Prevention is Better than Cure: An Example of MCHN Programming in Haiti Marie T Ruel IFPRI Collaboration between IFPRI, Cornell University, World Vision-Haiti Support: USAID through FANTA/AED, World Vision-Haiti, Govt. of Germany, World Food Programme

Background Food-assisted MCHN programs typically target underweight children < 5 y In spite of evidence that 1st 2 years is the « window of opportunity » for nutrition interventions Missing: programmatic evidence that targeting children < 2 y is effective in undernutrition

Main objective of the study: Compare impact on childhood undernutrition of 2 approaches of targeting FA-MCHN programs: The recuperative approach: targets underweight children < 5 y (WAZ < -2 SD) The preventive approach: targets all children months of age to prevent undernutrition *Both program models also target pregnant/lactating women

The Context: FA-MCHN (WV-Haiti) -Rally Posts -Mothers Clubs - Pre/post natal clinics - Mothers Clubs Food distribution points * Home visits are also scheduled for severely malnourished children and mothers soon after delivery PREG/LACTATING WOMENCHILD BENEFICIARIES Rally Posts Identification of beneficiaries Primary health care & nutrition services Eligible to receive food at:

Differences between Program Models PreventiveRecuperative Eligibility: -ALL 6-23 mo mo, malnourished (WAZ < -3) mo, malnourished (WAZ < -2) Duration in program, focus, timing -Duration (for child): 18 sessions -Focus: prevention -Timing of education: age-specific -Duration (for child): 9 sessions -Focus: malnourished child -Timing: when child malnourished

CommodityChildren 6-24 mo or malnourished <5 years Pregnant/lactating women Direct ration (kg) Indirect ration (kg) Direct ration (kg) Indirect ration (kg) WSB8 SFB 1055 Lentils Oil2 1.5 WSB=Wheat-soy blend; SFB=Soy-fortified bulgur; oil is fortified with vitamins A & E Food Assistance Package

20 clusters of communities, 10 Recuperative 752 children 10 matched pairs of clusters Intervention Cross-sectional baseline survey Cross-sectional final survey 10 Preventive 788 children 748 children PROGRAM ALLOCATION IMPACT ASSESSMENT Trial Profile: Cluster Randomized Trial 792 children

Survey data Anthropometry – children and mothers Community characteristics Household demographics, socioeconomic status, food security Maternal characteristics Behavior change outcomes Program participation

Baseline Characteristics (2002): No differences between groups CharacteristicPreventive (n=788) Recuperative (n=792) Stunting (%) Underweight (%) Wasting (%) Maternal height158.0 % women farming HH size % sanitation % electricity 2.0 Using WHO 2006 standards

Preventive communities had better anthropometry than recuperative at final survey Outcome (final survey) Preventive (n=752) Mean Recuperative (n=748 ) Mean Difference (preventive – recuperative) HAZ-1.53 * WAZ-0.96* WHZ-0.22* *p<0.05; random effects regression using child-level data, controlling for child age, gender, and adjusting for clustering at pair-level

Preventive communities had lower stunting, underweight & wasting than recuperative at final survey 4pp 6pp 4pp

Household food security is higher in preventive than recuperative communities at final survey * *

Impact on Food Security * *

* *

Conclusions Blanket age-targeting (preventive) of FA- MCHN is more effective at reducing undernutrition than targeting underweight children (recuperative) Differences in favor of preventive group were 4, 6 and 4 pp in stunting, underweight, wasting Before/after comparisons suggest some deterioration in undernutrition in recuperative communities (plausible given economic & political crisis in Haiti)

Comparing our sample with DHS surveys 2000 and 2005 (NCHS standards) Prevalences used for EMMUS 2005 are for all kids < 5 y in Central Department DHS 2000 DHS 2005 Baseline Preventive final Recuperative final DHS 2000 DHS 2005 DHS 2000 DHS 2005 Preventive final Recuperative final Baseline

Conclusions (2) Both programs helped mitigate the crisis, but preventive was more effective at doing so Benefits of preventive model are not due to differences in implementation and organizational conditions, nor in program use

Generalizability of findings Good program design (formative research) Effective implementation & service delivery (operations research) Good incentive structure, staff motivation and effective supervision Similar levels of undernutrition

The Sprinkles Study Add-on research study to: –Evaluate feasibility of distributing Sprinkles with food aid rations in context of MCHN program –Evaluate effectiveness in reducing anemia among 6-24 month old children Design: –Randomized, pre-post intervention with control group (receiving fortified WSB only) –Sample size: 261 (S+WSB); 161 (WSB)

How to use the Sprinkles SPRINKLES Vitamin ak lòt fòtifyan Pou mete nan manje Pa itilize l si sachè a dechire ou domaje. Konsève l nan yon kote ki sèk. Chak 1.0g gen :__________________ Vitamin A 300µg Vitamin C 30mg Acide Folique 160µg Fer 12.5mg Zinc 5mg Ingrédient non médicinal Maltodextrin Dosaj: Itilize yon sachè chak jou. Melanje yon ti sachè ak yon ti kantite manje jis avan ou sèvi manje a. Manufacturé par PED-MED Ltd Toronto en Canada MSP 2x9 Ped-Med Itilize l avan janvye 2007.

Dosage and Frequency Composition: 12.5 mg of Fe 5 mg Zn 400 mcg Vitamin A 160 mcg Folic Acid 30 mg Vitamin C Frequency: 1 sachet per day 30 sachets per month for 2 months

Distribution Method Program Food Distribution Points: With monthly distribution of food aid commodities 2 pre-packaged bags of 15 sachets/month On two consecutive months Education on how to use them – at Mothers Clubs

Prevalence of anemia (Hb<10 g/dL) at baseline and endline, by treatment %

Changes in anemia prevalence by age group

Conclusions Including Sprinkles distribution in MCHN-food assisted project is feasible Existing program venues (MC and FDP) are appropriate Good acceptance and appreciation by mothers and staff Compliance was very high; mothers understood how to use Sprinkles; and used them as instructed Impact on reducing anemia is large and maintained 7 mo later