Suanhoam: a cluster-randomized controlled trial to evaluate the effectiveness of a mixed intervention package in reducing child undernutrition in Lao People's Democratic Republic

This cluster-randomized controlled trial has a control and an intervention arm. The Control Arm will receive the standard primary health care services at their respective centres as mandated by the Ministry of Health. These standard activities include an ongoing drug revolving fund, health promotional materials developed by the Ministry, antenatal care (at least four visits during pregnancy), child immunizations (as per national guidelines), maternal weekly supplementation of Vitamin B1, iron and folic acid (for three months) and biannual child deworming - all services delivered by the front-line government health service staff. The Intervention Arm will include all the standard package services plus an additional community nutrition component. This will include five nutrition-specific elements delivered by either the trained community nutrition teams in the villages at 2 to 4-month intervals or at 3-monthly outreach visits to the village by health centre staff. The additional intervention community nutrition elements include the following: 1. Outreach days - • These are health outreach clinics whereby health centre staff travel to a village to deliver clinical and health promotion services with the support of the community nutrition team in each village. • These services will be delivered every 3 months using interactive and adult participatory approaches lasting 1-2 hours. • For children aged less than 5 years, these services will include immunisations in accordance with the Lao national immunisation schedule, and growth monitoring • Pregnant women and their partners will receive health advice about warning signs during pregnancy, antenatal and postnatal care, promotion of delivering in health facilities, and nutrition during pregnant and lactation • Caregivers of children aged less than 5 years will receive nutrition and health advice specific to their needs and interests, such as information about young infant and child feeding, promotion of safe food preparation and storage (for caregivers of children under 5 years) and home management of childhood illness and undernutrition. • This component will be monitored through a standardised report provided by outreach team documenting vaccines delivered, number of children having anthropometric assessments, and number of caregivers attending health promotion discussions. 2. Breastfeeding promotion – • This component will be delivered by community nutrition teams in their own village in one-on-one and small group discussions with pregnant women and caregivers of children under 5 years • These conversations will be an ongoing activity with community nutrition teams to provide advice to caregivers of young children as asked, but with a minimum of a 1hr session every 2 months • Community nutrition teams will cover topics such as early initiation of breastfeeding, exclusive breastfeeding up to six months (including discussion of the common practice of feeding young infants pre-masticated rice), continued breastfeeding until 24 months and addressing breastfeeding taboos • This activity will be monitored through diaries of contacts with caregivers kept by the community nutrition teams and validated through serial questionnaires of mothers (at the birth of the child and when the child is 6, 12 and 18 months of age). 3. Community-based nutrition education • This component will be delivered by community nutrition teams in their own village in one-on-one and small group discussions with pregnant women and caregivers of children under 5 years • These conversations will be an ongoing activity with community nutrition teams to provide advice to caregivers of young children as asked, but with a minimum of a 1hr session every 2 months • Community nutrition teams will cover topics such as complementary feeding, continued breast feeding, dietary diversity, sources of micronutrients and addressing food taboos • This activity will be monitored through diaries of contacts with caregivers kept by the community nutrition teams and validated through serial questionnaires of mothers (at the birth of the child and when the child is 6, 12 and 18 months of age). 4. Safe food preparation and storage • This component will be delivered by community nutrition teams in their own village in one-on-one and small group discussions with pregnant women and caregivers of children under 5 years • These conversations will be an ongoing activity with community nutrition teams to provide advice to caregivers of young children as asked, but with a minimum of a 1hr session every 2 months • Community nutrition teams will cover topics such sourcing clean water and boiling water for drinking, cooking meat thoroughly, washing fruits and vegetables before eating, covering food set aside and promotion of handwashing practices • This activity will be monitored through diaries of contacts with caregivers kept by the community nutrition teams and validated through serial questionnaires of mothers (at the birth of the child and when the child is 6, 12 and 18 months of age). 5. Home management of childhood illness and undernutrition • This component will be delivered by community nutrition teams in their own village in one-on-one and small group discussions with pregnant women and caregivers of children under 5 years • These conversations will be an ongoing activity with community nutrition teams to provide advice to caregivers of young children as asked, but with a minimum of a 1hr session every 4 months • Community nutrition teams will cover topics such as recognising danger signs of community illnesses and when to take the child to a health centre, home management of mild diarrhoea, continued breastfeeding of the sick child, improved complementary feeding during illness, and guidance of supplementary feeding for moderately malnourished children • This activity will be monitored through diaries of contacts with caregivers kept by the community nutrition teams and validated through serial questionnaires of mothers (at the birth of the child and when the child is 6, 12 and 18 months of age). The duration of the intervention period will be from enrolment of a pregnant women at any time during the third trimester until the child to be born is 18 months of age - a maximum period of 21 months in total for each parent-child dyad.