1. Tubaramure, a food-assisted integrated health and nutrition program in Burundi improves maternal and child hemoglobin levels and reduces anemia: a theory-based cluster-randomized controlled intervention trial
Jef L Leroy, Deanna Olney, Marie Ruel - IFPRI
Micronutrient Forum, Cancun • October, 2016

2. PM2A Preventing Malnutrition in children under 2 years of Age
First 1,000 days
Three components:
Food rations:
Household ration + individual ration (pregnant/lactating woman and child mo)
Health services:
Antenatal care, postnatal care, immunizations, micronutrient supplementation, other preventive/curative health and nutrition services
Behavior change communication (BCC):
Care and feeding practices, hygiene, and health practices
USAID FFP issued programming guidelines on preventive approach (PM2A) in 2009; approved funds for implementation + research in Burundi/Guatemala
Photo credit: Meghan Parker

3. Two studies: Guatemala and Burundi

4. Background: Burundi
Burundi is one of the world’s poorest countries (UNDP 2013)
81% of the population lives on < $1.25/day (World Bank, 2011); > 60% is food insecure
Region where study was carried out (central-eastern), high stunting (62%) (DHS 2010)
Country has been suffering from severe political and economic instability for decades

5. Background Food-assisted MCHN programs: Anemia in Burundi:
Widely used in low and middle income countries to alleviate the persistent problems of maternal and child undernutrition.
Evidence of their impact on maternal and child health and nutrition outcomes is scant, especially so for anemia.
Anemia in Burundi:
In 2011 the prevalence of anemia among pregnant women and children under five were estimated at 31 and 47 %, respectively.   
Given the size of the problem and the multiple causes of anemia that Tubaramure addresses (promotion of bednet use, utilization of health services, provision of CSB, etc.), a reduction of the prevalence of anemia would be expected.

6. Objectives
Estimate the impact of Tubaramure on Hb and anemia among children aged 0 to 23.9 mo and their mothers.
Explore the pathways of impact.

7. Study setting

8. Intervention package Study Arms Family food ration (monthly) CSB, kg
3 Treatment Groups
Control
Family food ration (monthly)
CSB, kg
12.0 –
Vegetable oil, kg
1.2
Individual food ration (monthly)1
6.0 / 3.0
0.6 / 0.3
BCC (care groups; meet twice/month)
Yes
Access to government health services
1Values are for pregnancy & first 6 mo of lactation / 6 to 23.9 mo old children

9. Design cRCT with 2 cross-sectional surveys (2010-2012)
Impact analysis: double difference colline-fixed effect model, controlling for potential confounding factors:
Controls for possible differences between groups at baseline
Standard errors adjusted for clustering.

10. Analytic approach Step 1: impact on final outcomes of interest
Step 2: impact on intermediary behaviors & practices
Step 3: dose-response analysis
Tubaramure
Child and maternal Hb and anemia
Tubaramure
Intermediary outcomes (diet, bednets, etc)
Intermediary outcomes (diet, bednets, etc)
Child and maternal Hb and anemia

11. Baseline characteristics (0-23.9 months)
Full sample
Study arm
Treatment
Control N
2,622
1,733
889
Household
Size
5.6±2.0
5.5±2.0
Head has no education/preschool, %
40.3
39.6
41.6
Head farms, %
76.3
75.4
78.0
Mother
Age, y
28.6±7.0
28.7±7.0
28.3±7.1
Has no education/preschool, %
51.8
50.8
53.7
Child
Age, m
12.8±6.8
12.6±6.8
13.2±6.8
Stunted, %
53.3
56.1
Wasted, %
7.2
7.5
6.7
Data are mean±SD unless otherwise specified. * Significantly different (p<0.05) between study groups.

12. Child hemoglobin (0-23.9 months)

13. Child hemoglobin (0-23.9 months)* *
* Different from 0, P<0.05

14. Other impacts in children (0-23.9 mo)
Outcome
Impact
Significant?
Infant and young child feeding (last 24 h)
Consumed CSB, %
43.5±3.1 *
Minimum dietary diversity (with CSB), %
11.2±3.7
Minimum dietary diversity (without CSB), %
7.0±4.1
Consumed Fe-rich foods (with CSB), %
35.0±3.4
Consumed Fe-rich foods (without CSB), %
2.4±2.6
Minimum meal frequency, %
12.9±3.9
Bed net use (last 24 h)
All, %
2.2±4.3
0 to 5.9 mo, %
23.0±5.9
6 to 23.9 mo, %
-2.8±4.4
Morbidity (last 2 wk)
Any illness, all, %
-9.4±3.4
Fever, all, %
-10.8±2.9
Data are estimated impact ± SE

15. Pathways of impact children (0-23.9 mo)
Consumed CSB
Minimum dietary diversity
Consumed Fe-rich foods
PM2A
Minimum meal frequency
Child hemoglobin
Bed net use
Illness
Fever

16. Conclusions
Using a large scale cluster-randomized controlled effectiveness trial:
We demonstrate impact of a food-assisted MCHN program on child and maternal (not shown) hemoglobin and anemia.
We demonstrate impact on intermediary variables (diet, morbidity, bed net use), which suggests plausible pathways of impact.
Marked increase in anemia (women and children) from baseline to follow-up is of great concern.
Findings suggest that food-assisted MCHN programs can protect poor families from economic or health shocks in vulnerable countries such as Burundi.

17. Acknowledgements
The research took place within the USAID FFP-funded Tubaramure program, led by Catholic Relief Services in consortium with Food for the Hungry, International Medical Corps, and Caritas Burundi. We thank the consortium partners for overseeing and implementing the program and for their collaboration with the research teams and processes.
Sources of financial support:
The study was made possible by the generous support of the American people through the support of the Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, and the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID), under terms of Cooperative Agreement No. AID-OAA-A , through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360.
This study also received support from the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by IFPRI