1. Community Action Research to Improve Nutrition and Growth in rural India CARING Delhi, March 2013

2. BACKGROUND OVERVIEW OF STUDY QUESTIONS FOR DISCUSSION OVERVIEW 2/30

3. In: Paul et al. Lancet India Series 2011 Data from IIPS - NFHS -3 (2005-6) Growth among children < 5 in NFHS-3 (2005-6) 3/30 BACKGROUND

4. 4/30 Growth among children < 3 in 36 clusters of Jharkhand and Odisha, 2010, n=3665 4/30

5. BACKGROUND 4/30 Growth among children < 3 in 36 clusters of Jharkhand and Odisha, 2010, n=3665 5/30

6. Immediate causes Basic causes Underlying causes Direct interventions: - Improved dietary intake for adolescent girls & mothers - Delaying the first pregnancy (>20 years) - Iron and calcium sup. for pregnant women - Antenatal care - Timely and exclusive breastfeeding - Timely, age-appropriate, hygienic complementary feeding - Illness prevention for children through: handwashing; immunisations.; Vitamin A; Iron; de-worming - Appropriate care during illness for children - Therapeutic feeding for children with SAM - Access to family planning for birth spacing Black et al. Lancet 2008 Sachdev HPS, World Bank Policy Brief 2011 India’s Expert Taskforce on Infant & Young Child Nutrition, 2009 DFID: The neglected crisis of undernutrition, 2009 Indirect interventions: - Support women ’ s education and empowerment - Increase access to safe water and sanitation - Support food security & sustainable livelihoods - Advocate for good nutrition governance BACKGROUND Consensus on interventions 12/30

7. p.293 RESTRUCTURING ICDS 2011 HIGH LEVEL EXPERT GROUP REPORT ON UNIVERSAL HEALTH COVERAGE FOR INDIA p.12 BACKGROUND Proposed policy changes 13/30

8. To develop and test a community intervention involving a facilitator modelled on a second (ICDS) Anganwadi worker to improve growth among children 0-18 months in two rural districts of Jharkhand and Odisha 14/30 CARING Research goal

9. To be useful… Bring attention to undernutrition in underserved areas through data-informed advocacy Be relevant to programmes and policy-makers by: -Documenting processes, costs and consequences of having a second AWW -Examining scalability 14/30 CARING The other goal… 15/30

10. CARING A two-pronged strategy HOME VISITSPARTICIPATORY GROUP MEETINGS Address immediate causes: Counseling for IYCF, illness prevention, and support for referrals Checking on growth monitoring and Mother Child Protection card milestones Begin to address underlying causes: Birth spacing, nutrition in pregnancy, WASH, women’s empowerment 16/30

11. Phase 1 Understanding Causes of Malnutrition, Inequities, discrimination and Rights and Entitlements Phase 3 Supporting frontline functionaries and resolving issues at local level Phase 2 Situational Analyses- Services, gaps Phase 4 Dialogue with service providers at blocks and district level- “Jan Samvad” CARING What about control areas? Meetings with Gram Vikas Samitys 22/30

12. CARING Research questions PRIMARY RESEARCH QUESTION What is 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? SECONDARY RESEARCH QUESTIONS 1.Does the intervention lead to improvements in feeding, infection control and caring practices for children 0-18 months? 1.Does the intervention lead to increases in food intake and dietary diversity for women during pregnancy and lactation? 2.What operational factors affect the intervention’s delivery and impact? 1.What are the potential scalability, operational requirements, cost and impact of the intervention beyond the trial area? 23/30

13. Design: Cluster-randomised controlled trial with 120 villages 60 villages will be randomly allocated to the intervention 60 villages randomly allocated to control Invite all mothers in third trimester of pregnancy in the 120 villages and their infants to join the study over a 12 months period Participants: cohort of 2520 mothers and children followed up in 3rd trimester of pregnancy, birth, 3, 6, 9, 12, and 18 months Process and economic evaluations: qualitative interviews with mothers and community health workers, and document reviews. CARING Study design 24/30

14. Primary outcome: length-for-age Z scores at 18 months Secondary outcomes: WHZ and WAZ at birth, 3, 6, 9, 12 and 18m Birthweight Infant mortality rate Dietary diversity & food intake for pregnant & lactating women Feeding, caring & infection control practices for children 0-18m Maternal empowerment and psyschosocial distress CBA knowledge of IYCF post-training CARING Evaluation indicators 25/30

15. Thank you