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: | Bilal Avan, Neha Batura, Sunil Bhopal, Gauri Diwan, Lu Gram, Assad Hafeez, Zelee Hill, Betty Kirkwood, Raghu Lingam, Atif Rahman, Shamsa Rizwan, Reetabrata Roy, Siham Sikander, 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 |
Problem
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.
Intervention
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. In Pakistan, SPRING was embedded into existing monthly home visits of Lady Health Workers (LHWs). In India, it was delivered by a civil society/non-governmental organisation (CSO/NGO) that trained a new cadre of Community Workers.
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.
Eligibility
Pregnant women and women with children under age two.
Results
1,443 children in India were assessed at age 18 months and 1,016 in Pakistan. There was no impact in either setting on ECD outcomes or growth. The percentage of children in the SPRING intervention group who were receiving diets at 12 months of age that met the WHO minimum acceptable criteria was 35% higher in India (95% CI: 4–75%, p = 0.023) and 45% higher in Pakistan (95% CI: 15–83%, p = 0.002) compared to children in the control groups.
Implementation was sub-optimal in both settings. In Pakistan issues were low field-supervision coverage and poor visit quality related to issues scheduling supervision, a lack of skill development, high workloads and competing priorities. In India, issues were low visit coverage - in part due to employing new workers and an empowerment approach to visit scheduling. Coaching caregivers to improve their skills was sub-optimal in both sites, and is likely to have contributed to caregiver perceptions that the intervention content was not new and was focused on play activities rather than interaction and responsivity - which was a focus of the coaching. In both sites caregiver time pressures was a key reason for low uptake among families who received visits.
Implication of findings
Important lessons were learnt. Integrating additional tasks into the already overloaded workload of CWs is unlikely to be successful without additional resources and re-organisation of their goals to include the new tasks. The NGO model is the most likely for scale-up as few countries have established infrastructures like the LHW programme. It will require careful attention to the establishment of strong administrative and management systems to support its implementation.
