Bangladesh MSNP: Agricultural/Livelihood Mixed Methods Study

NCT ID: NCT04185597

Last Updated: 2021-02-04

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 4067 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2018-07-07
• Study Completion Date: 2020-06-28

Brief Summary

Despite progress in reducing high levels of undernutrition in Bangladesh, gaps in progress persist. They are particularly acute between rural and urban areas, and between the lowest wealth quintile and highest. According to the 2016 Bangladesh DHS report, 38% of rural children under five were stunted compared to 31% of urban children. Forty-nine percent of children in the lowest wealth quintile were stunted compared to 19% in the highest.

To address these discrepancies and lower the overall level of stunting, research is being conducted to assist the government of Bangladesh (GoB) in determining the most effective ways to reduce levels of stunting. In particular, positive correlations between household production and consumption of nutritious food have been widely documented by development organizations in Bangladesh. However, information on how to optimize the delivery of household food production programs is needed.

The primary objective of this study is to compare the effectiveness of current standard practice with two multisectoral intervention packages focused on homestead food production:

1. Homestead food production (HFP) supported by community farmers, Social and Behavior Change Communication (SBCC), strengthened health services, and referrals to health and other services

2. HFP supported by retailers, SBCC, strengthened health services, and referrals to health and other services

The study's primary outcome is the percentage of children 6-23 months old receiving a minimum acceptable diet (MAD), as a proximate determinant for stunting. MAD is defined as the proportion of children 6-23 months old who receive both the minimum feeding frequency and minimum dietary diversity for their age group and breastfeeding status. It will be assessed based on the mother/caregiver report. Secondary outcomes include assessing the knowledge, attitudes, and practices around breastfeeding, complementary feeding, water sanitation and hygiene, health services and gender norms. Quantitative surveys, in depth interviews, focus group discussions, report reviews and process documentation will be used to assess intervention strengths, weakness, and cost effectiveness.

Detailed Description

According to the 2014 Bangladesh Demographic and Health Survey (BDHS), 36% of children under the age of five were stunted, 14% were wasted and 33% were underweight. These results reflect positive trends in stunting and underweight since 2004, though the rate of decline in undernutrition slowed from 2011 to 2014. And, despite positive trends, there remain gaps in key indicators between rural and urban areas and between those in the highest and lowest wealth quintiles. For instance, according to the BDHS, 38% of rural children under five were stunted compared to 31% of urban children. The wealth discrepancies are even greater; 49% of children under five in the lowest wealth quintile were stunted compared to 19% in the highest quintile.

In 2017, the GoB approved the second National Plan of Action for Nutrition (NPAN 2) 2016-2025. The plan aims to improve nutrition and eliminate malnutrition, with a focus on children, adolescent girls, and pregnant and lactating women. Specific targets of NPAN 2 include reducing stunting to 25% among children under 5; reducing wasting to less than 8% and reducing underweight to less than 15%. A significant acceleration in the annual rate of reduction to 3.3% needs to occur in order to achieve the ambitious Targets by 2025. This acceleration requires high-level political commitment, a strong policy framework, effective coordinating mechanisms, adequate resourcing, strong involvement of local civil society groups, and high impact, cost-effective, multisectoral nutrition interventions.

In 2017, USAID awarded FHI 360 the Strengthening Multisectoral Nutrition Programming through Implementation Science Activity (hereafter referred to as "the Project") to test and refine multisectoral nutrition approaches in high stunting areas of Bangladesh. Under the Project, research is being conducted to assess the effect of different multisectoral nutrition intervention packages aimed at improving nutrition outcomes that are known to contribute to overall healthy nutritional status of children under two in Bangladesh. One of the intervention packages to be studied by the Project focuses on integrated agricultural and livelihood activities, known as homestead food production (HFP). This protocol describes a cluster randomized controlled trial (cRCT) to compare two different HFP interventions to the current standard of practice. The two interventions:

1. Homestead food production (HFP) supported by community farmers, Social and Behavior Change Communication (SBCC), strengthened health services, and referrals to health and other services

2. HFP supported by retailers, SBCC, strengthened health services, and referrals to health and other services

A cluster-randomized, controlled trial (cRCT) design will be used to evaluate effectiveness. The interventions will be delivered at the level of the union, which is a geo-political unit with an average population of 25,000 people. A total of 45 unions in Khulna and Barishal Divisions of Bangladesh will be randomly allocated to one of the three study arms: Control (Current Practice), HFP intervention through community farmers (plus SBCC and strengthened health services), or HFP intervention through retailers (plus SBCC and strengthened health services) . Outcome data will be collected through face-to-face interviews using structured questionnaires with independently selected random samples of mothers/caregivers of children ages 6 to 23 months at baseline (pre-intervention) and again at endline. At both timepoints, participants will be chosen from a sub-sample of the general population who meet the eligibility criteria. Baseline data will be conducted prior to initiation of study activities. Endline data collection will be conducted after two years.

A process evaluation will be completed between baseline and endline to understand how well the interventions were implemented, their costs, and ways they may be improved.

The final evaluation of the cRCT to be done at endline, and will focus on comparing the effect of the intervention on the study outcomes. The study's primary outcome is the percentage of children 6-23 months old receiving a minimum acceptable diet (MAD), as a proximate determinant for stunting. MAD is defined as the proportion of children 6-23 months old who receive both the minimum feeding frequency and minimum dietary diversity for their age group and breastfeeding status. It will be assessed based on the mother/caregiver report. Secondary outcomes include assessing the knowledge, attitudes, and practices around breastfeeding, complementary feeding, water sanitation and hygiene, health services and gender norms.

It is anticipated an analysis of covariance (ANCOVA) approach will be used for a post-only comparison of study arms with possible adjustment for baseline levels in an aggregate manner (note: aggregation for baseline adjustment will be needed given the independent samples selected at each time point). Generalized mixed models will be used to compare the study groups; the will be adjustment for clustering at the Union level. A logit link will be used for the primary outcome as it is a dichotomous outcome, while other link functions will be used for other outcomes as appropriate. The comparison of each intervention to the standard of practice is the primary evaluation focus, while the comparison between intervention groups secondary, as the interventions' effects are not expected to be very different from each other. Adjustment for multiple comparisons is not anticipated. The main analysis will use an intention-to-treat (ITT) approach, where study participants' outcomes are analyzed in the study arm the Union was randomized to, regardless of whether or how much they have been exposed to the intervention.

Conditions

Stunting; Undernutrition

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: SINGLE_GROUP
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: NONE

Study Groups

HFP Intervention: Delivery by Community Farmers

HFP- Delivered by community farmers, supported by the study and linked to eligible households to educate on growing nutritious food and poultry rearing or fish culture

Strengthen referrals to health services- Improvements to referral networks will be implemented. Female community nutrition promoters (CNPs) will refer PLW to service delivery points; gradually this will be completed by peer leaders

Improving quality of health services- Health-related service providers will be trained and supervised on nutrition best practices

SBCC- Primary target is PLW. Delivered using traditional and digital channels. Voice messages will be sent to PLW twice per week. Family members (e.g. husband) will also be encouraged to sign up for different weekly messages. Mothers' groups consisting of ten or fewer will be established. Female CNPs will deliver SBCC during monthly mothers' group meetings, household visits, and in health facilities. CNP's role will later be replaced by peer leaders

Group Type: EXPERIMENTAL

HFP Intervention: Delivered by Community Farmers

Intervention Type: OTHER

Homestead food production (HFP) supported by community farmers, Social and Behavior Change Communication (SBCC), strengthened health services, and referrals to health and other services

HFP Intervention: Delivery by agricultural Retailers

HFP- Delivered by agricultural Retailers, supported by the study and linked to eligible households to educate on growing nutritious food and either poultry raring or fish culture

Strengthen referrals to health services- Improvements to referral networks will be implemented. Female CNPs will refer PLW to service delivery points; gradually this will be completed by peer leaders

Improving quality of health services- Health-related service providers will be trained and supervised on nutrition best practices

SBCC- Primary target is PLW. Delivered using traditional and digital channels. Voice messages will be sent to PLW twice per week. Family members (e.g. husband) will also be encouraged to sign up for different weekly messages. Mothers' groups consisting of ten or fewer will be established. Female CNPs will deliver SBCC during monthly mothers' group meetings, household visits, and in health facilities. CNP's role will be replaced by peer leaders

Group Type: EXPERIMENTAL

HFP Intervention: Delivered by agricultural Retailers

Intervention Type: OTHER

HFP supported by retailers, SBCC, strengthened health services, and referrals to health and other services

Standard of Practice

The standard of care includes nutrition and health services provided to all pregnant women and mothers of children under-2 as provided by the GoB and their supporting partners. Services that should be provided include clinic-level infant and young child feeding (IYCF) counseling, growth monitoring and promotion, immunization, iron and folic acid distribution for pregnant women, ANC, safe delivery at community and referral for complications, vitamin-A supplements for postpartum women and children, deworming and management of common childhood illness.

Group Type: ACTIVE_COMPARATOR

Control

Intervention Type: OTHER

Current Standard of Practice

Interventions

HFP Intervention: Delivered by Community Farmers

Homestead food production (HFP) supported by community farmers, Social and Behavior Change Communication (SBCC), strengthened health services, and referrals to health and other services

Intervention Type: OTHER

HFP Intervention: Delivered by agricultural Retailers

HFP supported by retailers, SBCC, strengthened health services, and referrals to health and other services

Intervention Type: OTHER

Control

Current Standard of Practice

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• mother/caregiver of child 6-23 months of age
• Child 6-23 months is mothers 1st or second (living) child
• resides in an extreme poor or poor household, which is defined in Barishal as less than BDT 2056/month on household expenditures or in Khulna as less than BDT 2019/month on household expenditures

• Minimum Eligible Age: 18 Years
• Eligible Sex: FEMALE
• Accepts Healthy Volunteers: Yes

Sponsors

United States Agency for International Development (USAID)

FED

Sponsor Role: collaborator

FHI 360

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Theresa Hoke, PhD

Role: PRINCIPAL_INVESTIGATOR

FHI 360

Taufique Jorder, DrPH

Role: PRINCIPAL_INVESTIGATOR

FHI 360

Locations

FHI 360

Dhaka, , Bangladesh

Countries

Bangladesh

References

BNNC (2017). Second National Plan of Action on Nutrition. Dhaka. Bangladesh National Nutrition Council (BNNC), 2017

Reference Type: BACKGROUND

Ahmed AU, et al. Which Kinds of Social Safety Net Transfers Work Bets for the Ultra Poor in Bangladesh? Operation and Impacts of the Transfer Modality Research Initiative. Dhaka, IFPRI and WFP, 2016.

Reference Type: BACKGROUND

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R; Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013 Aug 3;382(9890):427-451. doi: 10.1016/S0140-6736(13)60937-X. Epub 2013 Jun 6.

Reference Type: BACKGROUND

PMID: 23746772 (View on PubMed)

BBS (2017). Preliminary Report on Household Income and Expenditure Survey 2016. Dhaka, Bangladesh Bureau of Statistics (BBS), 2017.

Reference Type: BACKGROUND

Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008 Jan 19;371(9608):243-60. doi: 10.1016/S0140-6736(07)61690-0. No abstract available.

Reference Type: BACKGROUND

PMID: 18207566 (View on PubMed)

FHI 360 (2016). SHIKHA Project Final Report. Dhaka, Bangladesh: FHI 360

Reference Type: BACKGROUND

Food and Nutrition Technical Assistance III Project (FANTA). 2017. Multisectoral Nutrition Programming: FANTA Achievements and Lessons Learned. Washington, DC: FHI 360/ FANTA.

Reference Type: BACKGROUND

GoB. Bangladesh 2nd National Plan of Action (NPAN2) 2016-2025. 2015. Dhaka, Government of Bangladesh.

Reference Type: BACKGROUND

Islam F. National Social Security Strategy (NSSS): Progress of Action Plan preparation. Presented at the Technical Symposium on Nutrition Sensitive Social Protection in Bangladesh, December 2017.

Reference Type: BACKGROUND

MI. (2009). Investing in the future: A united call to action on vitamin and mineral deficiencies: Micronutrient Initiative

Reference Type: BACKGROUND

National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2016. Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International

Reference Type: BACKGROUND

Save the Children (2012). Nutrition in the First 1000 Days: State of the World's Mothers 2012 Save the Children

Reference Type: BACKGROUND

Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition. Geneva: World Health Organization; 2013. Available from http://www.ncbi.nlm.nih.gov/books/NBK258736/

Reference Type: BACKGROUND

PMID: 25473713 (View on PubMed)

Arimond M, Daelmans B, Dewey K; Steering Team of the Working Group on Infant and Young Child Feeding Indicators. Indicators for feeding practices in children. Lancet. 2008 Feb 16;371(9612):541-2. doi: 10.1016/S0140-6736(08)60250-0. No abstract available.

Reference Type: BACKGROUND

PMID: 18280315 (View on PubMed)

WHO, UNICEF, and USAID. (2015). Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene: Practical Solutions for Policies and Programmes. Switzerland: WHO

Reference Type: BACKGROUND

Other Identifiers

14165566

Identifier Type: OTHER

Identifier Source: secondary_id

1234890-6

Identifier Type: -

Identifier Source: org_study_id