Randomized control trials demonstrate that nutrition-sensitive social protection interventions increase the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children

Abstract

ObjectiveTo examine the impact of a nutrition-sensitive social protection intervention on mothers’ knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and the consumption of MMP and other Fe supplements by their children aged 6–59 months.DesignTwo randomized controlled trials with treatment arms including cash transfers, food transfers, cash and food transfers, cash and nutrition behaviour change communication (BCC), and food and nutrition BCC were implemented over two years. Both included a control group that received no transfer or BCC. Transfer recipients were mothers living in poor households with at least one child aged less than 2 years at baseline. Probit models were used to analyse endline data.SettingRural areas in north-west and south Bangladesh.SubjectsMothers (n 4840) and children 6–59 months (n 4840).ResultsA transfer accompanied by nutrition BCC increased the share of mothers with knowledge of Fe deficiency (11·9 and 9·2 percentage points for North and South, respectively, P≤0·01), maternal awareness of MMP (29·0 and 22·2 percentage points, P≤0·01), the likelihood that their children 6–59 months had ever consumed MMP (32 and 11·9 percentage points, P≤0·01), consumed MMP in the preceding week (16·9 and 3·9 percentage points, P≤0·01) and consumed either MMP or an Fe supplement in the preceding week (22·3 and 7·1 percentage points, P≤0·01). Improvements were statistically significant relative to groups that received a transfer only.ConclusionsNutrition-sensitive social protection (transfers with BCC added) may be a promising way to advance progress on micronutrient deficiencies.

Understanding the impact of nutrition-sensitive social protection interventions on the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children

“…In the case of the trials ( 7 ) conducted in the study published in a recent issue of Public Health Nutrition ( PHN ), the results showed that cash conditional on nutrition behaviour change communication (‘Cash + BCC’) yielded higher impacts in terms of knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and reported consumption thereof for children aged 6–59 months, than did cash only (‘Cash’) or cash and food (‘Cash & Food’) or food only (‘Food’). While these are important findings, as they show that in contexts where MMP are widely available, nutrition BCC interventions can help increase knowledge and awareness of the importance of micronutrients and that this can result in higher consumption of said MMP, the study exhibits the same pitfall that many other attempts to measure the impact of CCT on child health outcomes fall into: the inability to categorically attribute difference purely to conditionality.…”

“…Unlike other studies that have attempted to measure the impact of conditionality on child health outcomes, the PHN study ( 7 ) looked at knowledge and reported consumption of MMP only and did not measure any objective nutritional clinical outcomes such as anaemia. While it could be argued that once the efficacy of MMP in reducing anaemia has been proven, strategies to increase uptake, such as the ones discussed in the article, will be useful, the lack of objective nutritional clinical outcomes is an important limitation because it leaves us no nearer to answering the question of what impact CCT have on outcomes such as micronutrient deficiency.…”

“…Compliance with conditionality is expensive for poor people, especially in terms of time and the penalties meted out for non-compliance. The trials reported in the PHN article ( 7 ) had intense BCC interventions that required women to allocate an hour each week for nutrition education. Monitoring attendance at the BCC sessions would have been equally laborious for community health workers who had to follow up on each person who failed to attend.…”

“…An important and laudable difference in the ‘Cash + BCC’ intervention implemented in the trial ( 7 ) reported in the recent PHN issue is that the conditions were soft: the authors report that failure to comply with conditions did not result in caregivers not receiving the cash transfer, instead community health workers employed in the study followed up on each participant who failed to comply to understand their reasons for non-attendance of the BCC sessions. From the results of the trial it is clear that nutrition education regarding MMP and Fe deficiency was an important intervention in rural Bangladesh; what is also equally clear is that receipt of the cash was not strictly tied to attendance of the education sessions and yet caregivers still complied.…”

“…There is enough evidence to suggest that cash alone cannot tackle child malnutrition, but that a myriad of interventions including cash, nutrition education, housing, access to services such as water and sanitation, and infrastructural improvements are needed. However, additional empirical data are required on the impact of these ‘cash plus’ interventions on child health outcomes, as the findings reported in the PHN article ( 7 ) have notable weaknesses such as the lack of a BCC only comparison arm and baseline data for some of the outcomes. Furthermore, it is important to assess whether these findings can be replicated in other low- and middle-income settings.…”