"Age-Based Preventive Targeting of Food Assistance and Behaviour Change Communication for Reduction of Childhood Undernutrition in Haiti: A Cluster Randomised Trial," by Marie T Ruel, Purnima Menon, Jean-Pierre Habicht, Cornelia Loechl, Gilles Bergeron, Gretel Pelto, Mary Arimond, John Maluccio, Lesly Michaud, and Bekele Hankebo

Summary of research conducted in Haiti by the International Food Policy Research Institute (IFPRI) and Cornell University in conjunction with World Vision-Haiti's Title II Program and the U.S. Agency for International Development's (USAID) Food and Nutrition Technical Assistance(FANTA) project of the Academy for Educational Development. This study is featured in the February 16 issue of The Lancet as part of its ongoing focus on maternal and child undernutrition.

Both common sense and previous scientific research suggest that preventing malnutrition is preferable to treating it, especially because children can suffer irreparable harm from undernourishment during the first two years of life.

Despite compelling evidence that nutrition interventions are more effective when targeted as early as possible—and before children reach the age of two—common practice continues to be that food-assisted maternal and child health and nutrition programs target children up to five years of age, and only once they have become underweight.

This study in Haiti compared the effectiveness of two approaches and assessed their impact on childhood nutrition. Both programs provided food assistance and health and nutrition interventions to poor communities with high rates of child malnutrition.

The first, recuperative approach provided nine months of food and other health and nutrition assistance to children six months to five years of age once they became underweight. The second, preventative approach targeted all children 6-24 months of age with similar food and health and nutrition services, until they reached the age of 24 months, regardless of whether or not they were underweight. The preventive model also offered assistance and benefits to children from two to five years of age who were severely malnourished. Both approaches also targeted pregnant women and breastfeeding mothers.

Researchers conducted surveys in the participating communities at the beginning of the study (baseline), and exactly three years later. They measured children's height for age, weight for age, and weight for height and found that child stunting, underweight, and wasting (indicators of malnutrition) were 4, 6, and 4 percentage points lower, respectively, among communities participating in preventative programs than recuperative ones. These differences between the groups are substantial, and provide concrete evidence that preventing infants and young children from becoming undernourished is much more effective than treating children who are already moderately malnourished.

The study was conducted in the context of a five-year program implemented at the community level by World Vision in the Central Plateau region of Haiti. Twenty clusters of communities were selected for the study. Each cluster was paired with another one deemed to be similar in geographical and ecological conditions, access to a healthcare center, and existence of a World Vision private sponsorship program. Within each pair of clusters, one was randomly assigned to the preventative program model; the other to the recuperative one.

Both the recuperative and preventive programs offered exactly the same range of services for pregnant and breastfeeding women and for infants and children up to five years of age, and provided the same monthly food ration. The services included food assistance, growth monitoring, immunization, and vitamin supplementation. A behavior change and communication strategy, which emphasized health and nutrition education, was an important component of the programs.

The only aspects that differed between the two program approaches were eligibility criterion and duration of the assistance and interventions (as discussed above), and differences in the behavior change and communication strategy. For example, in the preventive program, a precise schedule was established to ensure that information was age-specific and reached mothers or other caregivers at the time when they most needed it. With the recuperative approach, learning sessions addressed topics of relevance for undernourished children, including causes of undernutrition and hygiene issues.

Although this research was conducted in rural Haiti, the findings are generalisable to other poor communities around the world, especially since children's patterns of growth and development are remarkably similar no matter where they live. The study reinforces the need to address malnutrition in the first two years of life and provides concrete evidence that preventive programs can be highly successful in combating child undernutrition on the ground, in real-life situations.

The research in Haiti was funded by multiple sources, including USAID's Food for Peace Program, USAID-Haiti, FANTA, World Vision-Haiti, the Government of Germany, and the United Nations World Food Programme.