depending on the age, both interventions have significant positive effects on HAZ and WHZ, up to a maximum of roughly 0.2 standard deviations.<sup>48</sup> Measuring children at four years of age in a follow-up study, Yousafzai et al. (2016) find that both interventions have insignificant effects on stunting, wasting, and underweight status.<sup>49</sup> Two studies examine the effects of nutrition counseling and micronutrient supplementation, under a ground-level operational arrangement that mirrors the LHW program. Khan, Rafique, Qureshi, and Badruddin (2013) examine a nutrition counseling intervention delivered by community workers to mothers at two sites in Balochistan and Sindh under an Aga Khan University Early Childhood Development program. The nutrition counseling was customized to each household, based on an assessment of child feeding patterns. Measured before and after the three-month intervention, the study finds that the wasting rate for young children fell from 19% to 7% in the Sindh site, and from 18% to 16% in the Balochistan site (the study does not test the statistical significance of the declines). The study also finds significant improvements in child feeding taking the form of more meals per day, and, depending on the site, the increased intake of plant protein, diary, vegetables, or fruit.

Soofi et al. (2013) examine the effects of providing micronutrient powder packets with and without zinc to households in a Karachi urban squatter settlement and rural district in Sindh, under a parallel experimental design. In all evaluation groups (control, powder packets without zinc, and powder packets with zinc), recruited community health workers provided counseling on breastfeeding, complementary feeding using locally available foods, and the treatment of diarrhea. All powder packets contained iron, folic acid, and vitamins A, C, and D. In the intervention groups, the powder packets were regularly distributed to households by the community health workers for a period of 12 months for children six to 18 months of age. Children were tracked until they attained 24 months of age. The study finds that the micronutrient supplementation interventions have a significant negative effect on iron-deficiency anemia. However, depending on the followup child age and the specific intervention, the interventions have either insignificant effects or significant positive effects on reported recent status of acute respiratory infection symptoms, diarrhea, or fever. The interventions also generally have insignificant effects on stunting, wasting, and underweight status.

Other studies have examined more general institutional and environmental factors associated with LHW performance. Measured by a score that captures the extent of core services delivered by such workers, OPM (2009) finds that their performance is positively associated with experience, hours worked, LHS supervision, district health administration engagement, district LHW workforce size, and the presence of women’s health committees.

> 48 The study also finds that, measured at 12 and 24 months of age, the stimulation intervention has significant positive effects on cognitive, language, socioemotional, and motor development, whereas the nutrition intervention has significant positive effects on cognitive, language, and socioemotional development. Gowani et al. (2014) find that both interventions are cost-effective, in relation to cognitive, socioemotional, and motor development outcomes. 49 The study also finds that the stimulation intervention had significant positive effects on cognitive ability and socioemotional and motor development, while the enhanced nutrition intervention had a significant positive effect on prosocial behaviors and motor development.

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