Feb 03, 2010 Posted by
Amala de Silva (Senior Lecturer, University of Colombo)
Sri Lanka has achieved excellent health indicators in maternal and infant mortality, life expectancy and immunization. Yet malnutrition remains a major problem.
The intergenerational vicious cycle related to malnutrition has four main stages: (i) low birth weight infants; (ii) child growth failure; (iii) malnourished stunted adolescents and (iv) small statured malnourished reproductive age women. Detailed evidence exists on three components of the vicious cycle for Sri Lanka. The DHS 2006/2007 data that links malnutrition (both under and over nutrition) in women aged 15-49 (the reproductive age group), weight at birth and in children under five to the asset index clearly shows that malnutrition is linked to economic inequalities. The very lack of national level information on the third component of this cycle is an issue of importance. Small studies, anecdotal evidence and the continuing intergenerational cycle clearly indicate that adolescent malnutrition is a major problem in the country.
Why is malnutrition a problem today but a crisis tomorrow?
Malnourished children are likely to end up as stunted adults with lesser intellectual abilities and hence lower productivity. Given the challenge of demographic transition a countries growth depends on improved productivity. Firstly then from an economic as well as a humanitarian angle focusing on reducing malnutrition is a priority.
Secondly, evidence clearly indicates that malnutrition at all stages of the life cycle is linked with income inequality. Early childhood mortality is negatively linked to wealth levels (DHS 2006/2007). Most deaths in early childhood, in countries with safe delivery and high levels of immunization are linked to foetal growth, with abnormalities in nutrition being a major determinant. Breaking the intergenerational cycle of malnutrition could contribute significantly to breaking the intergenerational cycle of poverty and improving equity.
Thirdly breaking the vicious cycle between maternal malnutrition and low birth weight is particularly important now given the wide spread acceptance of the Barker hypothesis on NCDs (that maternal malnutrition leading to poor gestational growth of the foetus causes the individual’s metabolism to be unfit to cope with higher levels of nutrition and so more prone to NCDs). Non Communicable diseases (NCDs) have major health impacts and impose heavy economic burdens on the individual, household and the national health system, apart from the major psychic costs that result from NCD morbidity and mortality at early ages.
What then are the policy issues that emerge in this context? What measures should be taken to break the intergenerational cycle? What new measures would you propose?
Should the health system be focusing on adolescent nutrition and if so what measures would be appropriate?
While much discussion in policy circles is on the need for inter-sectoral coordination, in practice this component seems dormant. What mechanisms could ensure more systematic and dynamic coordination?
Malnutrition while closely related to food security still is still complicated by the fact that on the one hand malnutrition remains a problem even in non-poor settings and on the other that obesity (a non-communicable disease risk factor) is a problem even among the poor. What socio-cultural factors should be addressed in this regard?
I totally agree with the points which made on malnutrition problem of our country. My thesis on “Socioeconomic determinants and inequalities in childhood and maternal malnutrition”, confirms the facts -- vicious cycle of malnutrition, interrelated factors that influence nutritional well-being of mother and child, and existing socioeconomic inequalities in malnutrition. Stunting levels of under five children in the most deprived group are almost four times higher than that of the most affluent group.
Information on nutritional levels of different socio-economic groups is useful in identifying segments of the population who are at risk. It enables the identification of relevant policies and where resources should be directed to redress the root causes of inequality in malnutrition. Therefore, I would like to highlight some key findings on determinants’ contribution to the socioeconomic inequality in malnutrition.
The largest contributions to inequality in child malnutrition relates to mother's having below secondary level education (20%) and poor exposure to media (10%) , residency in estate areas and poor sanitary facilities. Likewise, the largest contributions to inequality in maternal malnutrition are owing to residency in estate areas (13.2%). Women's education, exposure to media, and hygienic status of toilet and safe drinking water facilities also proved important contributors to the measured inequality. Vulnerable sub-groups, which are unduly prone to both poor nutrition and poor socio-economic conditions, warrants targeted policy attention.
Renuka Jayatissa (Head, Department of Nutrition , Medical Research Iinstitute)Says : 2010-02-14 11:17:32
I have received your mail on the above subject from Prof. Nimal Attanayake and thanks for raising the issues of malnutrition in SL. According to the questions that you have raised I would like to provide my comments.
1. What then are the policy issues that emerge in this context? What measures should be taken to brak the intergenerational cycle? What new measures would you propose?
We have already focused this issue especially life cycle approach to break this vicious cycle and conducted a nutrition and food security survey in 2009, nationally representative study including all 9 provinces and found how wealth index relate to malnutrition and most of the determinants were covered in this study. Study report will be available at the end of this month for public.
2. Should the health system be focusing on adolescent nutrition and if so what measures would be appropriate?
Health system has already started the interventions to combat this problem named Integrated Nutrition Package which will cover adolescents, pre pregnanat women, pregnant, lactating women and children. As a first measure it will be implemented in most vulnerable districts in the country from this year. Already some districts have initiated the implementation.
3. While much discussion in policy circles is on the need for inter-sectoral coordination, in practice this component seems dormant. What mechanisms could ensure more systematic and dynamic coordination?
For this we have proposed the coordination should come from higher up level from President or Priminister. We are still discussing this issue. Above mention package include the district and village level inter-sectoral coordination.
4. Malnutrition while closely related to food security still is still complicated by the fact that on the one hand malnutrition remains a problem even in non-poor settings and on the other that obesity (anon-communicable disease risk factor) is a problem even among the poor. What socio-cultural factors should be addressed in this regard?
This component has nicely come out in our regression analysis. Colombo district is facing the biggest problem in SL with highest acute under-nutrition and highest overweight and obesity. Planning to focused both together and implement a new intervention. This will be still working out. Most probably it will be implemented from next month.
Dileni Gunewardena (Senior Lecturer , University of Peradeniya)Says : 2010-02-17 01:57:51
This is an excellent informative and provocative piece. The key, as you point out is the link between maternal malnutrition and low birth weight. Low birth weight has been identified as a major distinction between child malnutrition in South Asian countries and sub-Saharan African countries—and holds the key to solving the so-called “Asian Enigma” –that child malnutrition in South Asia is far higher than in sub-Saharan Africa (SSA).
An article at http://www.unicef.org/pon96/nuenigma.htm points out that for every baby born in SSA with low birth weight, there are 2 low-birth-weight babies born in India, and 3 low-birth-weight babies born in Bangladesh. Anemia among women in South Asia is 1 ½ times higher in South Asia than in SSA, supporting the link between maternal malnutrition and child undernutrition.
The social conditions underlying low birth weight continue to affect a child after he/she is born. Child undernutrition is higher in South Asia despite its higher prevalence of breastfeeding compared with SSA. Not surprising, because the health and nutritional wellbeing of the women who are breastfeeding in South Asia is considerably lower than women in SSA. Thus, maternal nutrition tends to be crucial until the child is weaned.
What can be done? In Sri Lanka, much of what can be done directly has been done. This may explain why we are in a better situation than India or Bangladesh. Ante-natal care is quite good in most parts of the country. Maternal nutritional interventions (Thriposha) are given. The right nutrition education messages are given. So the problem is not one of service delivery. Besides, pre-natal care and nutrition may not help very much if the problem is one of chronic malnutrition among women of child-bearing age.
But this is where an inter- sectoral/integrated approach can help. Improving access to fuel and water so that the time and energy women spend on these tasks is reduced can drastically improve women’s wellbeing and increase the time they spend in childcare. Improved sanitation can reduce the risk of disease.
There is another point that is worth making in relation to child undernutrition in Sri Lanka. In addition to a clear association between poverty and child undernutrition, at the district level, there is an association between ethnicity and child undernutrition. This is evident http://www.statistics.gov.lk/DHS/dhs%20report/CHAPTER%2011%20-%20NUTRITION%20OF%20CHILDREN%20AND%20WOMEN.pdf at the district level (Badulla, Trincomalee and Batticaloa have the highest incidence of moderate child undernutrition), at the sector level (estate sector malnutrition is much higher than urban or rural) and at the household level (Deolalikar, Aturupane and Gunewardena 2008, see http://ideas.repec.org/p/unu/wpaper/rp2008-53.html ).
This is an area that is little recognized, particularly, that undernutrition among ethnic Tamil children is not just restricted to estate areas and is therefore little explored. Does the reason lie with service delivery (in the estates perhaps)? In culture, where patriarchy is arguably stronger among Tamil communities, this could affect the wellbeing of women. In employment opportunities, where women must work because men cannot find sufficient work to support their families? And certainly malnutrition among the displaced and newly resettled populations will be higher. It would make sense to concentrate interventions among this group of people, and look for ways to improve service delivery.
Finally, I would argue that the evidence is not yet compelling that obesity is a problem among the poor—children and mothers. In Western countries, yes. Women in the low-income categories are prone to obesity compared to women in higher income brackets and this tends to have an effect on birth weight, health and nutrition of their babies. I fear that focusing attention on obesity as a problem in Sri Lanka will take away much needed energy, and resources from addressing the compelling problem of poor, undernourished, children.
Dileni Gunewardena (Senior Lecturer , University of Peradeniya)Says : 2010-02-17 02:04:54
A quick response to Dr. S.J.'s comment on the lack of studies on inequality in malnutrition. A study by Deolalikar, Aturupane and Gunewardena, _The Determinants of Child Weight and Height in Sri Lanka: A Quantile Regression Approach_ available at http://www.wider.unu.edu/stc/repec/pdfs/rp2008/rp2008-53.pdf did just this. It found that many of the typically considered factors--parental education,electricity access, piped water, household expenditure--had larger effects on child weight and height at upper quantiles than lower quantiles--so as Dr. S. J. says the most vulnerable sub-groups warrant targeted policy attention.
Saroj Jayasinghe(Faculty of Medicine)Says : 2010-02-17 12:46:16
Very interesting (the write-up and the comments). Let me add my two cents worth. I see two issues. One is the average rate of childhood malnutrition. The other is the widening inequalities in the rates of malnutrition (i.e. gaps in rates between social and other groups).
Even though the average rate of childhood under-nutrition is coming down,inequalities between social groups are widening (See article, The social determinants of childhood mortality in Sri Lanka: time-trends & comparisons across South Asia
Indian Journal of Medical Research | October 1, 2007 | Houweling, Tanja A J; Jayasinghe, Saroj; Chandola, Tarani). There are only a few studies that have looked at inequalities, rather than the average. Therefore as Dr Amala de Silva has indicated, we need to focus on the the causes that give rise to inequalities too. These inequalities could take the form of income, assets, wealth as well as social status (this could be related to occupation, ethnicity, caste, rural vs urban etc.). We need more data on this aspect. The Report by the WHO' s Commission on Social Determinants of Health is a good starting point for interested readers should look at the website www.who.int/social_determinants/en/
Thank you for the interesting and informative discussion. I am keen to learn more on the impact of socio-cultural factors on child and adolescent nutrition. As pointed out by Dr. Dileni in her comment, it would also be interesting to see the relationship between child malnutrition and well-being of women among ethnic Tamil communities in Sri Lanka. A few questions that came to mind are: • Have the changes in food consumption patterns, coupled with changes in lifestyles of individuals across different income groups and sectors, impacted on long term and short term nutrition conditions of women and children? • Further, have the impact of intra-household food allocation on nutritional status of children as well as adolescents at the sectoral level and among ethnic groups been identified/ explored enough in Sri Lanka?
Priyanthi Fernando (Executive Director , CEPA)Says : 2010-02-26 05:47:43
Was at HARTI's Annual Research Colloquim this morning briefly. The session before tea was devoted to a rapid assessment carried out by P R Weerakkody and Ranjith Premlal de Silva of the "Kiri Weeduruwa" programme which aims at addressing early childhood malnutrition and providing livelihood options to small scale dairy farmers. My reading of the assessment was that the successful operation of the programme varied from location to location, (successful in Eravur Pattu and Reedimaliyadde?) and was dependent on several factors including cultural habits, spread of dairy farming, the institutional arrangements for the distribution of milk etc. But in relation to the topic of this blog, what was most interesting were the issues relating to targetting i.e. identifying children who are malnourished, ensuring that there are no intrahousehold leakages, and the sustainability of the initiative. Seems like the programme has no baseline, so it will not be possible to ascertain whether it has made any impact on child malnutrition, which is its main objective. The study recommends that the institutional arrangements be changed to allow the kiri weeduruwa to be distributed through pre-schools. I wondered though about the seeming lack of involvement of the local public health system in the scheme. I admit this is just my impressions of a short presentation, so wonder if colleagues at HARTI or elsewhere reading this blog can clarify, contest or add to some of the issues that I am raising.
Kalana Peiris (National Advisor , Plan Sri Lanka)Says : 2010-03-02 11:55:15
A very interesting discussion this is! I personally believe that all of us are focusing on the small bits and pieces which we are most interested in, of a larger puzzle. It is good and that is what needs to happen as long as we try to put every one's piece on the puzzle and try to complete the picture. So let me put my piece of the puzzle forward. The organization I work for is involved in working with some of the poorest communities in the country. According to the evidence generated by our internal studies and those that are experiential, let me highlight the following issues i. analysis of 24hour dietary recalls of more than 250 mothers whose children were undernourished in Medawachchiya revealed that about 75% of the children had been given commercially available biscuits, while only 40% had received any form of vegetable at least once a day, only 35% had received yams or a fruit. This is an interesting finding because the researchers had observed a lot of wasted fruits and yams while they were walking around the villages. Vegetable cultivation was the main form of livelihood of these communities. Initial assessments at Buttala reveals a similar situation. ii. Analysis by cross tabulating household data with levels of nutrition in those households revealed that when fathers were current smokers, children were three times as likely to be undernourished. Situation was similar when they were alcohol consumers iii. Whether it is poor exposure to media or is it quite the opposite? When the time spent in front of the television or reading the newspaper was cross tabulated, it clearly demonstrated that the more exposure to (mass) media (both children and adults)the more likely they are to consume junk food; even the poorest households! It is not surprising if one looks at what is being promoted vigorously over mass media. The same is represented by a poster at the village "petti kade" no matter how far the village is from a main road. iv. Knowledge on a nutritious, balanced meal was very high among the parents who were interviewed in 8 communities in 4 districts, namely Moneragala, Anuradhapura, Kandy and Matale. 90% of the advice given by the PHMs to mothers with children less than 5 years was on nutrition and growth. 60% of the time these advice were in the form of lectures. v. 98% of the children had their weight regularly checked and marked in a CHDR, but only 10% of the mothers were told about their child's weight. Probably the causes for malnutrition in Sri Lankan urban/rural/estate communities are entirely different to what we commonly perceive them to be, especially if we are depending on national level analyzes to arrive at conclusions.
In the middle of the discussion let me draw your attention to a new funding opportunity for Research Programme Consortia (RPCs) on “Undernutrition” at DFID.
Closing Date: 23 April 2010
DFID's Research Strategy 2008-13 sets out priorities for long-term research. Research Programme Consortia (RPCs) represent one of the ways in which DFID funds research. It anticipates funding three research themes where each RPC will be up to £7.5 million over six years, including an inception phase of up to one year.
The three themes are:
1. Improving Mental Health Services in Low Income Countries
2. Tackling the Structural Drivers of the HIV Epidemic
3. Tackling the Neglected Crisis of Undernutrition.
Follow the link for more information on the theme 3 …
Saroj Jayasinghe(Faculty of Medicine)Says : 2010-03-08 12:57:25
This is VERY interesting and it's great to see the amount of research that has already been done. The studies seem to echo findings that low birth weight is determined to a great extent by birth order and maternal anthropometry (mainly height). The continuing malnutrition maybe a failure to catch-up. This requires longitudinal studies which track mothers infants over part of the life course. (Anyone interested in this sort of study?). Are their qualitative studies that add weight to these excellent quantitative studies? We need some qualitative studies on families with malnourished children, and those with normal children. We may also be missing out some important variables. These essentially depend on the way we cut the cake. For example, what would be the impact of 'social status' on childhood malnutrition? Would families with low social status have a higher rate of childhood malnutrition? Is malnutrition higher in families that are less socially and economically empowered?
As highlighted by Dr. Saroj Jayasinghe, children born to malnourished mothers have higher probability being underweight. Also low weight birth is the entering point of continuing malnutrition --when pass through the different stages of the life cycle. So I would like to put forward few other determinants of low weight births. In addition to mother’s nutritional status, her knowledge and women’s status in the family have great impact on child’s birth weight. Teenage mothers face a higher risk of giving low weight births. Especially mothers in childbearing between 15-19 years are more likely to give low weight births. It is interesting that, when a mother takes decision herself on her health as well as mothers knowledge (reading a news papers at least once a week) reduces the likelihood of giving low weight births. These factors imply that adolescent women awareness programmes can make a significant contribution on improving nutritional levels. As highlighted by the other discussants there should be community level programmes to identify the socio-economic, cultural determinants. Community development programmes would entail to increase maternal awareness regarding feeding of their children. It may also motivate mothers to send their daughters to school -- thus increasing maternal literacy in the future (especially in the estate sector). In turn, better levels of maternal literacy will positively affect the socio-economic development of society.
Dileni Gunewardena (Senior Lecturer , University of Peradeniya)Says : 2010-03-17 01:15:52
Great discussion. A couple of thought provokers on Kalana Peiris' response. Why did mothers give their children biscuits rather than yams or fruit? The effect of advertising? Or convenience, because mothers' time may be becoming more costly (because of more work/lack of extended family...). How do we address this in an intervention? Campaign against junk food? Ask junk food manufacturers to fund nutrition interventions as CSR? Or ask them to come up with nutritious alternatives? On smoking, alcoholism and malnutrition. Not to take lightly the evils of smoking and alcoholism, but it may well be possible that families with these issues may anyway be poor caregivers and poor nutrition may be a result of a third, unobserveable factor (poor attitudes to health, bad parenting).
Dileni Gunewardena (Senior Lecturer , University of Peradeniya)Says : 2010-03-17 01:34:28
I wonder if anyone has done any studies linking PHWs and child malnutrition (or any other maternal/child health outcome) and also to what extent differences between culture/ethnicity of PHWs and the community being served matter. Anecdotal evidence suggests that if the PHW is from the same community, getting health messages across will occur almost naturally, continuously and informally. If the majority of PHWs are Sinhala, and the majority of malnourished households/communities are Tamil or Muslim, can this reduce the effectiveness of service delivery?
Amala de Silva (Senior Lecturer , University of Colombo)Says : 2010-03-19 12:18:35
A longitudinal study involving low birth weight babies and NCDs to test the Barker hypothesis for Sri Lanka would be interesting - has anyone done research on following up low birth weight babies as such? In the estate sector does the heavy work the women continue to do almost up to birth have an impact on the babies weight at birth? Anecdotal evidence has women returning to work rapidly after child birth which also could have a bearing on mothers and babies nutrition. Given all the negative evidence on the estate sector a detailed case study of this sector: social, cultural, health services, KAP and economic determinants would seem very important in order to identify relevant interventions.
Saroj Jayasinghe(Faculty of Medicine)Says : 2010-03-22 02:25:40
Dear all The discussion has brought up at least two points that are relevant to policy. One is that the some of the interventions are more likely to require social policies, legislation, population based approach and social action (in contrast to attempting to change individual behaviors). For example, lets take the finding that more exposure to (mass) media (both children and adults) is associated with higher chances of consuming junk food. This has been found even in studies abroad. If this is so, one obvious line to tackle poor nutritional habits is to consider regulation of advertisements, at least those that are aimed at infants and children? I think it is unfair to allow advertisements that harm children, particularly target them, and are aired on TV and radio. We have no chance in countering celebrities and sports stars! This approach is being considered elsewhere, and doctors have proposed restrictions on certain adverts that target children and promote obesity. For example, The Lancet editorial criticized sports celebrities and food manufacturers for cynically promoting junk food. They went on to demand legislation to force the food industry to 'clean up its act'...." Anonymous. [Thought for food. Lancet 2003;362: 1593] The second point is that reasons for high childhood malnutrition appears to differ according to socio-economic status and ethnicity (e.g. Dineli's note that parental education,electricity access, piped water, household expenditure--had larger effects on child weight and height at upper quantiles than lower quantiles). We have then got to consider policies that are relevant to certain social groups (lower socio-economic groups, ethnic groups) or special areas (e.g. Estates). Does the current policy environment allow this flexibility? I also wish to share this reference from Dept of Census and Stats on a regression analysis carried out to identify significant determinants of stunting, wasting and underweight. This should be relevant to national policy. The following variables were "predominant in the incidence of malnutrition in pre-school children". (http://www.statistics.gov.lk/social/nutrition%20status.pdf Stunting 1. Number of living children in the family. 2. Age of child. 3. Sector of residence. 4. Work status of mother. 5. Access to media by mother. 6. Mother’s educational level. 7. Type of latrine. 8. Child given colostrum 9. Mother washes her hands with soap after child defecated. Wasting 1. Age of child. 2. Sector of residence. 3. Work status of mother. 4. Access to media by mother. 5. Mother’s educational level. 6. Sex of child. 7. Access to safe drinking water. 8. Type of latrine. Underweight. 1. Number of living children in the family. 2. Age of child. 3. Sector of residence. 4. Work status of mother. 5. Access to media by mother. 6. Mother’s educational level. 7. Mother washes her hands with soap after child defecated. 8. Type of latrine Best wishes to all of you. Hope my comments are useful. Saroj
Great discussion -- each piece of cake is very nice. As highlighted by Dr. Saroj Jayasinghe, this discussion came out with very important policy implications which need urgent action. While emphasizing that policies relating to the improvement of household socio-economic status and safe environment in under privileged areas would have a major role to play in the well being of both child and mother; I would like to put forward few national level determinants which affects maternal malnutrition. The younger age women 15-24 olds are at a significantly higher risk of malnutrition. On the other hand, prevalence of malnutrition is higher among later married women -- later marriages are more prevalent among higher socio-economic groups. Due to that not meeting the added demands for nutrients, pregnant and lactating mothers are in a higher risk of malnutrition. Likewise, employed women are at a high risk of under-nutrition due to the multiple roles in the work place and at home -- work load, less leisure time combined with no proper eating routines. Therefore, it may be necessary to create greater awareness among women about the importance of own health and nutritional status to overcome this undue maternal malnutrition.
Malnutrition in childhood is a major issue in Sri Lanka. G.V.S Krishantha and I conducted a research study on the Determinants of Child Delivery Method in Sri Lanka (with reference to Kalubowila, Nagoda, Matara, Ratnapura and Balangoda Hospitals) with a sample of 330 mothers. The results were presented at the Annual Sessions of the Population Association of Sri Lanka in February, 2010. We formulated new measurements to measure the size and maturity of infants at birth as a sub component of this study. Size of the child was measures by a new index covering the weight of the child, shoulder width, height of the child and the size of the head. According to our measurements 38% of children were not the proper size at birth. Maturity measurement was based on period of Pregnancy (POA) and 18% of children were not at the proper stage of maturity according to our study. Considering the weight of children 17.3% were low weight infants (Less than 2500 g). Therefore I believe that malnutrition is a considerable problem today among infants at birth.
Dr. Dilini Gunawardhana raises the question about the influence of advertising on food patterns of children. Dr Saroj also mentions that child focused advertising results in childhood obesity. These days K.L.N. Samanthi and I are working on a research project relating to television Advertising and Food Demand among Children in Sri Lanka (based on a sample in Galle). According to the initial findings television advertising and the length of time watching television have statistically significant positive relationships with fast food consumption. Fast food consumption shows a significant positive relationship with the weight of children as well. 11% of mothers believe that advertisements strongly affected on the food demand of children while 47% of mothers believe that it has a considerable influence. Therefore like malnutrition childhood obesity is also likely to become a major health issue in the future.
Nutritional status is clearly compromised by diseases with an environmental component, such as those carried by insect or protozoan vectors,or those caused by an environment deficient in micronutrients. But the effects of adverse environmental conditions on nutritional status are even more pervasive.
Environmental contamination eg, destruction of ecosystem , loss of biodiversity, climate changes, and the effect of globalization , has contributed to an increasing number of health hazards.
And all affect nutritional status. Overpopulation , too is a breakdown of the ecological balance in which the population may exceed the carrying capacity of the environment .
This then undermines food production, which leads inadquate food intake and or the consumption of non-nutrious food, and thus to malnutrition.And can induce a cycle leading to additional health problems and deprivation.Malnutrition can create and perpetuate poverty.
Which triggers that hampers economic and social development.
And unsustainable resource use and environmental degradation.
( , )Says : 2010-06-15 12:45:27
This is a very pertinent discussion as we have been working in post conflict/disaster areas in Africa where most families lost all assets including the assets needed for generating income. This had increased poverty, increasing hunger and resulting in malnutrition. Many of those affected by war/disasters lost breadwinners (either due to war/tribal killings or as youth were recruited to fighting forces) which prevented them from getting back to normal income earning levels. Many families affected by war/disasters were not also aware that the remaining family members had talents/strengths-TS (The power to Think, Their Will/Drive/Entrepreneurial/Leadership traits and latent skills) that could be refined to become marketable or utilized to venture into businesses and self-employment. In DR Congo, we carried out research and established Advisory Centers for Better Living (ACBL) to provide a package of services in order that families are recovered and strengthened. Please read the services we offered at: http://www.changemakers.com/en-us/system/files/Advisory%20Centres%20for%20Better%20Living%20%28CCMV%29.jpg However, we found that even if services and loans were available, those who had been affected by war/disasters were unwilling/hesitant to restart their lives. We had to carry out sessions to change their mindsets to set aside their trauma/past hurts and engage them to access resources as they did not have many other options. (i.e. Either vegetate in their misery, allow remaining family members to degrade and die OR refine their TS access resources and enhance livelihoods) We had to carry out additional sessions to visualize the manner investing the TS/advice/resources/loans available could make them become “not poor" economically and restart their lives.
The little research I carried out in poor areas in Sri Lanka revealed that the loss of breadwinners happens when many families loose their able bodied persons due to their seeking employment opportunities out of their villages, sometimes in large towns or in other countries. When these breadwinners are unable to earn sufficiently, or are unable/unwilling to send funds home, the families they left in their villages become destitute. This increases hunger and malnutrition. I also found in remote rural areas that there were some incidences where a lack of responsibility and loss of social and moral values had prevented breadwinners from supporting their families.
I would like to know if there are any measures in Sri Lanka to set up centres for better living in areas where the very poor live, in order that they can be provided advice, sensitized on the manner they can recover and provided services/loans to live better lives?.
Thank you
Sunimal Alles
+94722826620
Skype: sunimal.alles
