Transforming delivery

How to choose the best interventions and delivery strategies to scale up nutrition?

The right nutrition intervention bundle in the first 1000 days for a fair start to life

Blog by Masum Billah and Mohd Anisul Karim, icddr,b

In current times, human capital is regarded as essential to the growth and development of nations. Factors that impede investment in the development of human capital hinder national development, arrest economic progress and deprive the country the benefits of globalization. One such adverse factor is stunting – a condition where an individual does not grow in length as they should in utero and over the first 5 years of life.

The first 1000 days encompasses the period from conception up until the child is 2 years of age. The height of the child at this age is the single best indicator of how well-off, cognitively and economically, a person will be down the road. Nutrition during this critical period is crucial to influence stature and later life outcomes. However, intuitively, many people think that everyone would have different growth trajectories during this period and that this would be influenced heavily by our genetic make-up. In reality, provided optimal environmental conditions, all children, regardless of where they live, were found to grow at similar rates in utero.

This makes research on what interventions work, can be delivered to everyone, are cost-effective and can bring about changes in a single generation – of utmost importance. To fill the evidence gap on an appropriate combination of preventive nutrition interventions, a cluster randomized trial is being conducted in a food-insecure zone of Bangladesh. The policies underpinning investments based on this research is expected to be transformative in developing counties with a high undernutrition burden. This research, funded by Transform Nutrition and led by researchers at icddr,b –attempts to explore how the right nutrition interventions can be delivered at scale to optimize human growth as capital for national and global development.

Large-scale community-based trials and their systematic reviews have demonstrated what works when implemented at scale. We know that awareness of the problem is important to drive care-seeking behaviour, and being educated makes people more likely to seek the right help. We also know that mothers appropriately counselled tend to adopt healthier practices during and after pregnancy. Counselling for exclusive breastfeeding and weaning at the right time result in a significant increase in these practices. We also understand that in resource-poor settings, nutritional supplements may improve dietary diversity. Thus, a more pertinent question, perhaps, is what combination of counselling (during and after pregnancy) and supplement (or absence of it) gives us the best value for money. This “bundling of nutrition interventions trial” currently taking place in Bangladesh is an attempt to answer a) the combined effect of the different intervention combinations, and b) if there is any evidence of synergy between prenatal and complementary feeding supplement on stunting prevention.

The TN Bundling study has 3 interventions bundled in different combinations in 4 arms with the 5th arm being the comparison group:

  1. First arm: delivers a validated counselling strategy to promote maternal nutrition during pregnancy, exclusive breastfeeding and complementary feeding, along with prenatal nutrition supplement for pregnant women and complementary food supplement for the child from 6 to 24 months of age.
  2. Second arm: provides the counselling intervention with prenatal supplementation only.
  3. Third arm: combines the same counselling intervention as above with post-natal supplementation for the child from 6-24 months of age.
  4. Fourth arm: pregnant women in this arm receive only the counselling intervention.
  5. Fifth arm: where participants will continue to follow existing practices as is.

All interventions are being delivered door-to-door by community health workers. Pregnant women are enrolled in early pregnancy and are followed up until the children reach their second birthday.  The child’s height for a given age will reflect the effectiveness of the intervention bundle in each of the 4 arms compared to the comparison arm.

We will also be exploring changes in mother and child’s dietary and hygiene practices, and childhood gut infections that have huge impact on health. A comparatively novel approach used in this project is a bespoke electronically guided (tablet-based) intervention delivery and data collection platform for all staff, and a web-based real-time monitoring system for supervisors. Further details of the study can be accessed here.

The preliminary results of the trial are due in 2018. Choosing the right combination of interventions, based on the trial findings, will help policymakers in Bangladesh and other developing countries to make data-driven budgetary decisions. This will ultimately build on the demographic dividend Bangladesh has already achieved and accelerate our progress towards a middle income country.

A malnutrition mobile app randomised trial in Wajir, Kenya

A mobile health application developed to help with Integrated Management of Acute Malnutrition (IMAM) which enables health workers and volunteers to identify and initiate treatment for children with acute malnutrition before they become seriously ill,was evaluated in 40 health facilities in Wajir Kenya. A research brief is now available Preliminary findings from a malnutrition mobile app randomised trial in Wajir, Kenya which summarises the findings.

A mobile health application to manage acute malnutrition

Community based Management of Acute Malnutrition (CMAM) is a proven high-impact and cost-effective approach in the treatment of acute malnutrition in developing countries. However, success is limited if treatment protocols are not followed, record keeping and data management is poor and reliable data is not available in time for decision makers.

There is strong evidence that mobile device based (mHealth) applications can improve frontline health workers’ ability to apply CMAM treatment protocols more effectively and to improve the provision of supply chain management. A new Transform Nutrition working paper is now available A mobile health application to manage acute malnutrition Lessons from developing and piloting the app in five countries which we hope will inform future mobile health projects.

A mobile app to manage acute malnutrition

A new Transform Nutrition research brief A mobile app to manage acute malnutrition is now available. In this brief programme staff in Niger, Chad, Mali, Kenya and Afghanistan discuss the challenges they faced adapting a mobile health app and rolling it out in some of the most remote, hard to reach health facilities in the world and make valuable recommendations for other mobile health application developments .

 

Challenging dominance: identity politics in the Integrated Child Development Services (ICDS) Programme, India

By Shilpa Deshpande, PhD Candidate, Institute of Development Studies, University of Sussex

Ten years before I joined the ICDS as an anganwadi worker, my cousin mother-in-law used to work here. At that time, the division of the village population between anganwadi workers was such that lower caste households were served by my mother-in-law whereas only the higher caste households were served by Lata madam, this was her rule….so… my mother-in-law’s field area was scattered across the village. Then when I joined, Lata madam said that just like my mother-in-law I should be given the lower caste communities. I refused…. I said give me any part of the village but I want half and I want it along a continuous line then only will I be able to work. This led to a fight, which continued for several days.

Meena, Anganwadi worker [Read more...]

Pastoral Community Platforms as channels for Behavioural Change for Nutrition

New research just been published by Transform Nutrition and Vétérinaires Sans Frontières Suisse with preliminary findings of a study on Pastoral Community Platforms as Channels for Behavioural Change for Improved Nutrition (BCIN) The research was designed to explore the potential of using pastoral-community platforms for channeling maternal, infant and young-child nutrition messages to community members. We have also published some useful case studies which provide an insight into the perceptions of the participants of the study who live in the study area.

Bangladesh : Delivering for Success at Scale

Conference on Delivering for Success at Scale 7- 8 February 2017, BRAC Auditorium, Mohakhali, Dhaka, Bangladesh

This conference built on the longstanding partnership between BRAC, ICDDR,B and the Institute of Development Studies (IDS) to explore the role of knowledge in the conceptualisation, design, delivery and management of development programmes and policies. Bangladesh has been a lead player in the use and integration of research into development decision-making, notably in relation to health systems, nutrition, social protection, agriculture and poverty. Evidence will continue to be important in strategic development planning by the Government of Bangladesh among others.

The conference included examples of how high quality research can be embedded within programmes, showcased research findings, discussed the challenges of integrating research with programmes, highlighted successful examples and discussed future needs. The UK Department for International Development funded Transform Nutrition and Future Health Systems presented relevant research.

Read an article about the conference in the Bangladesh Financial Express ‘On health and nutrition’. We also published a blog by Rittika Brahmachari, IIHMR Pathways to scaling up interventions: reflections from delivering for success at scale 

For more information contact Aazia Hossain aazia@icddrb.org

What factors influence community nutrition workers in performing their jobs? Preliminary findings from Bihar, India

by Aparna John, PhD candidate, Institute of Development Studies at University of Sussex

Child undernutrition rates in India are among the highest in the world (Raykar et.al, 2015). Despite the decline in undernutrition indicators such as stunting (low height for age), underweight (low weight for age) and wasting (low weight for height), India is home to 40 million stunted and 17 million wasted children. The Government of India has invested in efforts to reduce childhood undernutrition and improve maternal and child health through one of its flagship programmes — the Integrated Child Development Services (ICDS) Scheme. ICDS, the world’s largest community nutrition programme, is delivered by 1.34 million village based female workers, Anganwadi workers (AWWs). [Read more...]