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BRIEF May 30, 2019

SPRING: Linking Implementation Strength, Outcomes and Lessons Learned to Inform Scale Up

India and Pakistan both have an enormous number of children at risk for poor development because of malnourishment and lack of appropriate stimulation when they are young. The Sustainable Program Incorporating Nutrition and Games, or SPRING, uses home visits by community-based health workers to improve development. In both countries, SPRING is being implemented in concert with government programs that support child development, and the results of the evaluations will help policymakers better understand what is effective and scalable.

Research Area:     Early Childhood Nutrition, Development, and Health
Country:India and Pakistan
Evaluation Sample:6,000 mothers and children 
Timeline:    24-month intervention from 2014-2016
Intervention:  Monthly home visits
Researchers: Neha Batura, Gauri Diwan, Zelee Hill, Betty Kirkwood, Ildo Jose Lautharte Junior, Shamsa Rizwan , Reetabrata Roy, Jolene Skordis, Seyi Soremekun
Partners:         London School of Hygiene and Tropical Medicine; University of Liverpool, UK; University College London; Human Development Research Foundation, Pakistan; Sangath, India; Ministry of Health, Pakistan, Health Services Academy, Pakistan, the Lady Health Worker Programme, Pakistan; Wellcome Trust


India and Pakistan both have millions of children at risk of not reaching their developmental potential because of malnourishment and lack of appropriate stimulation and learning opportunities. India alone is home to more than 40 million stunted children under age 5 and despite some improvement, child undernutrition rates in India are among the highest in the world. In Pakistan, one-third of all children are underweight, nearly 44 percent are stunted, 15 percent are wasted, and about half are anemic.


The Sustainable Program Incorporating Nutrition and Games (SPRING) program is a home visiting program for pregnant women and children in their first two years of life, where community workers work with families to promote better child care practices related to infant and young child feeding and mother-child interaction and play and to encourage family support and involvement.

Evaluation design

This evaluation has been set up as a cluster randomized control trial. In India, the 24 clusters consist of catchment areas of health subcenters, randomly assigned to 12 treatment subcenters and 12 control subcenters. In Pakistan, the 20 clusters are union councils, randomly assigned to 10 treatment councils and 10 control councils. Researchers in India and Pakistan are evaluating the impact of the program on the home environment, child growth and development.


Pregnant women and women with children under age two.


The results will be available in 2019.

Next steps

The Government of India currently is exploring how they can better use community-based workers to improve child development and the team hopes to present the results when the analysis is complete to provide new information to the government. Likewise, in Pakistan, where early childhood development is a priority for the government, the research team expects to present findings to the government to encourage use of the results.



Prize for best research presentation at the Academic Pediatrics Association of Great Britain and Ireland Annual Meeting in Dublin to Sunil Bhopal for “SPRING and the potential contribution of early life stress to understanding the SPRING causal pathway” (March 2017)