ArticlesAge-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial
Introduction
The United States Agency for International Development (USAID) spends nearly US$100 million a year on food-assisted child health and nutrition programmes, which aim to reduce food insecurity and childhood undernutrition. These programmes usually target services to families with children younger than 5 years who are identified through growth-monitoring activities as underweight. Although widely implemented, these programmes and other large-scale government-sponsored programmes targeted to underweight children have shown little effect in reducing childhood undernutrition.1, 2, 3, 4, 5
In this paper, targeting underweight children is called a recuperative approach. The term refers to targeting children with mild and moderate underweight (Z scores for weight-for-age of less than −1 [mild] or −2 [moderate]). We do not address severe acute undernutrition, which is defined as weight-for-height Z scores of less than −3, nor do we discuss related treatment approaches such as community therapeutic care.6
Research evidence suggests that a preventive approach based on targeting nutrition interventions as early as possible in children's lives might be more effective than recuperation to reduce childhood undernutrition. Published studies on the process and timing of growth faltering, and on the effectiveness of food supplementation, provide convincing evidence that the first 2 years of life (in addition to the prenatal period) is the window of opportunity for nutritional interventions. Research has shown that this period is not only the time of greatest vulnerability7, 8 and risk of possibly irreversible long-term physical and mental damage,9, 10, 11, 12, 13, 14 but is also the period of greatest benefits from nutrition interventions.15, 16, 17 Consequently, there is increasing interest in developing, implementing, and assessing nutritional interventions to address childhood undernutrition based on a preventive approach.
This paper presents the results of an evaluation study based on a cluster randomised trial, which compared the effect on child growth of a preventive and a recuperative approach of targeting a food-assisted maternal and child health and nutrition programme in Haiti. The hypothesis was that targeting all children aged 6–23 months (preventive) would be more effective at reducing the community prevalence of stunting, underweight, and wasting than would targeting underweight children younger than 5 years (recuperative). A cluster randomised trial was used for the evaluation because the two programme models were delivered at the community level, rather than the individual level.
Section snippets
Setting and programmatic context
The research was undertaken in the context of a new 5-year programme implemented by World Vision-Haiti in the Central Plateau region of Haiti, where World Vision operates in all 12 communes and serves a population of roughly 600 000.
The programme offers a range of services for pregnant and lactating women and for children 0–59 months of age, and is based on five contact points between programme staff and beneficiaries: (a) rally posts, where beneficiary identification is done, and where health
Results
There were no differences between the groups at baseline in any of the child anthropometric measures or in other child, maternal, and household characteristics (table 1). At the end of the 3-year intervention, children from preventive communities had significantly higher mean Z scores for height for age (+0·14), weight for age (+0·24), and weight for height (+0·24) than the recuperative group (child-level means adjusted for cluster effect and for child age and sex; table 2). Differences in the
Discussion
This study shows, using a cluster-randomised trial, that an age-based preventive model for delivering a package of food assistance and maternal and child health and nutrition interventions was more effective at reducing childhood undernutrition than the traditional, recuperative model based on targeting underweight children. Results of our operational research done in 2004, also showed that the two programme models were operating equally well and that the organisational conditions were
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