When preventing undernutrition, it is more effective to focus on children who are at risk earlier than to attempt recuperative programs on children already affected. A preventive nutrition intervention program was analyzed in the February 16, 2008 issue of The Lancet, in a follow up of the recent Lancet Series on Maternal and Child Undernutrition.
Dr. Marie Ruel, of the Food Consumption and Nutrition Division, part of the International Food Policy Research Institute in Washington, DC, USA, worked with colleagues to perform a cluster randomized trial of both of these methods of intervention in Haiti. In the preventive model, all children from 6-23 months old were addressed, while the recuperative model targeted only underweight children aged 6-60 months. The models also addressed pregnant and lactating women.
Communities were paired together based on the accessibility to various services and several other factors. Then, models were randomly assigned to each cluster. Through two cross-sectional surveys, taken at a baseline and then after three years, differences in undernutrition were measured in children aged 12-41 months. At these points, several indications of undernutrition were observed.
No differences were found between the program groups at the baseline. After follow up, stunting, being underweight, and wasting were approximately 5 percentage points lower in the preventative rather than recuperative communities. Mean anthropometric indicators were higher in the preventive group as well: weight for age and weight for height by 0.24 Z scores. Height for age was higher by 0.14 Z scores in the preventive group, but this is not statistically significant. The preventive program showed greater effects for children given the full span of 6-23 months than children who were delivered therapy for a shorter period of time. The quality of each of the programs was not different, and the use of services for maternal and child health and nutrition were comparable.
In conclusion, the authors believe that the preventive program can yield more effective results: “This study shows, using a cluster-randomized 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.”
Howard White, Independent Evaluation Group, World Bank, Washington, DC, USA, wrote a Comment accompanying the article. He states that the study showed that a universal approach could be superior to a targeted one, and that randomized trials can be used for social programs in developing countries. That said, he also raises concerns about the experimental design of the study, specifically in the lack of a control group and that the researchers did not examine whether implementation differences explain the relative underperformance of the recuperative model.
Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial
Marie T Ruel, Purnima Menon, Jean-Pierre Habicht, Cornelia Loechl, Gilles Bergeron, Gretel Pelto, Mary Arimond, John Maluccio, Lesly Michaud, Bekele Hankebo
The Lancet, Vol. 371, Issue 9612, 16 February 2008, Pages 588-595
Written by Anna Sophia McKenney