Community intervention to improve growth among children under 2 in rural India

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.

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.

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.