Effectiveness of SNF, Cash and BCC to Prevent Stunting Among Children 6-24 Months in Rahim Yar Khan, Pakistan
Condition: Stunting
MeSH terms: Growth Disorders
Study type: Interventional

Summary: 
      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.
    

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.
    

Intervention name(s): SNF (Wawamum); Social and behaviour change communication (SBCC); Cash
Intervention type(s): Dietary Supplement; Behavioral; Other
Intervention description(s): 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.; 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.; Cash totaling 1600 rupees per month will be transferred by BISP throughout the study period.
Allocation: Randomized
Intervention model: Factorial Assignment
Intervention model description: Control Group
Cash-based transfers only by BISP
Cash-based transfers and Social & behaviour change communication (SBCC)
Cash-based transfer and SNF
Cash-based transfers, SNF and SBCC
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Specialized Nutritious Food (SNF); Social and Behaviour change communication (SBCC); Cash-based transfers