Effectiveness of SNF, Cash and BCC to Prevent Stunting Among Children 6-24 Months in Rahim Yar Khan, Pakistan

Effectiveness of a Programme Comprised of SNF, Cash-based Transfers and BCC to Prevent Stunting Among Children 6-24 Months in Rahim Yar Khan, Punjab, Pakistan

Malnutrition is a public health problem, with long-lasting physiological consequences and increased risk of morbidity and mortality. It can be recognized as one of the key obstacles in national development, due to its influence on individual productivity, school performance and physical work capacity. Malnutrition is a hidden crisis in Pakistan, with rates increasing during the last decade. High prevalence of food insecurity, illiteracy, lack of nutritional knowledge, poor hygiene status, and under recognized role of nutrition are some of the possible causes. The situation of malnutrition in Pakistan necessitates an urgent need for addressing its causes through various nutrition interventions, in order to ensure a bright future for the coming generations.

Although, malnutrition is a major problem across Pakistan, its burden and implications in the remote districts of Punjab are quite evident. The levels of undernutrition in district Rahim Yar Khan are high, with 47% of children being underweight. These numbers also highlight the presence of long-term undernutrition in the district, as evidenced by 45% of the children being stunted in 2014.

Given the alarming situation of child malnutrition in district Rahim Yar Khan, the World Food Program (WFP) Pakistan is proposing an intervention program comprised of cash-based transfers, specialized nutritious foods and behaviours change communication to prevent stunting in district Rahim Yar Khan, province Punjab. The interventions will be delivered through the existing health system and Benazir Income Support Programme (BISP). It is anticipated that the intervention will reduce the widespread macro and micro nutrient malnutrition and food insecurity in the targeted areas. Furthermore, to ensure the presence of adequate evidence to persuade policymakers for further scaling up, it is essential that an impact evaluation be conducted. Therefore, the Department of Paediatrics and Child Health, Aga Khan University (AKU) using robust methodologies on a representative sample size in the district of Rahim Yar Khan to assess the effectiveness of the WFP interventions on process and outcome indicators.

Study Overview

• Status: Completed
• Conditions: Stunting
• Intervention / Treatment: Other: Cash; Behavioral: Social and behaviour change communication (SBCC); Dietary supplement: SNF (Wawamum)

Detailed Description

Malnutrition is a public health problem, with long-lasting physiological consequences and increased risk of morbidity and mortality. It can be recognized as one of the key obstacles in national development, due to its influence on individual productivity, school performance and physical work capacity. Malnutrition is a hidden crisis in Pakistan, with rates increasing during the last decade. High prevalence of food insecurity, illiteracy, lack of nutritional knowledge, poor hygiene status, and under recognized role of nutrition are some of the possible causes. The situation of malnutrition in Pakistan necessitates an urgent need for addressing its causes through various nutrition interventions, in order to ensure a bright future for the coming generations.

The second Lancet Series on Maternal and Child Under-nutrition (2013) and the Scaling-Up Nutrition (SUN) Initiative give some recommendations on selected effective approaches for the management and prevention of under-nutrition, such as breastfeeding counselling or micronutrient supplementation, but evidence gaps still remain, particularly concerning indirect interventions. The World Health Organization highlighted in 2010 the need to consider prevention strategies when implementing programs aiming at reducing stunting rates. There is also evidence showing that preventive programs, such as supplementation, can be more effective to reduce childhood under-nutrition than nutrition rehabilitation. Reviews on cash transfer experiences show that this type of intervention has the potential to prevent undernutrition. However, most of the cash transfer programs implemented and scientifically evaluated do not have a clear nutritional objective, which leads to inconclusive evidence regarding their nutritional benefits.

Although, malnutrition is a major problem across Pakistan, its burden and implications in the remote districts of Punjab are especially evident. The levels of undernutrition in district Rahim Yar Khan are high, with 47% of children being underweight. These numbers also highlight the presence of long-term undernutrition in the district, as evidenced by 45% of the children being stunted in 2014.

Given the alarming situation of child malnutrition in Rahim Yar Khan district, the World Food Programme (WFP) Pakistan is proposing an intervention programme comprised of cash-based transfers, specialized nutritious foods and behavior change communication to prevent stunting in Rahim Yar Khan district, Punjab province. The interventions will be delivered through the existing health system and the social protection programme, Benazir Income Support Programme (BISP). It is anticipated that the intervention will reduce the widespread macro and micro nutrient malnutrition and food insecurity in the targeted areas. Furthermore, to ensure the presence of adequate evidence to persuade policymakers for further scaling up, it is essential that an impact evaluation be conducted. The study will be conducted by the Aga Khan University (AKU) using robust methodologies on a representative sample size in the district of Rahim Yar Khan. This document will describe the methods and strategies that AKU will employ to assess the effectiveness of the interventions on process and outcome indicators.

• Study Type: Interventional
• Enrollment (Actual): 2179
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Punjab
    • Rahim Yar Khan, Punjab, Pakistan, 64200
      • Tehsil Rahim Yar Khan

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 9 months to 8 months (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. BISP beneficiary for intervention arms and poverty score between 16.18 - 20.00 according to the BISP approach for control group;
2. Living in the catchment area of LHW;
3. Have at least one child of 6-7 months old at the time of inclusion, and;
4. Willing and able to provide written informed consent for the study.

Exclusion Criteria:

1. Non BISP households
2. Planning to migrate form the study area in next 18 months
3. Unable to provide written informed consent
4. Children with severe malnutrition and/or chronic illness

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: None (Open Label)

Number of Arms

5

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control; Receiving current Government of Punjab health services
Experimental: Cash-based transfers; Cash-based transfers only by BISP	Other: Cash; Cash totaling 1600 rupees per month will be transferred by BISP throughout the study period.
Experimental: Cash with SBCC; Cash-based transfers and Social & behaviour change communication (SBCC)	Other: Cash; Cash totaling 1600 rupees per month will be transferred by BISP throughout the study period.; Behavioral: Social and behaviour change communication (SBCC); SBCC messages will be delivered by LHWs in their monthly routine household visits. Male and female group sessions will be arranged on quarterly basis with the help of health committees.
Experimental: Cash with SNF (Wawamum); Cash-based transfers and SNF (Wawamum)	Other: Cash; Cash totaling 1600 rupees per month will be transferred by BISP throughout the study period.; Dietary supplement: SNF (Wawamum); A monthly ration of 30 sachets of SNF (one 50 gram sachet of Wawamum per child per day) will be provided by LHWs. Each recruited child will receive SNF on a monthly basis for the duration of 18 months during his/her age of 6-24 months.
Experimental: Cash,SNF (Wawamum) & SBCC; Cash-based transfers, SNF (Wawamum) and SBCC	Other: Cash; Cash totaling 1600 rupees per month will be transferred by BISP throughout the study period.; Behavioral: Social and behaviour change communication (SBCC); SBCC messages will be delivered by LHWs in their monthly routine household visits. Male and female group sessions will be arranged on quarterly basis with the help of health committees.; Dietary supplement: SNF (Wawamum); A monthly ration of 30 sachets of SNF (one 50 gram sachet of Wawamum per child per day) will be provided by LHWs. Each recruited child will receive SNF on a monthly basis for the duration of 18 months during his/her age of 6-24 months.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Reduction in stunting	10% reduction in stunting in children	18 months
SBCC package on the basis of formative research	SBCC package will be developed on the basis of formative research	3 months
Cost-effectiveness of intervention packages for prevention of stunting in children	Cost effectiveness analysis will run through the full three years of the program cost	18 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Weight gain in kilograms	Child weight in kilograms will be measured on monthly basis	18 months
Length gain in centimeters	Child length in centimeters will be measured on monthly basis	18 months
Impact of the intervention on micronutrient deficiencies	Impact of the intervention on micronutrient deficiencies will be measured at 24 months by biochemical analysis	At 24 months of age
Improvement in IYCF practices	Improvement in IYCF practices will be measured from monthly follow-up data	18 months
Improved nutrition, hygiene and health related knowledge and practices	Improved nutrition, hygiene and health related knowledge and practices will be measured from endline KAP data	18 months
Proportion of households with moderate or severe hunger (food insecurity)	Food insecurity will be measured from baseline and endline data	18 months
Uptake of health services and interventions	Uptake of health services and interventions will be measured from baseline and endline data	18 months

Collaborators and Investigators

• Sponsor: Aga Khan University
• Collaborators: Benazir Income Support Programme (BISP); Department of Health, Government of Punjab; World Food Programme (WFP)
• Investigators: Principal Investigator: Sajid B Soofi, FCPS, MBBS, Aga Khan University

Publications and helpful links

General Publications

• Soofi SB, Ariff S, Khan GN, Habib A, Kureishy S, Ihtesham Y, Hussain M, Rizvi A, Sajid M, Akbar N, Garzon C, de Pee S, Bhutta ZA. Effectiveness of unconditional cash transfers combined with lipid-based nutrient supplement and/or behavior change communication to prevent stunting among children in Pakistan: a cluster randomized controlled trial. Am J Clin Nutr. 2022 Feb 9;115(2):492-502. doi: 10.1093/ajcn/nqab341.
• Khan GN, Kureishy S, Ariff S, Habib MA, Usmani AA, Mubarik A, Hussain M, Akbar N, Rodriguez de Castro P, Garzon AC, de Pee S, Soofi SB. Specialized Nutritious Food Combined With Cash Transfers and Social and Behavior Change Communication to Prevent Stunting Among Children Aged 6 to 23 Months in Pakistan: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc. 2020 Aug 24;9(8):e19001. doi: 10.2196/19001.

Study record dates

Study Major Dates

• Study Start (Actual): May 26, 2017
• Primary Completion (Actual): July 31, 2019
• Study Completion (Actual): July 31, 2019

Study Registration Dates

• First Submitted: August 12, 2017
• First Submitted That Met QC Criteria: September 27, 2017
• First Posted (Actual): October 3, 2017

Study Record Updates

• Last Update Posted (Actual): March 19, 2020
• Last Update Submitted That Met QC Criteria: March 18, 2020
• Last Verified: March 1, 2020

More Information

Terms related to this study

• Keywords: Specialized Nutritious Food (SNF); Social and Behaviour change communication (SBCC); Cash-based transfers
• Additional Relevant MeSH Terms: Pathologic Processes; Growth Disorders
• Other Study ID Numbers: CBT Study Rahim Yar Khan

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No