Community intervention to improve growth among children under 2 in rural India
Lead Research Organisation:
University College London
Department Name: Institute of Child Health
Abstract
Many children in developing countries die or fail to grow to their full potential because of undernutrition. Forty percent of the world's undernourished children live in India. There is a critical window of opportunity to prevent undernutrition and its long-term consequences by intervening to improve the health of mothers and children between conception and two years of age. For over eight years now, international agencies, scientists and activists have recommended the introduction of a new community worker focused on improving the health and nutrition of mothers in pregnancy and children under 2 in rural areas of India. Currently there is currently is no scientifically tested, cost-effective and scalable intervention model for such a worker. In the proposed research we will test a community intervention implemented by a community worker modeled on the one proposed by the Indian government in order to understand whether it can reduce child undernutrition and how it could be scaled up. The findings from this research will be generalisable to rural areas of India with a high prevalence of undernutrition, which is a population of over 170 million, and have relevance to other low and middle-income country settings.
Technical Summary
Study objectives
To determine:
1. 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
2. Whether the intervention leads to improvements in feeding, infection control and caring practices for children 0-18 months
3. Whether the intervention leads to increases in food intake and dietary diversity for women during pregnancy and lactation
4. The operational factors that affect the intervention's delivery and impact
5. The scalability, operational requirements, cost and impact of the intervention beyond the trial area
Design: Cluster-randomised controlled trial with 120 clusters (villages and hamlets of c.1000 population), 60 per arm.
Participants: Birth cohort of 2520 children and their mothers followed up at seven time points: third trimester, 0, 3, 6, 9, 12 and 18 months
Interventions
Intervention arm only: a community-based agent will carry out two activities: (a) monthly home visits for growth monitoring and promotion for improved feeding, infection control and caregiving with all children 0-2 years and their mothers; (b) a monthly participatory women's group meeting to catalyse individual and community action on maternal and child health and nutrition. 120 villages will be randomised to two trial arms.
Intervention & control arms: a capacity building intervention with Village and Health Sanitation and Nutrition Committees
Primary outcome: length-for-age Z scores at 18 months. Selected secondary outcomes: weight-for-height and weight-for-age z scores at birth, 3, 6, 9, 12 and 18 months; growth velocity; dietary diversity and food intake for pregnant and lactating women; feeding, caring and infection control practices for infants/children aged 0-18 months. A process evaluation will address objective 4. An economic evaluation will address objective 1 and a sub-study on scalability will address objective 5.
To determine:
1. 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
2. Whether the intervention leads to improvements in feeding, infection control and caring practices for children 0-18 months
3. Whether the intervention leads to increases in food intake and dietary diversity for women during pregnancy and lactation
4. The operational factors that affect the intervention's delivery and impact
5. The scalability, operational requirements, cost and impact of the intervention beyond the trial area
Design: Cluster-randomised controlled trial with 120 clusters (villages and hamlets of c.1000 population), 60 per arm.
Participants: Birth cohort of 2520 children and their mothers followed up at seven time points: third trimester, 0, 3, 6, 9, 12 and 18 months
Interventions
Intervention arm only: a community-based agent will carry out two activities: (a) monthly home visits for growth monitoring and promotion for improved feeding, infection control and caregiving with all children 0-2 years and their mothers; (b) a monthly participatory women's group meeting to catalyse individual and community action on maternal and child health and nutrition. 120 villages will be randomised to two trial arms.
Intervention & control arms: a capacity building intervention with Village and Health Sanitation and Nutrition Committees
Primary outcome: length-for-age Z scores at 18 months. Selected secondary outcomes: weight-for-height and weight-for-age z scores at birth, 3, 6, 9, 12 and 18 months; growth velocity; dietary diversity and food intake for pregnant and lactating women; feeding, caring and infection control practices for infants/children aged 0-18 months. A process evaluation will address objective 4. An economic evaluation will address objective 1 and a sub-study on scalability will address objective 5.
Planned Impact
Our research has the potential to benefit two main non-academic constituencies in the short and medium term:
(a) Communities in the study areas
Both of the trial arms will receive an intervention to strengthen the capacity of government-mandated Village Health, Sanitation and Nutrition Committees (VHSNCs). This intervention seeks to help VHSNCs address inequities in the provision of health and nutrition services, raise community awareness of rights and entitlements for health, and monitor the quality of local services. It is likely to lead to immediate gains in community capacity for addressing maternal and child undernutrition during the trial period. The intervention will have further, medium-term benefits, through the diffusion of effective processes and monitoring tools.
(b) Policy-makers, implementers and advocacy networks
The study directly responds to the demand for evidence from policy-makers and implementers on effective community interventions to improve nutrition in the first 1000 days of life. In India, it responds to the specific need to understand whether a community intervention delivered by a second Anganwadi worker or its equivalent will lead to improvements in child growth and what the costs, operational requirements, and impact of scale up might be. As such it will contribute directly to evidence-based policy-making with short-term benefits by 2015 (through the trial results) and medium-term benefits through improved decision-making on health and nutrition programmes.
We have links with highly active Indian advocacy networks which have been instrumental in achieving key policy changes for health and nutrition. These networks require data on maternal and child undernutrition and effective interventions in underserved areas to mobilise implementers and policy-makers. We will share data from the trial control areas with three networks (the Right to Food Campaign, the Public Health Resource Network and People's Health Movement, India) through bespoke powerpoint presentations and materials so that they can use these to raise the issue of maternal and child undernutrition in underserved areas through their forums.
(a) Communities in the study areas
Both of the trial arms will receive an intervention to strengthen the capacity of government-mandated Village Health, Sanitation and Nutrition Committees (VHSNCs). This intervention seeks to help VHSNCs address inequities in the provision of health and nutrition services, raise community awareness of rights and entitlements for health, and monitor the quality of local services. It is likely to lead to immediate gains in community capacity for addressing maternal and child undernutrition during the trial period. The intervention will have further, medium-term benefits, through the diffusion of effective processes and monitoring tools.
(b) Policy-makers, implementers and advocacy networks
The study directly responds to the demand for evidence from policy-makers and implementers on effective community interventions to improve nutrition in the first 1000 days of life. In India, it responds to the specific need to understand whether a community intervention delivered by a second Anganwadi worker or its equivalent will lead to improvements in child growth and what the costs, operational requirements, and impact of scale up might be. As such it will contribute directly to evidence-based policy-making with short-term benefits by 2015 (through the trial results) and medium-term benefits through improved decision-making on health and nutrition programmes.
We have links with highly active Indian advocacy networks which have been instrumental in achieving key policy changes for health and nutrition. These networks require data on maternal and child undernutrition and effective interventions in underserved areas to mobilise implementers and policy-makers. We will share data from the trial control areas with three networks (the Right to Food Campaign, the Public Health Resource Network and People's Health Movement, India) through bespoke powerpoint presentations and materials so that they can use these to raise the issue of maternal and child undernutrition in underserved areas through their forums.
Publications
Style S
(2017)
Experiences in running a complex electronic data capture system using mobile phones in a large-scale population trial in southern Nepal.
in Global health action
Description | Audrey Prost participated in the WHO advisory committee on the strategic review of the Integrated Management of Childhood Management of Illnesses and conducted an in-depth review of its community component |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Participation in a guidance/advisory committee |
Description | Ekjut and UCL contribute to Participatory Learning and Action being recommended by National Health Mission to improve women and children's health in 10 States of India |
Geographic Reach | Asia |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | Influenced training of Accredited Social Health Activists practising Participatory Learning and Action in nine states |
Geographic Reach | National |
Policy Influence Type | Influenced training of practitioners or researchers |
URL | http://nhsrcindia.org/sites/default/files/PLA%20Module%20for%20ASHA_English.pdf |
Description | Scale of participatory learning and action across the state of Jharkhand |
Geographic Reach | Local/Municipal/Regional |
Policy Influence Type | Influenced training of practitioners or researchers |
Impact | From 2017 to 2018, 2000 ASHA supervisors were trained to facilitate Participatory Learning and Action meetings across the State of Jharkhand. From December 2017 to November 2018, they facilitated a total of 129032 meetings across 21 districts (an estimated population of 22 million). Across the six districts participating in a concurrent, controlled evaluation, we estimate that the intervention averted between 80 and 90 neonatal deaths over one year (Dec 2017 to Dec 2018). If the coverage of meetings is maintained at scale, the intervention may avert over 1000 neonatal deaths across 21 districts. |
Description | Bill and Melinda Gates Foundation - Agriculture and Nutrition Research call (2015) |
Amount | £1,738,186 (GBP) |
Organisation | Bill and Melinda Gates Foundation |
Sector | Charity/Non Profit |
Country | United States |
Start | 12/2015 |
End | 12/2019 |
Description | CIFF Research grant |
Amount | £1,082,405 (GBP) |
Organisation | Children's Investment Fund Foundation |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 11/2015 |
End | 11/2020 |
Description | Community Prevention of Acute Malnutrition |
Amount | £514,918 (GBP) |
Funding ID | 2002-04502 |
Organisation | Children's Investment Fund Foundation |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 07/2021 |
End | 07/2025 |
Description | GCRF Early Child Education: Creches and participatory nurturing groups to improve early childhood development among children aged 0-36 months in rural Jharkhand and Odisha, India |
Amount | £1,878,824 (GBP) |
Funding ID | ES/T004029/1 |
Organisation | Economic and Social Research Council |
Sector | Public |
Country | United Kingdom |
Start | 02/2020 |
End | 12/2023 |
Title | Longitudinal data on health and nutrition in the first 1000 days of life for 2500 children in rural eastern India |
Description | We have collected longitudinal data on the health and nutritional status of 2500 children enrolled within our trial. This de-identified dataset has been made fully available on UCL Discovery (open access repository) in March 2021. |
Type Of Material | Database/Collection of data |
Year Produced | 2021 |
Provided To Others? | Yes |
Impact | This dataset will provide a resource to answer a number of questions about the growth trajectories of children in rural India, predictors of mortality among malnourished children under six months of age, and the geographical patterning of undernutrition. |
Description | Collaboration with World Health Organisation on child mortality risk stratification analysis |
Organisation | World Health Organization (WHO) |
Country | Global |
Sector | Public |
PI Contribution | We are contributing data from the CARING trial to a pooled analysis of risk factors for mortality, stunting and wasting among children under five years of age. |
Collaborator Contribution | WHO are leading the data analyses. |
Impact | No outputs yet |
Start Year | 2021 |
Description | Partnership for CARING trial (MRC Global Health Trial Grant) |
Organisation | Ekjut |
Country | India |
Sector | Charity/Non Profit |
PI Contribution | I coordinated the formation of the trial team which includes partners from PHFI and Ekjut (India). |
Collaborator Contribution | PHFI and Ekjut were instrumental in the development of the Global Health Trial proposal, and are leading the implementation of the trial. |
Impact | Outputs: We have written two articles published in 2015 and 2016: one is the protocol for our cluster randomised controlled trial, the second is a mixed methods baseline study on the functioning of Village Health, Nutrition and Sanitation Committees in rural India. This involved collaboration between the social scientists on our team (S Bhattacharyya and A Srivastava), and the clinicians and field teams involved in fieldwork in our rural trial areas. Outcomes: We have started the trial and are currently into its final year. We have held two trial Technical Advisory Group meetings with a broad range of scientific and policy stakeholders. |
Start Year | 2013 |
Description | Partnership for CARING trial (MRC Global Health Trial Grant) |
Organisation | Public Health Foundation of India |
Country | India |
Sector | Public |
PI Contribution | I coordinated the formation of the trial team which includes partners from PHFI and Ekjut (India). |
Collaborator Contribution | PHFI and Ekjut were instrumental in the development of the Global Health Trial proposal, and are leading the implementation of the trial. |
Impact | Outputs: We have written two articles published in 2015 and 2016: one is the protocol for our cluster randomised controlled trial, the second is a mixed methods baseline study on the functioning of Village Health, Nutrition and Sanitation Committees in rural India. This involved collaboration between the social scientists on our team (S Bhattacharyya and A Srivastava), and the clinicians and field teams involved in fieldwork in our rural trial areas. Outcomes: We have started the trial and are currently into its final year. We have held two trial Technical Advisory Group meetings with a broad range of scientific and policy stakeholders. |
Start Year | 2013 |
Description | Partnership with the UPAVAN team |
Organisation | London School of Hygiene and Tropical Medicine (LSHTM) |
Department | Faculty of Epidemiology and Population Health |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Following the Caring trial I was approached by Dr Suneetha Kadiyala, from LSHTM, to collaborate on a randomised controlled trial of a community-driven and digital technology-enabled agriculture intervention for nutrition in Odisha, India. The trial is ongoing until December 2020. |
Collaborator Contribution | I am Co-I on Dr Kadiyala's trial and have designed its process evaluation. |
Impact | Kadiyala, S., Prost, A., Harris-Fry, H., O'Hearn, M., Pradhan, R., Pradhan, S., Mishra, N.K., Rath, S., Nair, N., Rath, S., Tripathy, P., Krishnan, S., Koniz-Booher, P., Danton, H., Elbourne, D., Sturgess, J., Beaumont, E., Haghparast-Bidgoli, H., Skordis-Worrall, J., Mohanty, S., Upadhay, A., Allen, E. (2018) Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child nutritional outcomes in rural Odisha, India: study protocol for a cluster randomised controlled trial. Trials 9;19: 176. doi: 10.1186/s13063-018-2521-y. |
Start Year | 2016 |
Title | Community intervention to improve growth among children under two in rural India |
Description | We are currently carrying out a cluster randomised controlled trial to test the impact of a public health behavioural intervention involving a community worker carrying out participatory women's group meetings and counselling through home visits to promote optimal feeding, infection control and caregiving for children under two in rural India. The worker is modelled on an agent already approved by the Government of India. |
Type | Preventative Intervention - Behavioural risk modification |
Current Stage Of Development | Late clinical evaluation |
Year Development Stage Completed | 2012 |
Development Status | Under active development/distribution |
Impact | The intervention is currently being implemented in 60 villages of eastern India. It has been discussed and approved by the Health Department in the State of Jharkhand and the Department of Women and Child Development, in Odisha. |
Title | Participatory women's groups to improve maternal and newborn health across the state of Jharkhand, India |
Description | We tested a community intervention with participatory women's groups in which groups follow a four-phase participatory learning and action cycle to identify, prioritise, and address problems faced by women and babies in the perinatal period in eastern India through two cluster randomised controlled trials (2010 and 2016). This intervention was adopted by the Government of Jharkhand and scaled up to an entire state over 2017-2019. It is currently implemented in over 56,000 women's groups. |
Type | Therapeutic Intervention - Psychological/Behavioural |
Current Stage Of Development | Wide-scale adoption |
Year Development Stage Completed | 2016 |
Development Status | Under active development/distribution |
Clinical Trial? | Yes |
Impact | The evaluation of the scaled up intervention is being written up. Existing results suggest that the scaled up intervention led to 24% reduction in neonatal mortality in evaluation districts. |
Description | Delhi trial dissemination meeting |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | On the 26th of April 2017, we will conduct a dissemination and discussion of the trial findings with policy-makers from the Women and Child Development Ministry in the Central Government as well as in Jharkhand and Odisha, and members of the Right to Food movement. We will hold a panel discussion to debate the implications of the trial results for the Integrated Child Development Services and national-level plans to introduce a new worker to focus on the nutrition of children under three in 200 high-burden districts of India. We hope that this meeting will stimulate discussion of the trial findings and translate into policy decisions in eastern India and other regions with high-burden districts. |
Year(s) Of Engagement Activity | 2017 |
Description | Production and dissemination of a film on activities related to the trial |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Media (as a channel to the public) |
Results and Impact | The film has been screened in several public presentations in regional and national fora in India, as well as placed in the internet with social media (twitter and Facebook) flagging. It sparked discussions about research on nutrition and interventions to improve children's growth in rural underserved areas of india. It also encouraged us to think about developing a new, shorter film (5 mins) for much broader dissemination in 2015, and we are currently planning the script for this. Regional and national stakeholders (e.g. other researchers, policy-makers and NGO stakeholders) understood the purpose of the study and the intervention activities. |
Year(s) Of Engagement Activity | 2013 |
URL | https://www.youtube.com/watch?v=IwJYWADoNmk |