CARING
Community Action Research
to Improve Nutrition and Growth in rural India
Delhi, March 2013
OVERVIEW
BACKGROUND
OVERVIEW OF STUDY
QUESTIONS FOR DISCUSSION
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BACKGROUND
Growth among children < 5 in NFHS-3 (2005-6)
In: Paul et al. Lancet India Series 2011
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Data from IIPS - NFHS -3 (2005-6)
BACKGROUND
Growth among children < 3 in 36 clusters of Jharkhand and Odisha, 2010, n=3665
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BACKGROUND
Growth among children < 3 in 36 clusters of Jharkhand and Odisha, 2010, n=3665
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BACKGROUND
Direct interventions:
Consensus on interventions
- Improved dietary intake for adolescent girls & mothers
- Delaying the first pregnancy (>20 years)
- Iron and calcium sup. for pregnant women
- Antenatal care
Immediate
causes
- Timely and exclusive breastfeeding
- Timely, age-appropriate, hygienic complementary feeding
- Illness prevention for children through:
handwashing; immunisations.; Vitamin A; Iron; de-worming
- Appropriate care during illness for children
Immediate
causes
- Therapeutic feeding for children with SAM
- Access to family planning for birth spacing
Underlying
causes
Indirect interventions:
- Support women’s education and empowerment
- Increase access to safe water and sanitation
Basic
causes
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- Support food security & sustainable livelihoods
- Advocate for good nutrition governance
Black et al. Lancet 2008
Sachdev HPS, World Bank Policy Brief 2011
India’s Expert Taskforce on Infant & Young Child Nutrition, 2009
DFID: The neglected crisis of undernutrition, 2009
BACKGROUND
Proposed policy changes
HIGH LEVEL EXPERT GROUP REPORT ON UNIVERSAL HEALTH COVERAGE FOR INDIA
p.293
RESTRUCTURING ICDS 2011
p.12
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CARING
Research goal
To develop and test a community intervention
involving a facilitator modelled on a second (ICDS)
Anganwadi worker to improve growth among
children 0-18 months in two rural districts of
Jharkhand and Odisha
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CARING
The other goal…
To be useful…
Bring attention to undernutrition in underserved areas through
data-informed advocacy
Be relevant to programmes and policy-makers by:
- Documenting processes, costs and consequences of having a
second AWW
- Examining scalability
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CARING
A two-pronged strategy
HOME VISITS
Address immediate causes: Counseling
for IYCF, illness prevention, and support
for referrals
Checking on growth monitoring and
Mother Child Protection card milestones
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PARTICIPATORY GROUP MEETINGS
Begin to address underlying causes:
Birth spacing, nutrition in pregnancy,
WASH, women’s empowerment
CARING
What about control areas? Meetings with Gram Vikas Samitys
Phase 1
Understanding Causes
of Malnutrition,
Inequities, discrimination and
Rights and Entitlements
Phase 4
Phase 2
Dialogue with service
providers at
blocks and district level“Jan Samvad”
Situational AnalysesServices, gaps
Phase 3
Supporting frontline
functionaries and
resolving issues at
local level
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CARING
Research questions
PRIMARY RESEARCH QUESTION
What is the impact and cost-effectiveness of a community intervention with participatory
women’s groups and home visits on linear growth among children 0-18 months in rural
India?
SECONDARY RESEARCH QUESTIONS
1. Does the intervention lead to improvements in feeding, infection control and caring
practices for children 0-18 months?
1. Does the intervention lead to increases in food intake and dietary diversity for women
during pregnancy and lactation?
2. What operational factors affect the intervention’s delivery and impact?
1. What are the potential scalability, operational requirements, cost and impact of the
intervention beyond the trial area?
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CARING
Study design
• Design: Cluster-randomised controlled trial with 120 villages
• 60 villages will be randomly allocated to the intervention
• 60 villages randomly allocated to control
• Invite all mothers in third trimester of pregnancy in the 120 villages and their
infants to join the study over a 12 months period
• Participants: cohort of 2520 mothers and children followed up in 3rd trimester
of pregnancy, birth, 3, 6, 9, 12, and 18 months
• Process and economic evaluations: qualitative interviews with mothers and
community health workers, and document reviews.
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CARING
Evaluation indicators
Primary outcome: length-for-age Z scores at 18 months
Secondary outcomes:
• WHZ and WAZ at birth, 3, 6, 9, 12 and 18m
• Birthweight
• Infant mortality rate
• Dietary diversity & food intake for pregnant & lactating women
• Feeding, caring & infection control practices for children 0-18m
• Maternal empowerment and psyschosocial distress
• CBA knowledge of IYCF post-training
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Thank you