Optimizing Community Health Worker Resources to Scale Child Nutrition Programs in Rural Pakistan

The two treatments or interventions were as follows:
HBGM: A CRP (Community Resource Person) installed the growth-poster inside the home, counseled the caregiver on how to use it to measure their child's height, and revisited the household once every month for one year to support the caregiver in measurement, and provided continued counseling on optimal nutritional practices, and recorded the anthropometric measurement in a booklet as an administrative record; and
HBGM-light: A CRP installed the growth-poster inside the home, counseled the caregiver on how to use it and on optimal nutritional practices during the first visit, followed-up with the mother the next month in a second visit to remind caregivers to regularly use the growth chart and reinforce their knowledge on how to use it. In addition to this, the first visit by the CRP was followed by automated voice calls every 2 weeks for the rest of the treatment period to remind the caregiver about using the poster, encouraging regular visits to the nearby health facility for height/weight measurement by a healthcare professional, and conveying key messages on best nutritional practices.

2023-05-01

2024-05-01

Height-for-age z-score (HAZ): This measures a child’s linear growth. It compares a child's height to the median height of a healthy reference population of the same age and sex, as established by the WHO Child Growth Standards (WHO 2006).
Stunting: Stunting is a binary outcome, taking on a value of 1 if the child’s height-for-age z-score is below -2.

Weight-for-height z-score (WHZ): This measures a child's body proportion or "wasting," indicating acute malnutrition. It compares a child's weight to the median weight of a healthy reference population of the same height and sex, as established by the WHO Child Growth Standards (WHO 2006).

Weight-for-age z-score (WAZ): This measures a child's overall body mass relative to their age, reflecting both acute and chronic malnutrition. It compares a child's weight to the median weight of a healthy reference population of the same age and sex, as established by the WHO Child Growth Standards (WHO 2006) for children 0-5 years.
Child Health History: Captures recent child health interventions and illness episodes in line with WHO (2006) child health indicators, including Vitamin A supplementation, deworming, iron intake, diarrheal prevalence and management (e.g., ORS, zinc), fever, and acute respiratory infection symptoms, as well as care-seeking behavior, treatment sources, timeliness, and medications used.
Underweight: Underweight is a binary variable, taking on a value of 1 if the child’s weight-for-age z-score is below -2.
Wasting: Wasting is a binary variable, taking on a value of 1 if the child’s weight-for-height z-score is below -2.

We proposed a cluster-RCT with households in rural Sindh testing two versions of home-based-growth-monitoring (HBGM) vis-a-vis a pure-control group (status-quo). The experimental arms and corresponding sample sizes were as follows, with the sample size for each cluster/village being ~15 children who were 6-18 months old at baseline. Total sampling frame consisted of 3000 children across 200 villages, while the actual sample size comprised 2848 children:
Control: 80 villages (1,200 children, 1129 sampled)
Treatment 1 – HBGM: 60 villages (900 children, 861 sampled)
Treatment 2 – HBGM-light: 60 villages (900 children, 858 sampled)

The context necessitated voice-calls instead of text messages due to the low levels of literacy among the study population (with over 90% of them having access to at least one mobile phone in the household [PLSM 2019-20]). While these interventions required in-person interactions between the CRPs and the caregivers, steps were taken to minimize potential transmission of COVID-19, such as using masks and hand sanitizers. Note, however, that the design of HBGM-lite significantly reduced the number of household visits, and evidence on its relative efficacy can therefore inform the design of similar policies in current and future pandemics. Finally, these innovations will be implemented in the areas of rural Sindh that are yet to be covered by the existing CRP-based programming.
Our intervention design attempted to address concerns around intra-household reallocation (for instance, from daughters to sons) in two ways. The poster had visuals highlighting the benefits of good nutrition to both boys and girls. The counseling emphasized that there is no difference in nutritional needs between the two genders. Moreover, a key objective of the counseling was to help caregivers understand the benefits of food of better quality (e.g., eggs vs. packaged foods/snacks that may cost the same), which would benefit all children in the household, irrespective of gender. Note that, as mentioned earlier, the national gender gap in stunting rates is minimal (1.1 pp higher for boys).

There were a total of 285 villages in our selected district as per the RSPN (our field partner) definition of a village.

We restricted the sample frame to villages that lay within +/- 1 SD of the mean values of the following selection criteria:
1. Average distance from a health facility within a village
2. Average proportion of households eligible for Benazir Income Support Program (BISP)
(The eligibility criterion to receive BISP support defined by the government is any household having a PMT score of less than 24)
3. Average number of households in a village

This was to ensure that we did not draw any village that was:
● Either too far away from the nearest health facility, OR
● Had extremely poor or extremely rich households, OR
● Had too few households to select from

Our sampling frame was thus restricted to 270 out of 285 villages, from which we randomly drew 200 villages for the study.

Village level

Yes

200 villages.
Control — 80 villages
Treatment 1 – HBGM: 60 villages
Treatment 2 – HBGM-light: 60 villages

2848

Control —1129 individuals
Treatment 1 – HBGM: 861 individuals
Treatment 2 – HBGM-light: 858 individuals