Effect of Participatory Women's Groups and Counselling through Home Visits on Children's Linear Growth in Rural Eastern India (CARING Trial): A Cluster-Randomised Controlled Trial

"A pragmatic approach to design community strategies for stunting reduction might...be to prioritise action on immediate determinants...while providing an enabling social environment for changes in more distal determinants, for example by sharing information about health, nutrition, and sanitation entitlements, and bolstering women's agency."

Around 30% of the world's stunted children live in India. Aware that interventions to promote children's growth in high-burden settings have the potential to increase survival and school attainment, offer protection against adult chronic disease, and bolster human development, the Government of India proposed a new cadre of community-based workers to improve nutrition in 200 districts. This cluster-randomised controlled trial (RCT) aimed to find out the effect of such a worker carrying out home visits and participatory group meetings on children's linear growth in rural Jharkhand, where 48% of children younger than 5 years are stunted, and rural Odisha, where 35% in rural Odisha, in eastern India.

In two adjoining districts of Jharkhand and Odisha, 120 clusters (around 1,000 people each) were randomly allocated to intervention or control using a lottery. In the intervention arm, the researchers recruited 60 new female community-based workers called Su-Poshan Karyakarta (SPK), meaning good nutrition worker, in consultation with local village health sanitation and nutrition committees and existing Anganwadi workers. Each SPK worked in her own village and any nearby hamlets, and covered around 1,000 people. SPKs and supervisors received 14 days of training during the intervention period and attended supervision meetings twice a month.

The SPK was responsible for two main activities: (i) conducting a single home visit to each pregnant woman in the third trimester of pregnancy for counselling on maternal nutrition, followed by monthly home visits to all children younger than 2 years with counselling for growth promotion; and (ii) facilitating 2-3 participatory meetings with local women's groups per month that reinforced actions linked to immediate causes of undernutrition. These meetings were primarily intended for pregnant women and mothers of children younger than 2 years and adolescent girls, but they were open to all community members. The groups followed a 4-phase participatory learning and action cycle in which they: (i) assessed the health and nutrition situation in their community, guided by picture cards; (ii) decided on actions to take after listening to stories created by the SPKs using local themes; (iii) took action, such as enhancing the density and diversity of complementary foods using local products and toy-making for children; and (iv) evaluated the process.

In both intervention and control clusters, the implementing local civil society organisation Ekjut held 5 participatory meetings with village health sanitation and nutrition committees in between the committees' regular monthly meetings for 2 years. Meetings aimed to strengthen the capacity of village health sanitation and nutrition committees to assess community health needs, prepare and implement village health plans, and monitor the provision of local health and nutrition services. This was the only activity implemented in control clusters besides routine government services.

Between October 1 2013 and December 31 2015, the researchers recruited 5,781 pregnant women. Data collectors visited each woman in pregnancy, within 72 hours of her baby's birth, and at 3, 6, 9, 12, and 18 months after birth. In the final analysis, the researchers measured 1,253 eligible children at 18 months in intervention clusters and 1,308 eligible children in control clusters.

Mean length-for-age Z score at 18 months was -2.31 (standard deviation (SD) 1.12) in intervention clusters and -2.40 (SD 1.10) in control clusters (adjusted difference 0.107, 95% CI -0.011 to 0.226, p=0.08). The intervention did not significantly affect exclusive breastfeeding, timely introduction of complementary foods, morbidity, appropriate home care, or care-seeking during childhood illnesses. However, in intervention clusters, more pregnant women and children attained minimum dietary diversity (adjusted odds ratio [aOR] for women 1.39, 95% confidence interval (CI) 1.03-1.90; for children 1.47, 1.07-2.02), more mothers washed their hands before feeding children (5.23, 2.61-10.5), fewer children were underweight at 18 months (0.81, 0.66-0.99), and fewer infants died (0.63, 0.39-1.00).

Thus, although certain secondary outcomes were improved, the introduction of the SPK to promote interventions for growth during the first 1,000 days of life in areas with a high burden of undernutrition in rural eastern India did not significantly increase children's length. Reviewing other trials conducted in India and elsewhere, the researchers suggest that "The evidence available to date...confirms that community interventions to improve infant and young child feeding and hygiene through handwashing, care-giving and care-seeking during illness, though necessary, will only lead to small changes in length-for-age Z score. This further underscores the importance of investing in girls and women's nutrition and going beyond immediate determinants to achieve substantial reductions in stunting."

The article explores some alternative options to expand the coverage of nutrition-specific interventions for pregnant women and children younger than 2 years in rural areas in India. For example, the Mother's Absolute Affection programme, which was launched in 2016, mandates the training and incentivisation of accredited social health activists (ASHAs) to promote infant and young child feeding in the first 2 years of life through home visits and group meetings, along with screening and referral for acute malnutrition with mid-upper arm circumference - activities very similar to those tested in this trial. The National Health Mission has also sanctioned the scale-up and incentivisation of ASHAs to conduct participatory learning and action meetings to improve maternal and child health across 10 states.

In conclusion: "Future research might...explore how to optimise the home visiting and participatory women's groups materials created during this trial and other studies...so that the number and content of home visits aligns with those recommended in WHO's Caring for the Childs Healthy Growth and Development, and women's groups have an opportunity to discuss how to address the immediate and underlying determinants of child undernutrition in a voluntary, participatory, and context-appropriate manner..."