Prevention is Better than Cure:An Example of MCHN Programming in Haiti

Marie T RuelIFPRI

Collaboration between IFPRI, Cornell University, World Vision-Haiti

Support: USAID through FANTA/AED, World Vision-Haiti, Govt. of Germany, World Food

Programme

Background

• Food-assisted MCHN programs typically target underweight children < 5 y

• In spite of evidence that 1st 2 years is the « window of opportunity » for nutrition interventions

• Missing: programmatic evidence that targeting children < 2 y is effective in undernutrition

Main objective of the study:

Compare impact on childhood undernutrition of 2 approaches of targeting FA-MCHN programs:

The recuperative approach: targets underweight children < 5 y (WAZ < -2 SD)

The preventive approach: targets all children 6-24 months of age to prevent undernutrition

*Both program models also target pregnant/lactating women

The Context: FA-MCHN (WV-Haiti)

-Rally Posts-Mothers’ Clubs

- Pre/post natal clinics- Mothers’ Clubs

Food distribution points

* Home visits are also scheduled for severely malnourished children and mothers soon after delivery

PREG/LACTATING WOMENCHILD BENEFICIARIES

Rally Posts

Identification of beneficiariesPrimary health care & nutrition services

Eligible to receive food at:

Differences between Program Models

Preventive Recuperative

Eligibility:

-ALL 6-23 mo

-24-59 mo, malnourished (WAZ < -3)

- 6-59 mo, malnourished (WAZ < -2)

Duration in program, focus, timing

-Duration (for child): 18 sessions

-Focus: prevention

-Timing of education: age-specific

-Duration (for child): 9 sessions

-Focus: malnourished child

-Timing: when child malnourished

Commodity Children 6-24 mo or malnourished <5 years

Pregnant/lactating women

Direct ration (kg)

Indirect ration (kg)

Direct ration (kg)

Indirect ration (kg)

WSB 8      

SFB   10 5 5

Lentils   2.5 2 2

Oil 2   1.5 1.5

WSB=Wheat-soy blend; SFB=Soy-fortified bulgur; oil is fortified with vitamins A & E

Food Assistance Package

20 clusters of communities,

10 Recuperative

752 children

10 matched pairs of clusters

Intervention

Cross-sectional baseline survey

Cross-sectional final survey

10 Preventive

788 children

748 children

PR

OG

RA

M

A

LLO

CA

TIO

NIM

PA

CT

AS

SE

SS

ME

NT

Trial Profile: Cluster Randomized Trial

792 children

Survey data

• Anthropometry – children and mothers

• Community characteristics• Household demographics,

socioeconomic status, food security

• Maternal characteristics• Behavior change outcomes• Program participation

Baseline Characteristics (2002): No differences between groups

Characteristic Preventive (n=788)

Recuperative (n=792)

Stunting (%) 36.7 37.4

Underweight (%) 17.6 17.8

Wasting (%) 5.2 4.3

Maternal height 158.0 158.0

% women farming 42.0 43.0

HH size 6.7 6.8

% sanitation 56.0 57.0

% electricity 2.0 2.0

Using WHO 2006 standards

Preventive communities had better anthropometry than

recuperative at final survey

Outcome (final survey)

Preventive (n=752)

Mean

Recuperative (n=748 )

Mean

Difference (preventive – recuperative)

HAZ -1.53 * -1.67 + 0.14

WAZ -0.96* -1.20 + 0.24

WHZ -0.22* -0.46 + 0.24

*p<0.05; random effects regression using child-level data, controlling for childage, gender, and adjusting for clustering at pair-level

Preventive communities had lower stunting, underweight & wasting than

recuperative at final survey

0

10

20

30

40

Stunting Underweight Wasting

%

Baseline combined Recuperative final Preventive final

4pp

6pp

4pp

Household food security is higher in preventive than recuperative communities at final survey

6.5

7

7.5

8

8.5

9

9.5

HH food insec scale No mo food inadequacy

Baseline Preventive Recuperative

*

*

Impact on Food Security

Experiences of severe food insecurity, by program group

To bed hungry Kids to bed hungry

Pe

rce

nta

ge

of h

ou

se

ho

lds

0

20

40

60

80

100

Baseline (both)Preventive, finalRecuperative,final*

*

Impact on Food Security

*

*

Months of HH food insufficiency, by program group and current participation

Program group

preventive recuperative

Mo

nth

s o

f H

H f

oo

d in

suff

icie

ncy

0.00.5

5.0

5.5

6.5

7.0

7.5

8.5

9.0

9.5

1.0

6.0

8.0

10.0

Non-participant HHCurrently participating

**

Conclusions

Blanket age-targeting (preventive) of FA-MCHN is more effective at reducing undernutrition than targeting underweight children (recuperative)

Differences in favor of preventive group were 4, 6 and 4 pp in stunting, underweight, wasting

Before/after comparisons suggest some deterioration in undernutrition in recuperative communities (plausible given economic & political crisis in Haiti)

Comparing our sample with DHS surveys 2000 and 2005

(NCHS standards)

0

5

10

15

20

25

30

35

40

Stunting Underweight Wasting

DHS 2000 baseline final prev final rec DHS 2005

Prevalences used for EMMUS 2005 are for all kids < 5 y in Central Department

DHS 2000

DHS 2005

Bas

elin

e

Pre

ven

tive

fin

al

Re

cup

era

tive

fin

al

DHS 2000

DHS 2005

DHS 2000

DHS 2005

Pre

ven

tive

fin

al

Re

cup

era

tive

fin

al

Ba

selin

e

Conclusions (2)

Both programs helped mitigate the crisis, but preventive was more effective at doing so

Benefits of preventive model are not due to differences in implementation and organizational conditions, nor in program use

The Sprinkles Study

• Add-on research study to:– Evaluate feasibility of distributing Sprinkles with

food aid rations in context of MCHN program

– Evaluate effectiveness in reducing anemia among 6-24 month old children

• Design: – Randomized, pre-post intervention with control

group (receiving fortified WSB only)

– Sample size: 261 (S+WSB); 161 (WSB)

How to use the SprinklesSPRINKLES

Vitamin ak lòt fòtifyanPou mete nan manje

Pa itilize l si sachè a dechire ou domaje. Konsève l nan yon kote ki sèk.

Chak 1.0g gen :__________________Vitamin A 300µgVitamin C 30mgAcide Folique 160µgFer 12.5mgZinc 5mg

Ingrédient non médicinal Maltodextrin

Dosaj: Itilize yon sachè chak jou. Melanje yon ti sachè ak yon ti kantite manje jis avan ou sèvi manje a.

Manufacturé par PED-MED LtdToronto en Canada MSP 2x9

www.pedmed.org Ped-MedItilize l avan janvye 2007.

Dosage and Frequency

Composition:• 12.5 mg of Fe• 5 mg Zn• 400 mcg Vitamin A• 160 mcg Folic Acid• 30 mg Vitamin C

Frequency:• 1 sachet per day• 30 sachets per month for 2 months

Distribution Method

Program Food Distribution Points:• With monthly distribution of food aid

commodities• 2 pre-packaged bags of 15 sachets/month• On two consecutive months

Education on how to use them – at Mother’s Clubs

Prevalence of anemia (Hb<10 g/dL) at baseline and endline, by treatment

%

Changes in anemia prevalence by age group

Age at baseline (mo)

6-8.9 9-11.9 12-14.9 15 -17.9 18-20.9

Ch

an

ge

in

an

em

ia p

reva

len

ce

(pe

rce

nta

ge

po

ints

)

-40

-30

-20

-10

0

10

20

30

40 S-WSBWSB

Conclusions Including Sprinkles distribution in MCHN-food

assisted project is feasible Existing program venues (MC and FDP) are

appropriate Good acceptance and appreciation by mothers

and staff Compliance was very high; mothers understood

how to use Sprinkles; and used them as instructed

Impact on reducing anemia is large and maintained 7 mo later