Elsevier

The Lancet

Volume 371, Issue 9612, 16–22 February 2008, Pages 588-595
The Lancet

Articles
Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial

https://doi.org/10.1016/S0140-6736(08)60271-8Get rights and content

Summary

Background

Food-assisted maternal and child health and nutrition programmes usually target underweight children younger than 5 years of age. Previous evidence suggests that targeting nutrition interventions earlier in life, before children become undernourished, might be more effective for reduction of childhood undernutrition.

Methods

We used a cluster randomised trial to compare two World Vision programmes for maternal and child health and nutrition, which included a behaviour change and communication component: a preventive model, targeting all children aged 6–23 months; and a recuperative model, targeting underweight (weight-for-age Z score <−2) children aged 6–60 months. Both models also targeted pregnant and lactating women. Clusters of communities (n=20) were paired on access to services and other factors and were randomly assigned to each model. Using two cross-sectional surveys (at baseline and 3 years later), we tested differences in undernutrition in children aged 12–41 months (roughly 1500 children per survey). Analyses were by intention to treat, both by pair-wise community-level comparisons and by child-level analyses adjusting for the clustering effect and child age and sex. This study is registered with ClinicalTrials.gov, number NCT00210418.

Findings

There were no differences between programme groups at baseline. At follow-up, stunting, underweight, and wasting (using WHO 2006 reference data) were 4–6 percentage points lower in preventive than in recuperative communities; and mean anthropometric indicators were higher by +0·14 Z scores (height for age; p=0·07), and +0·24 Z scores (weight for age and weight for height; p<0·0001). The effect was greater in children exposed to the preventive programme for the full span between 6 and 23 months of age than in children exposed for shorter durations during this period. The quality of implementation did not differ between the two programmes; nor did use of services for maternal and child health and nutrition.

Interpretation

The preventive programme was more effective for the reduction of childhood undernutrition than the traditional recuperative model.

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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