University where she collaborated with colleagues on research studies to promote better domestic and international early childhood policy. Both at the Center and through her coursework, Ms. Gowani aims to address social issues affecting young children and their families by evaluating the impact of programs and policies targeted to this sector. Ms. Gowani has served as a consultant with the Asian Development Bank, UNICEF, and the Economist magazine's Economic Intelligence Unit doing systems design work, literature reviews, desk reviews, and data collection and analysis. Prior to returning to academia, Ms. Gowani worked as a Monitoring and Evaluation Specialist with the Aga Khan Foundation. Most prominently in her work there, she designed an Education Management Information System (EMIS) to help the Foundation monitor and evaluate progress in its 3,000 schools globally. Ms. Gowani is also an active volunteer in a community-based early childhood program that supports parents and children ages birth–6 years of age. Ms. Gowani speaks English and Urdu/Hindi fluently, and is conversant in French and Gujarati. She is also an aspiring travel writer.
Jena Derakhshani Hamadani, PhD
International Center for Diarrheal Disease Research, Bengladesh
Dr. Jena Derakhshani Hamadani graduated from Rajshahi Medical College, Bangladesh in 1983. She completed her Diploma in Child Health with distinction from Bangladesh Institute of Child Health under Dhaka University and received her PhD on child development from the Institute of Child Health under University College London in UK. She is an international scientist at icddr,b and is the Head of its Child Development Unit. She is a member of the advisory board of the Bangladesh Government's early learning and development standards (ELDS) that develops indicators and monitoring system for ECD programs in Bangladesh. Dr. Jena has conducted several projects on child development in Bangladesh and has over 50 publications in peer reviewed journals. She received several awards for best scientific presentations in international and national conferences.
Raghu Lingam, PhD MBChb
London School of Health and Tropical Medicine
Raghu Lingam is a Clinical Senior Lecturer in Epidemiology at the London School and Honorary Consultant Community Paediatrician at North Bristol NHS Trust. He is a clinical academic with specific interest is in child survival, growth, development and disability. He is currently the study coordinator of SPRING (Sustainable Programme Incorporating Nutrition & Games). The SPRING programme aims to develop, and then test, an integrated, up-scalable, culturally appropriate, equitable and sustainable community-based intervention package to promote child growth, development and survival, in India and Pakistan.
David Pelletier, PhD
David Pelletier is an associate professor of nutrition policy in the Division of Nutritional Sciences at Cornell University. His research, teaching and public engagement focuses on improved methods for the analysis and design of nutrition policy, tools for the scaling up nutrition interventions and the application of implementation science to nutrition. He has conducted or supervised research and project work in Ethiopia, Kenya, Tanzania, Malawi, Lesotho, Nigeria, Indonesia, China, Bolivia, Guatemala, Peru and Haiti. He has consulted on nutrition strategy development with the World Bank, USAID, UNICEF, WHO, the Bill and Melinda Gates Foundation, the Academy for Educational Development and the International Food Policy Research Institute. His most recent projects include the Mainstreaming Nutrition Initiative, the Micronutrient Program Assessment Project and the scaling up of an iron-folic acid supplementation strategy in Haiti.
Oliver Petrovic, MD, MPH
Since June 2009, Dr. Oliver Petrovic is Early Childhood Development Specialist at UNICEF New York Head Quarters, providing technical support to UNICEF country offices in Policy Advocacy, Monitoring and Research.
Dr. Petrovic has worked as UNICEF programme specialist in Serbia and Montenegro, supporting the social reform processes and implementing several innovative projects focused on finding excluded children and their integration into social systems.
He holds Medical Degree (Belgrade University, School of Medicine) and MPH, School of Public Health, Belgrade.
John Phuka, MBBS
University of Malawo
John Phuka, MBBS, PhD University of Malawi, College of Medicine John Phuka received a medical degree from the University of Malawi, College of Medicine in 2001. He attended School of Public Health at the University of Tampere and earned a PhD in International Health (Epidemiology) in 2009. Thereafter, he was a postdoctoral fellow at the University of Malawi working in iLiNS Project which is investing new solutions in promoting growth and child development in low resource settings. Currently, he is a member of faculty of Medicine at the College of Medicine University of Malawi and is now a Senior Lecturer. John's research interests include integration of nutrition, health and psychosocial stimulation to promote child growth and early child development.
Atif Rahman, MD, PhD
University of Liverpool
Atif Rahman is professor of child psychiatry at the University of Liverpool, UK. He is a Visiting Professor at the Institute of Psychiatry, Rawalpindi, Pakistan, and Honorary Executive Director of the Human Development Research Foundation, Islamabad. Rahman's research has focussed on the epidemiology of maternal mental health, the impact of maternal depression on child health and development, and community-based psychosocial interventions for maternal depression in low-income settings. He has assisted the WHO and UNICEF in developing and revising their packages of care for mental health and early child development. He is co-PI of SHARE, the South Asian Hub for Research, Advocacy and education in mental health, a 5-year programme funded by the NIH in the USA. He is co-Director of SPRING, a 5-year programme of research on sustainable interventions for child nutrition and development in India and Pakistan, funded by the Wellcome Trust, UK. He divides his time between the UK and South Asia, where most of his research is based.
Rebecca J. Stoltsfuz, PhD
Rebecca Stoltzfus is Professor in the Division of Nutritional Sciences and Director of the Program in International Nutrition. She holds a PhD and MS in Human Nutrition from Cornell University and a Bachelor's degree in chemistry from Goshen College. She has been a member of the National Academy of Sciences Food and Nutrition Board, Associate Editor of the Journal of Nutrition, president of the Society for International Nutrition Research, and is a Fellow of the International Union of Nutritional Sciences. She is a member of the WHO Expert Advisory Panel on Nutrition, and recipient of the Kellogg Award of the American Society for Nutrition for excellence in international nutrition research. Her research focuses on the causes and consequences of malnutrition in women and children in low-income countries, with research projects ongoing in Zimbabwe, Haiti, Bangladesh, Kenya and Ethiopia.
Mark Tomlinson, PhD
Professor Mark Tomlinson is based in the Department of Psychology at Stellenbosch University and received his PhD in Psychology from the University of Reading in the UK. His scholarly work has involved a diverse range of topics that have in common an interest in factors that contribute to infant and child development in contexts of high adversity, and how best to prevent compromised infant and child development in these contexts. He has completed research investigating the impact of maternal depression on infant and child development. He has also completed four large randomised controlled trials, all of which have examined the impact of interventions delivered by community health workers on maternal and child health. He has received research grants from the Wellcome Trust (UK), National Institute of Alcohol Abuse and Alcoholism; National Institute of Drug Abuse (USA), Department for International Development (UK), and recently from Grand Challenges Canada.
Conceptual Overview of Integrated Interventions to Address Optimal Child Growth and Development
Maureen Black, PhD
There is growing evidence that the building blocks for long-term health and well-being are formed during the early years of life, often beginning prenatally. During these early years disparities in children's growth and development begin to appear, associated with poverty, general undernutrition, specific nutritional deficiencies, illnesses, environmental toxins and the lack of opportunities for stimulation, responsive relationships, and protection from harm. Children in low and middle-income countries are at high risk for disparities early in life that can interfere with their ability to benefit from school and other resources, and increase their vulnerability to negative academic, social, psychological, and health consequences. The loss of productive potential and the burden of illnesses affect not only individual children and families, but can have devastating effects on the social capital of communities and countries.
Evidence from nutrition interventions has shown that ensuring adequate nutrients early in life can protect children, promote their growth, and stimulate their motor, cognitive, and socio-emotional development. Evidence from early child development interventions has shown that providing high quality early child care, stimulation, and responsive interactions can prevent or ameliorate early disparities, enabling children to proceed along normal developmental trajectories ready to learn and to take advantage of social and community opportunities. Yet, in most cases, nutrition and early child development programs are introduced independently, responsible to different sectors, and with very little overlap.
The presentations in this special issue address a wide range of topics related to integrated early child development–nutrition interventions, ranging from the theoretical rationale to issues of planning, implementing, and evaluating integrated interventions; and extending to strategies to impact nutrition and early child development policies. Case studies of integrated interventions are included, along with "lessons learned" and recommendations for future research and implementation strategies. The goal is to identify the steps to encourage investment in full scale implementation of successful integrated interventions.
Economic Perspectives on Integrating Early Child Stimulation with Nutritional Interventions
Harold Alderman, PhD, International Food Policy Research Institute
There is a strongly-held view that there is a narrow window for effective nutritional interventions and a widely-known stylized depiction of age-dependent economic rates of returns to investments in cognitive and socio–emotional development. Both indicate critical periods in early life. Moreover, the fact that both the physical and cognitive development of a child in these early years of its life are highly dependent on child care practices and the characteristics of the care givers, such as their level of education or depression, motivates an interest in finding effective means to enhance stimulation in the context of nutritional programs, or vice versa. Nevertheless, there is relatively little evidence, to date, on how to align age-specific patterns of interventions and how to undertake cost-benefit analysis for integrated interventions. Thus, many core questions need further consideration in order to design integrated nutritional and stimulation programs. This presentation looks at some of these questions both from the standpoint of physical synergy—complimentary inputs, from an economic perspective—and from the perspective of managerial synergy in which joint management of programs reduces costs of delivery, even if no physical synergy might exist. The presentation also provides some guidelines as to how the economic returns from joint nutrition and stimulations programs might be estimated.
Measures and Indicators for Assessing Impact of Interventions Integrating Nutrition, Health, and Early Childhood Development
Edward A. Frongillo, PhD, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC USA
When interventions integrating nutrition, health, and early childhood development are implemented, evaluation studies of effectiveness assessing intermediate and ultimate impacts on the four domains of food and nutrition, family care, health, and child development are needed. Such evaluations studies should aim to demonstrate impact, both benefits and potential harms, and to understand mechanisms through which impact has been achieved. This presentation reviews existing measures and indicators in order to suggest sets of measures and indicators suitable for use in evaluation studies of effectiveness of integrated interventions for children under 5 years. Within each of the four domains, multiple constructs and sub-constructs were considered. For each construct and sub-construct, we identified measures and indicators using several search processes, and then reviewed them in relation to four characteristics: validity, responsiveness to intervention inputs and activities, equivalence in constructs and items across contexts with appropriate adaptation, and feasibility to use in effectiveness studies. Suggested measures and indicators for each domain, construct, and sub-construct are tabulated and described. We discuss overall strengths and weaknesses of measures and indicators across the domains and constructs, further research establishing validity of measures, and guidance on the adaptation of measures to particular contexts.
Systematic Review on the Effects of Combining Child Development with Nutrition or Health Interventions on Children's Nutritional Status and Development
Sally McGregor, MBBS, MD, DPH, FRCP, University College London
We searched electronic data bases and agency reports, other published reviews and used personal contacts to identify trials including a child development component (psychosocial stimulation through home visiting, parent groups, parent counselling or centre based) combined with a health or nutrition component (e.g. growth monitoring, education on feeding, or nutritional supplementation) involving children under 5 years in low- or middle-income (LAMI) countries. Of 1533 studies initially identified we narrowed the pool to 21 because most did not fit the inclusion criteria. To be included in our review, studies must have had a non-intervened comparison group of similar socio-economic background. They must also include a child development outcome (cognitive, motor, school achievement, socio-emotional or behaviour) and a health or nutrition outcome (e.g. height/weight, haemoglobin) and present results with statistical analyses. Any study that was not a randomised controlled trial was rated by two of us for quality with the McMaster University Effective Public Health Practice Project Quality Assessment Tool and any rated "weak" were excluded. There remained 21 studies. We aimed to assess the impact of the separate interventions, their combined effect and any potential interaction.
Only 4 studies were designed to show independent effects of each intervention and combined effects with randomisation to 4 groups: nutritional supplementation, stimulation, both interventions and control. Three of these used macronutrient supplementation and showed no change in the effect of the independent interventions when combined (additive effects). One used zinc supplementation and there was a significant synergistic interaction with stimulation and zinc on child development. A further two randomised trials assessed the effect of one intervention and combined interventions In one trial the small benefit to linear growth from nutritional education was lost when stimulation was added, in the other the effects of stimulation remained when nutrition (micronutrients) was added.
The remaining studies only show the effects of combined treatment. Six studies added a child development component to a health or nutrition intervention. All showed benefits to child development outcomes one also showed a nutritional status benefits. In the other two studies adding micronutrients to meals at a preschool benefitted child development but not nutritional status and a centre-based preschool with meals benefited child development and growth compared with no intervention.
Finally, 7 studies were non-randomised evaluations of 8 large programs, all comprised centre-based components and most provided meals, one was mother's education groups only. Five showed benefits to child development one had no effect and two showed deficits. Only one benefited nutritional status consistently and that was a home visiting program whereas two showed some deficits. The implications of these findings are discussed.
Using UNICEF's Multi-Indicator Cluster Survey (MICS) Round 4 to study early childhood development outcomes
Oliver Petrovic, MD,MPH, UNICEF
Experience and scientific evidence has shown that several preconditions must co-exist to ensure that children get the best start in life and the opportunity to thrive: (i) effective and responsive care of the young child by the primary caregiver, family and community; (ii) access to and use of quality ECD and other basic social services for young children and (iii) a supportive policy environment in place. Situation analysis shows that: home environment is not conducive to optimal early childhood development; low access to early childhood care and education services (ECCE), marked with significant disparities and Policy and Programming Environment not supportive to ECD. The basic causes for hindering ECD programmes expansion and integration are lack of capacity to implement ECD policies / programmes, weak leadership and governance, lack of coordination mechanisms (essential in provision of ECD interventions), and a lack of data to design and monitor ECD progress. The root causes of all the issues listed above can be summarized in the lack of political will to invest in ECD; and existing exclusion and stigma of the most deprived young children and their families.
Systematic Seview of Implementation Processes to Deliver Integrated Programs
Aisha K. Yousafzai, PhD, Aga Khan University
This presentation reviews the implementation processes for interventions that integrate nutrition and psychosocial stimulation for children under five years of age in low- and middle-income countries. We examine the content of the program, the delivery strategy, intensity and duration, personnel training and supervision, compliance, and fidelity. This presentation complements the paper 'Systematic Review of Integrated Interventions: What Works and Does Not Work?' which addresses outcomes of integrated interventions. A systematic search of the Global Health Ovid database yielded 1020 articles of which 24 fit the criteria, and two further studies recently completed were reported on by author communication. Some of these articles describe efficacy studies where nutritional supplements or education along with psychosocial stimulation experiences or education were delivered directly to children or to caregivers of children. Other presentations describe large-scale programs such as conditional cash transfers in Latin America, Integrated Child Development Services' Anganwadi preschools in India, and World Bank collaborations with national governments in Africa. A summary table of the implementation processes of the 26 programs is included. We conclude with a set of recommendations summarizing what we know so far regarding best practices for integrative programs.
Formative Research Methods for Designing Culturally Appropriate, Integrated Vhild Nutrition and Development Interventions: An Overview
Margaret E. Bentley, PhD, RD University of North Carolina at Chapel Hill
Nutritional and developmental insults in the first few years of life have profound public health implications, including substantial contributions to neonatal, infant, and early childhood morbidity and mortality, as well as longer term impacts on cognitive development, school achievement, and worker productivity. Optimal development that can lead to the attainment of the individual's fullest potential therefore requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. Researchers and policymakers have called for integrated child nutrition and development interventions for more than twenty years, yet there are only a handful of efficacy trials and even fewer examples of integrated interventions that have been taken to scale. While a critical component to the design of such interventions is formative research, there is a dearth of information in both the literature and policy arenas to guide this phase of the process. To move the field forward, this presentation first provides an overview of formative research methods with a focus on qualitative inquiry, a description of the critical domains to be assessed (infant and young child feeding, responsive feeding, and child development), and currently available resources. Application of these methods is provided through a real-world case study—the design of an integrated nutrition and child development efficacy trial in Andhra Pradesh, India. Recommendations for next steps are discussed, the most important of which is the need for a comprehensive set of formative guidelines for designing locally tailored, culturally appropriate integrated interventions.
Leveraging Families' Strengths, Paraprofessionals, and Bundled Services to Improve Child Outcome
Mark Tomlinson, PhD, Centre for Public Mental Health, Department of Psychology, Stellenbosch University, South Africa
Children are to be protected in intergenerational networks, with parents who have positive mood, resources to feed their children, and skills to promote early childhood development. Globally, more than 200 million children are raised annually without these resources. This article reviews the potential contributions of increasing coverage and penetration of services for these children, the opportunities created by bundling multiple services within one provider, the potential leveraging of paraprofessionals to deliver care, and mobilizing communities to support children in households at high risk for negative outcomes.
Understanding Care for Early Stimulation and Feeding Practices: The Building Blocks for a Sustainable and Feasible Intervention in India and Pakistan
Raghu Lingam, PhD MBChb , London School of Health and Tropical Medicine
SPRING, Sustainable Program Incorporating Nutrition & Games, is a program of research which aims to improve the survival, growth and development of children in areas of rural India and Pakistan delivered at scale through existing health systems.
The program, based on an extensive formative research, recognizes that different populations view and make sense of the world in diverse ways, and allows us to gain an insider's view of the factors that hinder or facilitate behaviour change. This presentation describes how families interact, play with and feed children, their expectations of growth and development and the perceived benefit, consequences, opportunities and barriers of adopting recommended feeding and developmental behaviours. Qualitative data were collected in 2011–2012 from communities purposively selected to reflect the diversity of the two study areas through 160 contacts with a range of respondents including pregnant and delivered women, grandmothers, fathers and community based workers. Methods used were in depth interviews, narratives and observations.
The presentation will report key findings and similarities and differences between the two sites will be highlighted. The implications of the findings for intervention design will be discussed.
Advantages and Disadvantages of Integration: Opportunities for Integrating Early Childhood Development (ECD) and Nutrition Programming
Ann M. DiGirolamo, PhD, MPH, CARE International
A growing body of evidence supports the notion that integrated programs addressing nutrition and stimulation provide stronger impacts on nutritional and developmental outcomes than either intervention alone. When translating evidence into practice, several advantages and challenges for integration can be noted. Combined interventions may be more efficient than separate interventions, because they are intended for the same population and make use of the same facilities, transportation and client contacts. In addition, for families, particularly for those most at risk, combined interventions can also lead to increased access to services. However, in order for integrated nutrition and ECD interventions to be successful, a variety of challenges must be addressed. These include work load of staff and supervisors, communication and coordination among different ministries and among staff in different sectors, and common language and measurement. It must be acknowledged at both the national and community levels that comprehensive, integrated care addressing both the physical and developmental needs of the child is key to promoting optimal health, growth and development for children. Emergencies present a unique opportunity for integrated services, but also present several unique challenges in addition to those mentioned above.
Water, Sanitation, and Hygiene (WASH), Nutrition and Early Child Development: A Critical Review and Conceptual Framework
Rebecca J. Stoltzfus, PhD, Cornell University
There is scarce research and programmatic evidence on the effect of poor water, sanitation and hygiene (WASH) conditions of the physical environment on early child cognitive, sensory–motor, and socio–emotional development. Furthermore, many common WASH interventions are not designed to protect babies in the first 1000 days of life. We review evidence on WASH, anemia and child growth, and provide a conceptual framework of pathways through which WASH affect child development; primarily through inflammation and stunting. Infants and young children in low income countries are frequently ingesting high quantities of fecal bacteria and pathogens through mouthing soiled fingers and play items, and the exploratory ingestion of soil and poultry feces. Frequent childhood infections from such exposures affect mother–child interaction and child feeding behavior, with cumulative negative consequences on growth and development. Furthermore, recent evidence suggest that chronic fecal–oral transmission of pathogenic and non-pathogenic microbes inflame the small intestine mucosal lining and result in a highly permeable gut, with impaired barrier and absorptive functions, and subsequent chronic immune stimulation. Evidence is mounting that these processes contribute to stunting and may also cause anemia, both well-described risk factors for deficits in child development. Current early child development research and programs lack proven interventions to provide a clean play and infant feeding environment in addition to established priorities of nutrition, stimulation and child protection. Solutions to this problem will require a combination of behavior change and appropriate technologies, designed for rugged environments and conducive to infant play and exploration. We propose the concept of "Baby WASH" as an additional component of early childhood development programs.
Rationale, Design, Methodology, and Sample Characteristics for an Integrated Child Development and Nutrition Intervention Among Infants in Rural India (PROJECT GROW SMART): A Randomized Controlled Study
K. Hurley, PhD, Department of International Health, Johns Hopkins Bloomberg School of Public Health
Background: More than 200 million children under five years of age from low-income and middle-income (LAMI) countries do not attain their developmental potential, largely due to poverty, nutritional deficiencies, and inadequate learning opportunities. While evidence suggest that addressing co-occurring risk factors such as lack of stimulation and micronutrient deficiencies simultaneously may produce maximum effects on child development, little is known about the effectiveness of such integrated programs. Project Grow Smart examines how innovative multiple micronutrient (MMN) fortification strategies for infants combined with early learning opportunities impact children's development. This presentation provides an overview of the study design, methodology and sample characteristics from baseline survey data and key lessons learned.
Method / Design: We recruited 497 mother–infant dyads into a double-blinded four-arm randomized controlled trial in rural India and randomly assigned them to receive: 1) MMN only 2) play and communication messages only; 3) MMN and play and communication messages; 4) placebo. Study outcomes include infant cognitive, motor, and social–emotional development. Mediators include infant micronutrient status and observed parent-child interactions. Data are also being collected on village-level resources, household assets and food security, maternal demographics, micronutrient status, mental health, parenting competence, feeding history and behaviors, and infant anthropometry, morbidity, and temperament.
Discussion: This study is timely and responds to the 2011 Lancet Series on Early Child Development in LAMI countries which identified the need to evaluate the effectiveness of approaches that combine early child development and nutrition interventions. Findings will generate new information to help guide large-scale policy and programs designed to reduce lost developmental, educational, and economic potential of children in resource poor setting.
Trial registration: NCT01660958
A Job Analysis of Community Health Workers in Context of Integrated Nutrition and Early Child Development
John Phuka, MBBS, University of Malawo
Background: With increasingly recognized role of Community Health Workers (CHWs) as a critical link in improving access to services and achieving many health care goals CHW are likely to participate or solely implement integration of children's nutrition, health and psychosocial development in low income countries like Malawi. Given the financial and human resources constraints in these developing countries, CHWs are expected to do more without necessarily receiving the needed support to do their jobs well or additional staffing support.
Objective: To evaluate the role of Malawian Community Health Workers in integrating children's nutrition, health and psychosocial development.
Methods: We conducted a qualitative study using key informant interviews, semi- structured and focus group discussions.
Findings: At least two Ministries, Ministry of Health (MoH) and Ministry of Gender and Social Welfare (MoGoW) have policy and organisational structure for implementing children's nutrition, health and stimulation in Malawi. However, coverage of community workers between the two Ministries is different. Despite strong policy guidance integration of children's nutrition, health and psychosocial stimulation is weak or non-existent and some activities depend on non-trained volunteers. Largely, CHW are not readily available to the community because of task shifting which is being implemented to cover staff shortage in other health care delivery departments. Re-organisation of the organisational structure, and provision of appropriate incentives and training may allow for the integrated activities.
Conclusion: Promotion and implementation of children's nutrition, health, psychosocial activities through introduction of care for child development package through community health workers (CHW) is possible but feasibility assessment with strong formative approach is needed.
Integration of a Scalable Maternal Psychosocial Well-being Component into a Child Development Intervention: Challenges and Opportunities
Atif Rahman, MD, PhD, University of Liverpool
Maternal Psychosocial Well-being (MPW) is a wide-ranging concept which encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem-solving) as well as the social (e.g., family and community support, empowerment, culture) aspects of motherhood. Child nutrition and development programs generally rely on the mother for their effective delivery, and there is strong evidence that poor MPW is associated with negative child nutrition and development outcomes. However, the field of MPW interventions has lagged behind, especially those that can be integrated into large-scale programs. Building on several years of research in Pakistan, we attempt to define MPW as it applies to child nutrition and development programs. We describe the development and piloting of an approach for MPW that has the potential for integration at scale in a combined nutrition and early child development program.
Cost Effectiveness of Responsive Stimulation and Nutrition Interventions Implemented in the Pakistan Early Child Development Scale Up (PEDS) Trial
Saima Gowani, EdM, Harvard University, Boston, Massachusetts, USA, PhD Candidate, Teachers College, Columbia University, New York, New York, USA
Early childhood programs have been heralded as a way to improve children's health and educational outcomes the world over. However, few studies in developing countries calculate the effectiveness of quality early childhood interventions. Even fewer estimate the costs associated with such programs. This study looks at the costs and effectiveness of a cluster randomized effectiveness trial on children followed from birth to 24 months in rural Sindh, Pakistan. Responsive stimulation and/or enhanced nutrition interventions were integrated in the Lady Health Worker Program. Outcomes suggested that children who receive responsive stimulation had significantly better development outcomes at 24 months than those that only received nutrition supplementation. A cost effectiveness analysis of the results verifies that early childhood interventions that include responsive stimulation are more cost effective than a nutrition intervention alone with respect to the promotion of early development. Approximate costs of responsive stimulation intervention integrated in an existing community based service providing basic health and nutrition care, is $3.75 per month per child. This presentation discusses these findings and considerations for future research.
Micronutrient Provision Among PAININ Beneficiaries
Florencia Lopez Boo, PhD, Inter American Development Bank
This presentation studies the cost-effectiveness of providing micronutrient supplements as part of an integrated early childhood development program in Nicaragua. Using a unique non-experimental longitudinal dataset from Nicaragua, we will estimate average treatment effects via propensity score matching techniques on the prevalence of anemia among disadvantaged children aged 0–3 years receiving micronutrient supplements. We will investigate whether the effects are sustained over time and whether there are differential impacts by child's age, dosage of micronutrient supplements, and program delivery modality. We find that the program seem to have reduced anemia by 9 percentage points (pp) overall and by 17 pp for children under 1. There are no differences by dosage (number of sachets) of micronutrients received, nor by program delivery mode. We calculated to cost–benefit ratio at a range between 2 and 4.24.
Advancing the Nutrition and ECD Policy Agenda: Indicators and Guidance
David Pelletier, PhD, Cornell University
A substantial body of scientific evidence demonstrates the developmental, health and social benefits of nutrition and early childhood development (ECD) interventions, and strong rationales exist for integrating these at the policy, programmatic and delivery levels. A priority and a challenge now is for national governments and development partners to strengthen investments, governance and quality implementation related to nutrition and ECD interventions. This presentation provides a set of frameworks and tools for advancing this policy agenda and illustrates their use in selected countries. One of these tools is the ECD component of the Systems Approach for Better Education Results (SABER). This tool identifies policy levers for strengthening the enabling environment, implementation and quality assurance related to ECD and provides indicators of the level of development in each of these three areas within a given country. A second tool is the Agenda Setting Framework, adapted from previous research in global health and nutrition, which provides process guidance and indicators for moving ECD and nutrition higher on national agendas. The broader application of these tools can guide and document the state of development of nutrition and ECD policies and actions at country level and provide the global community with a systematic basis for tracking progress and mobilizing assistance.
Coauthors: Michelle Neuman and Gretel Pelto
Strengthening Systems for Integrated Early Childhood Development Services: Cross-National Analyses of Governance
Pia Rebello Britto, PhD, Yale University
In recent years there has been a rise in services and programs for young children and families, many of which have been accompanied by rigorous evaluations demonstrating effectiveness. However, a majority of the world's youngest children still do not have access to quality early childhood development services. In part, the lack of inequitable services can be explained by poor systems level coordination, requiring a systematic approach to scaling up of programs. Our study seeks to explore the governance mechanisms required to strengthen coordination by using a comparative approach across multiple low and middle income country contexts. There is wide recognition of the interdependency between the factors implicated in system strengthening, such as capacity building, finance and costing, and governance; nevertheless, governance is critical because of the infrastructure support it provides to the system. In this presentation we present the results of an interdisciplinary study exploring the role of governance in improving equity, access and quality of ECD services in 2 low-income (Cambodia and Lao PDR) and 2 middle-income (Kenya and Peru) countries. The presentation will present results with implications for scale up of programs from a systems strengthening perspective with particular reference to coordination required for integrated ECD services in LMIC.
Integrating Early Child Development Programs into Health and Nutrition Services in Bangladesh: Its Benefits and Challenges
Jena Derakhshani Hamadani, PhD, International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
Bangladesh is one of the poorest countries of the world with the highest population density. Its government recognizes the importance of early childhood development (ECD) and its immense educational and financial benefits hence it has incorporated ECD activities in its national plan of action. However ECD activities are not yet fully established in the country and only some sporadic programs are conducted with little or no evaluations.
In this presentation we present ECD programs that are integrated into health and nutrition services in Bangladesh. We found four evaluation reports of such programs and seven published research projects. We provide short reviews on coverage, methodology and effects of the published reports and share our experience of challenges faced and steps taken to solve them.
Overall, very few programs are based on scientific evidence and fewer are even evaluated. The research projects so far conducted are promising and there is sufficient evidence to confirm the prospect of integrating ECD activities into nutrition and health programs.
Suggestions are made on measures to overcome the implementation problems and on suitable methods to establish high quality ECD programs in Bangladesh and in other low and middle income countries, especially those in this subcontinent.
Issues in the Timing of Integrated Early Interventions: Contributions from Nutrition, Neuroscience and Psychological Research
Theodore D. Wachs, PhD, Purdue University
There is an increasingly large body of evidence documenting that children from low income families living in both high and low income countries have an elevated likelihood of being exposed to multiple biological and psychosocial risks that can significantly compromise their development. One implication of these findings is the importance of integrating and implementing multi-dimensional biological (e.g., nutritional supplementation) and psychosocial interventions (e.g., cognitive stimulation) to compensate for exposure to multiple risks and to promote development. In designing developmental interventions a critical and long-standing question is identifying the age period(s) in which interventions will have the strongest and longest lasting impact upon development. Attempts to answer this question are often framed in terms of either "critical periods" or "sensitive periods." Conceptually both critical and sensitive periods refer to time windows where the degree of potential plasticity in development is highest and the impact of exposure to normative experiences, developmentally facilitative experiences or developmental risks are particularly strong. However, in contrast to critical periods the time windows of sensitive periods are broader and there is continued, though reduced, plasticity both before and after the sensitive period.
The primary question addressed by this presentation is: can we identify optimal time (age) periods in which to provide integrated biological and psychosocial interventions to promote the development of children from low income families who are at risk for compromised development? To address our primary question we will review evidence from three relevant disciplines: nutrition, neuroscience and developmental psychology. Nutritional evidence will be used to identify age-linked domains of brain development that are most sensitive to protein and iron deficits or supplementation. Neuroscience evidence will be used to assess the importance of timing of exposures to environmental stressors for maintaining physiological integrity of the neuroendocrine and immune systems, both immediately and in the long-term. Psychological evidence will focus on the sensitivity of critical dimensions of cognitive and social–emotional development to exposure to contextual risk and protective influences at different ages. Integration of findings across these three disciplines will be used to draw conclusions about issues directly relevant to our primary question such as: are there different time periods that are optimal for biological versus psychological outcomes or interventions; how much residual plasticity is their outside of optimal intervention windows; are later occurring interventions necessary to maintain the impact of earlier interventions?
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