AmyLe AvneetKaur RubabHaider KennyEstrella WaterAccessandExclusiveBreastfeedingInitiation Problem: As public health nutritionists, our team isworkingwithalargeslumcommunityin SouthAfrica to improve theirlivingconditions.ThiscommunityislocatedinCapeTown,SouthAfrica.

.Thistownhas been growing over the past ten years. The villagers in this town have been working in the expanding tourism industry. Since the population of this town moved from rural to urbansetting,theyhaveaccess tohighcaloricfoodswithpoormicronutrientcontentinthefood. A typical slum living arrangement consists of four to five families sharing one room and have limited access to aclean watersupply.Sincethelivingarrangementsamongthefamiliesaresoconfined, it makes the overall slum population more vulnerable to catching infectious diseases. The lack of clean water supply adds another risk factor to the spreading of diseases among the population. The needs assessment results show that the neonatal mortality rate in 2012 was 43 deaths per 1,000 live births. The maternal mortality rate in 2012 was 67 deaths per 100,000 deliveries of infants. Lastly, the mortalityrateamonginfantsinthistownwas58deathsper1,000livebirths,in2012. The women of this town spend mostoftheir timeworkingoutside ofthehome.Forthisreason, many mothers are not able to exclusively breastfeed their infants for an extensive period of time. The households in this town do not have electricity so they do not own refrigerators to store the milk for infantswhilethemothersareawayatwork. As anintervention,wemustprovideawaytodecreasethemortalityrateamongthewomen and children, provide clean water supply and to encouragebreastfeedingpracticesforinfants.Accordingto

the needs assessment results show that the use of infant formula in the last 24 hour (child 02 yr) was 60%. Goal: We have two primary goals in ordertoaddresstheneonatal,infantandmaternalmortalityrates problems in the slums. Our primary goal is to provide clean water. Clean water isvitalforeveryone to live a healthy life. Clean water access will decrease the mortality rate among women and children.We want to build more water stations and provide water containers for mothers that participate in the intervention. This will help provide families with adequate amount of daily water. Oursecondgoalisto provide breastfeeding and nutrition education to mothers living in the slums. It is important for mothers to understand the shortterm and longterm benefits of breastfeeding for both mothers and infants. We will continue to promote and encourage the World Health Organizations exclusive breastfeeding recommendationof6months. Targetgroup: Our target groups will be women and infants in a large slum community on the fringe of Cape Town, South Africa. This population has been steadily growing over the past 10 years and the rates have relativelynotchangedbetween2005to2012.Thiscommunityexperiencesalimitedaccesstofree clean waterwhichcontributestothespreadofdiseases.Contaminantscanleadtoconstant orincreased mortality rates in women and children. In this population, women and children are one of the most vulnerable to diseases. According to the needs assessment data, neonatal mortality rates have decreasedby0.2%,infantmortalityratesby0.1%,andmaternalmortalityratesby0.5%between2005 and 2012. In addition, exclusive breast feeding for infants between 36 months of age is lessthan1%. This population is of particularly interesting to our program because of the misconceptions there are

regarding breastfeeding, illnesses that may arise as a result of early weaning and use of unclean water whichleadtochangesinthemortalityrateofapopulation. Programmethods: To overcome the problem of lower breastfeeding rate, we will provide women with nutritional education about the benefits of breastfeeding for six months. Our intervention program WaterAccess and Exclusive Breastfeeding Initiation will be in progress for three years. According to the population of each slum, we will split the population in sectors.Wewillprovidetwonutritionalsessionsoneinthe morning and one in the evening. In order to provide the slum population with clean water, each family will receive aLifeSackwaterfiltertotakewiththemasan incentiveforattendingthenutritioneducation lectures. The Life Sack filter uses SODIS (Solar Water Disinfection System) technology to kill deadly microorganisms and bacteria in water. As the women come in forlectures,theywilltakehomeawater filter with them so they can provide their families with clean water to drink. This way, it will be obligatory for them to attend the lectures because not only will they benefit from the breastfeeding education,theycanalsotakehomesomethingfortheirfamilies. Objectives: Health objective A: By 2018, mortality rates among neonatal in theslumcommunityofCape Town,SouthAfricawillbereducedby2.0%. Health objective B: By 2018, mortality rates among infants in the slum community of Cape Town,SouthAfricawillbereducedby2.0%. Health objective C: By 2018, maternal mortality rates in the slumcommunityofCapeTown, SouthAfricawillbereducedby2.0%. Behavioral objective: By 2018 exclusive breastfeeding rates among infants between 36

monthsintheslumcommunityofCapetown,SouthAfricawillbeincreasedby20%. Program Based Objective: By 2018, 75% of women in the slumcommunityofCapeTown, SouthAfricawillattendtheweekly,sixmonthbreastfeedingeducationclasses. Preventionlevels: We want to put our efforts into primary prevention because it prevents disease by controlling risk factorsthatarerelatedtoinjuryanddisease.Byhavingmorewomenexclusivelybreastfeedingfor6 months we are helping mothers get back to theirnormalbodyweight.Breastfeedingalsohelpsmothers and theirinfantsbond.Motherswhobreastfeedhaveahormonereleaseof prolactinandoxytocinwhich helps mothers create emotional and physical bond with their infant. Breastfeeding infants can also help prevent some diseases that may occur later in their lives, such as type 1 and type 2 diabetes, high cholesterol, and inflammatory bowel disease. Breastfeeding may also reduce the risk of developing obesity and certain cancers later in life. Breastfeeding also provides optimal nutrition for the infants bodythattheformulalacks.

TypeofIntervention: Our program is a community based intervention because we are making a change to a small town in Africa by implementing a three year program based on our two primary goals. The times and locations at which the education sessions will beofferedwillallowustobeaccessibletothemajorityof thetargetgroup. SpecificOutcomeMeasurements: Upon entry to the education program, women will be interviewedabouttheirknowledge ofthe healthbenefitsofbreastfeeding,useofcleanwaterandincidenceofinfantmortality.

1. Exclusive Breastfeeding rates: Women will be interviewed and the interviewer will fill out a survey for them.These interviewswillconsist ofapretestwhichwillbeconductedbeforethecourseof the education. Another interview will take place after they have completed their education. This interviewwilldeterminehowmuchtheyhavelearnedfromtheclasses. 2. Neonatal infant mortality rate: Women will be interviewed and the interviewer will fill out a surveyforthem. Example questions: 1. How many times do you breastfeed your baby a day? 2. How often do you refill your Life Sack water filter a week? 3. What are some benefits of breastfeeding for mothers? 4. Whataresomebreastfeedinghealthbenefitsforinfants? Data Collection: We can collect breastfeeding data from mothers after they attend our nutrition educationclasses.WecanadministersurveystopeoplewhoareutilizingtheLifeSackwaterfilter. Twoconfoundingvariables: 1.Perceptions/Culturalmythsaboutbreastfeeding 2.Limitedaccesstocleanwaterandpoorsewage Costeffectiveanalysis: Our program is extremely costeffective because we are investing our time and money in preventing mortality rates from infection, disease and long term health complications such as CVDand T2DM by advocating 6month exclusive breastfeeding, nutrition education and clean water access. In order to calculate the costeffectiveness we must take anthropometric measurements such as monthly weight change andBMI.Wecanusedatafromsurveystoaddressbehavioral changesintheslums.We canusebothclosedendedandopenendedquestions. To implement this program we need to have nutritionists to provide education, lactation

specialists to teach women ways of breastfeeding and locals of the community to give us insight of the culture. The supplies that we will need are classroom supplies, Life Sack water filters, cost of advertising/flyers,andfood,housing,andtransportationforstaffmembers. OperatingEffectiveness: Approach A: Our program will have at least 75% coverage because we are targeting women and their families by providingthewomenwillanincentive(waterfilter)toattendthelectures.Thisway, we are not only helping women but wearehelpingtheirfamiliesaswellwhichinturnwillcovermoreof the slums population. We are not worried about leakage because we wanttospreadoutourprogram tobeabletoreachmorepeopleinthepopulation. Approach B: Our program will have long term effects on the mortality rates of women and infants because we are providing clean water which in turn will prevent diseases from spreading throughout the population. We are also implementing breastfeeding practices which will provide better nutrients for the infants making them less vulnerable to illnesses and prevent them from developing diabetesandobesityinthelongrun.