Prevention or Cure? Comparing Preventive and Recuperative Approaches to Targeting Maternal and Child Health and Nutrition Programs in Rural Haiti

This 15-page document is an executive summary of a paper (later published under a different title in The Lancet journal) comparing strategies for reducing child malnutrition in Haiti through targeting food assistance and behaviour change communication (BCC). The research, initially conceived by the Food and Nutrition Technical Assistance (FANTA) Project, Academy for Educational Development (AED), was conducted by the International Food Policy Research Institute and Cornell University in the context of a 5-year development programme implemented by World Vision in the Central Plateau region of Haiti. The research was supported by the United States Agency for International Development (USAID), the United Nations World Food Programme (WFP), and the German Agency for Technical Cooperation (GTZ). In short, the study demonstrated that a preventive approach to food-assisted nutrition programmes is more effective in reducing child malnutrition than a recuperative approach. (In preventive approaches to food-assisted maternal and child health and nutrition programmes, food is provided to all children 6-24 months in areas with a high prevalence of malnutrition, whereas in recuperative approaches, food is used to rehabilitate children (typically those under age 5) already suffering from moderate malnutrition.) In both groups, pregnant and lactating women were also eligible to participate in the programme (until the 6th month of lactation). Researchers found that indicators of malnutrition - stunting, wasting, and underweight - were 4 to 6 percentage points lower in communities that participated in preventive programmes, compared with those that received a recuperative approach.

The evaluation used a community-level, cluster-randomised pre-post design, whereby 10 paired clusters of communities were randomly assigned to either the preventive or the recuperative programme group. To receive the food benefits, all eligible children in both programme groups were required to be present on a regular (monthly) basis at Rally Posts (which provide preventive health care services), Mothers' Clubs (MCs) (which are small peer group education sessions), and food distribution sessions (also monthly). Pregnant and lactating mothers were expected to attend pre- and post-natal consultations, also on a monthly basis. The MCs were the mainstay of the BCC strategy used by both programme approaches. The sequencing of MC sessions was age-based in the preventive approach and mothers attended a maximum of 18 monthly sessions (every month when the child was between 6 and 24 months of age), while in the recuperative approach, the session topics were chosen to be relevant for mothers of malnourished children, and 9 monthly sessions were offered (as per design of recuperative programme). Health staff who facilitated the MCs were trained in the technical content of the MC sessions as well as in adult education-based communication and facilitation skills. One of the authors explains that, "with a preventive focus, the message is that they have to fight malnutrition instead of seeing it as a benefit, because the criteria for admission is no longer malnutrition. The message is much more positive, and the earlier intervention gives us more time to educate them in healthier behaviors and about better nutrition."

Cross-sectional surveys were conducted to assess the prevalence and severity of undernutrition among children 12-41 months of age at baseline and 3 years later, and statistical methods for analysing group randomized designs were applied to evaluate impact. At endline, the adjusted prevalence of stunting, underweight, and wasting among children 12-41 months in preventive areas was 33.9%, 14.8%, and 3.7%, respectively, whereas in recuperative communities, it was 38.2%, 20.8%, and 7.4%, respectively. Mean height-for-age, weight-for-age, and weight-for-height scores were also significantly higher in the preventive compared to the recuperative programme communities at the end of the study. There were no differences between the groups at baseline.

The executive summary continues with a multidimensional look at the impact of these different strategies. For instance, one section of the paper details the impact on child feeding and care practices, noting that the final survey included an assessment of the awareness, trial, and adoption of 7 key practices recommended by the programme. The evaluators found that, "[f]or most key practices, respondents in preventive program areas were more likely to report awareness, trial and adoption than were respondents in recuperative areas...probably as a result of their longer exposure to the BCC intervention and the more timely delivery of the messages (i.e., at the age when knowledge and adoption of specific practices was most relevant)." That said, the authors conclude that "[a] well-designed and well-implemented behavior change strategy can improve infant feeding practices regardless of whether a preventive or recuperative approach is used..." One communication-focused insight to emerge for future research and programming is that "the role of limited food and economic resources in dampening the potential impact of BCC programs in impoverished contexts should be kept in mind."

Click here to access the full Executive Summary in PDF format. Please contact FANTA at the address listed below to request the complete evaluation. Also, the following free (with free registration) Lancet article examines the same evaluation: "Age-based Preventive Targeting of Food Assistance and Behaviour Change and Communication for Reduction of Childhood Undernutrition in Haiti: A Cluster Randomised Trial" (February 2008).