Effect of the SPRING home visits intervention on early child development and growth in rural India and Pakistan:
Betty R Kirkwood1, Siham Sikander2,3, Reetabrata Roy1,4
1Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Insights
The Sustainable Programme Incorporating Nutrition and Games (SPRING) intervention did not improve child development or growth outcomes. However, it significantly increased the proportion of children meeting minimum acceptable diet criteria in both India and Pakistan.
Area of Science:
- Global child development and nutrition
- Public health interventions
- Socioeconomic disadvantage
Background:
- Millions of children worldwide do not reach their full developmental potential due to cycles of disadvantage.
- Parent-focused, face-to-face interventions show promise for improving developmental outcomes, but scaling them remains a challenge.
- The Sustainable Programme Incorporating Nutrition and Games (SPRING) was developed to address this by testing scalable home-visit models.
Purpose of the Study:
- To develop and test a feasible, affordable program of monthly home visits by community-based workers (CWs) to improve child development and nutrition.
- To evaluate two distinct delivery models of the SPRING program in Pakistan and India.
- To assess the impact of the SPRING intervention on early childhood development (ECD) outcomes and child growth.
Main Methods:
- Parallel cluster randomized trials were conducted in Pakistan (20 Union Councils) and India (24 health sub-centre catchment areas).
- Mother-baby dyads were recruited, and primary outcomes included BSID-III composite scores for psychomotor, cognitive, and language development, plus height-for-age z-score (HAZ) at 18 months.
- Intention-to-treat analyses were performed on data from 1,016 children in Pakistan and 1,443 children in India.
Main Results:
- The SPRING intervention had no significant impact on early childhood development (ECD) outcomes or growth in either India or Pakistan.
- However, the intervention group showed a significant increase in children meeting WHO minimum acceptable diet criteria at 12 months.
- This increase was 35% higher in India (p=0.023) and 45% higher in Pakistan (p=0.002) compared to control groups.
Conclusions:
- Implementation challenges, including overloaded community worker workloads and the need for re-organized goals and resources, likely explain the lack of impact on ECD and growth.
- The civil society/non-governmental organization (CSO/NGO) delivery model shows greater potential for scale-up compared to integrating tasks into existing government health worker programs.
- Successful large-scale implementation requires robust administrative and management systems to support community-based workers.
Introduction:
Almost 250 million children fail to achieve their full growth or developmental potential, trapping them in a cycle of continuing disadvantage. Strong evidence exists that parent-focussed face to face interventions can improve developmental outcomes; the challenge is delivering these on a wide scale. SPRING (Sustainable Programme Incorporating Nutrition and Games) aimed to address this by developing a feasible affordable programme of monthly home visits by community-based workers (CWs) and testing two different delivery models at scale in a programmatic setting. In Pakistan, SPRING was embedded into existing monthly home visits of Lady Health Workers (LHWs). In India, it was delivered by a civil society/non-governmental organisation (CSO/NGO) that trained a new cadre of CWs.
Methods:
The SPRING interventions were evaluated through parallel cluster randomised trials. In Pakistan, clusters were 20 Union Councils (UCs), and in India, the catchment areas of 24 health sub-centres. Trial participants were mother-baby dyads of live born babies recruited through surveillance systems of 2 monthly home visits. Primary outcomes were BSID-III composite scores for psychomotor, cognitive and language development plus height for age z-score (HAZ), assessed at 18 months of age. Analyses were by intention to treat.
Results:
1,443 children in India were assessed at age 18 months and 1,016 in Pakistan. There was no impact in either setting on ECD outcomes or growth. The percentage of children in the SPRING intervention group who were receiving diets at 12 months of age that met the WHO minimum acceptable criteria was 35% higher in India (95% CI: 4-75%, p = 0.023) and 45% higher in Pakistan (95% CI: 15-83%, p = 0.002) compared to children in the control groups.
Discussion:
The lack of impact is explained by shortcomings in implementation factors. Important lessons were learnt. Integrating additional tasks into the already overloaded workload of CWs is unlikely to be successful without additional resources and re-organisation of their goals to include the new tasks. The NGO model is the most likely for scale-up as few countries have established infrastructures like the LHW programme. It will require careful attention to the establishment of strong administrative and management systems to support its implementation.
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