Global child health Original research Arch Dis Child: first published as 10.1136/archdischild-2018-316471 on 10 October 2019. Downloaded from Rojiroti microfinance and child nutrition: a cluster randomised trial Shalini Ojha ,1 Lisa Szatkowski,2 Ranjeet Sinha,3 Gil Yaron,4 Andrew Fogarty,2 Stephen John Allen,5 Sunil Choudhary,6 Alan Robert Smyth 7 ► Additional material is ABSTRact What is already known on this topic? published online only. To view Objective To determine whether Rojiroti microfinance, please visit the journal online for poor Indian women, improves child nutrition. (http:// dx. doi. org/ 10. 1136/ Microfinance programmes have been Design Cluster randomised trial. ► archdischild- 2018- 316471). implemented widely in poor communities in Setting Tolas (village communities) in Bihar State. 1Division of Medical Sciences low- income and middle- income countries. Participants Women and children under 5 years. and Graduate Entry Medicine, Some microfinance programmes have brought Interventions With Rojiroti microfinance, women form ► University of Nottingham, economic benefits to female participants. Nottingham, UK self- help groups and save their money to provide loans 2 Studies evaluating the impact of microfinance Division of Epidemiology & to group members. After 6 months, they receive larger ► on child health and nutrition have not been Public Health, University of external loans. Tolas were randomised to receive Rojiroti Nottingham, Nottingham, UK rigorous, and results have been conflicting. 3Department of Community immediately or after 18 months. Medicine, Patna Medical Outcome measures The primary analysis compared College, Patna, Bihar, India the mean weight for height Z score (WHZ) of children 4 GY Associates Ltd and Trustee, under 5 years in the intervention versus control tolas Harpenden, UK What this study adds? 5Department of Child Health, who attended for weight and height measurement 18 months after randomisation. Secondary outcomes The Liverpool School of Tropical ► In a cluster randomised trial, we found that Medicine, Liverpool, UK were weight for age Z score (WAZ), height for age Z several indices of child nutrition were better, at Global child health 6Centre for Promoting score, mid-upper arm circumference (MUAC), wasting, 18 months, in the groups randomised to Rojiroti Sustainable Livelihood (CPSL), underweight and stunting. Patna, Bihar, India microfinance. 7 Results We randomised 28 tolas to each arm and Division of Child Health, ► Weight for height Z score (primary outcome) Obstetrics & Gynaecology, collected data from 2469 children (1560 mothers) at was significantly better in the intervention Nottingham University, baseline and 2064 children (1326 mothers) at follow- up. group (−1.02) versus controls (−1.37). Nottingham, UK WHZ was calculated for 1718 children at baseline and ► In poor and marginalised communities in Bihar, 1377 (674 intervention and 703 control) at follow- up. Rojiroti microfinance appears to prevent a Correspondence to At 18 months, mean WHZ was significantly higher for Professor Alan Robert Smyth, deterioration in nutritional indices, in children Child Health, Nottingham intervention (−1.02) versus controls (−1.37; regression under five, at times of food insecurity. Unversity, Nottingham NG7 coefficient adjusted for clusteringβ =0.38, 95% CI 0.16 2UH, UK; to 0.61, p=0.001). Significantly fewer children were http://adc.bmj.com/ alan. smyth@ nottingham. ac. uk wasted in the intervention group (122, 18%) versus control (200, 29%; OR=0.46, 95% CI 0.28 to 0.74, all low-income and middle- income countries, acute Received 28 October 2018 malnutrition remains highly prevalent.4 Revised 12 September 2019 p=0.002). Mean WAZ was better in the intervention Child health follows a social gradient where Accepted 15 September 2019 group (−2.13 vs −2.37; β=0.27, 95% CI 0.11 to 0.43, 5 Published Online First p=0.001) as was MUAC (13.6 cm vs 13.4 cm; β=0.22, wealthier means healthier. Recent economic growth 10 October 2019 95% in India has not led to a reduction in childhood CI 0.03 to 0.40, p=0.02). In an analysis adjusting 6 on September 29, 2021 by guest. Protected copyright. for baseline nutritional measures (259 intervention undernutrition. Bihar (population 116 million) is children and 300 control), only WAZ and % underweight one of the poorest and most deprived states in India showed significant differences in favour of the (population 1.3 billion). Nearly 90% of the popula- intervention. tion is rural and has poor access to healthcare and education. Of the 100 districts in India with the Conclusion In marginalised communities in rural India, 7 child nutrition was better in those who received Rojiroti highest prevalence of malnutrition, 23 are in Bihar. Rojiroti (‘daily bread’) microfinance has been oper- microfinance, compared with controls. 8 Trial registration number NCT01845545. ating in Bihar since 2001. Participants are women, and 62% are from scheduled castes (disadvantaged groups, recognised in the Indian Constitution).8 It is delivered by the non- governmental organisation INTRODUCTION the Centre for Promoting Sustainable Livelihood Globally, 50 million children under 5 years suffer (CPSL) (https://www. rojiroti. org). Women form © Author(s) (or their from acute malnutrition or wasting (weight for self- help groups (SHGs) and contribute their own employer(s)) 2020. Re- use height Z score (WHZ) of below −2).1 These chil- savings to a fund, from which they can request permitted under CC BY. dren are at least three times more likely to die than small loans. Later, women may become eligible for Published by BMJ. their better nourished peers.2 Two- thirds live in larger loans funded by CPSL (see box 1).9 1 To cite: Ojha S, Szatkowski L, Asia. Ending all forms of child malnutrition by Our hypothesis was that Rojiroti microfinance Sinha R, et al. Arch Dis Child 2030 is a Sustainable Development Goal.3 In spite would improve nutrition among children under 2020;105:229–235. of programmes to address malnutrition in almost 5 years. We tested this through a cluster randomised Ojha S, et al. Arch Dis Child 2020;105:229–235. doi:10.1136/archdischild-2018-316471 229 Original research Arch Dis Child: first published as 10.1136/archdischild-2018-316471 on 10 October 2019. Downloaded from to allocation. The tola was the unit of randomisation and the Box 1 The principles of Rojiroti microfinance child the unit of analysis. ► Women are asked to form self- help groups (SHGs). ► They contribute small amounts of money to a communal fund Procedures (approximately Rs2.5, or US 4 cents, per member per week). Phase 1 (feasibility) recruitment took place August–September ► Women are expected to attend at least four SHG meetings 2013 (20 tolas). Once feasibility was established, the pilot stage (held weekly), before their savings entitle them to a loan. commenced, with phase 2 recruitment (30 tolas February–March ► These loans are initially small (70 cents) and come from the 2014). Recruitment stopped during the monsoon, and phase 3 SHG fund. recruitment (six tolas) was in September 2014. At baseline, we ► After 6 months, women in the SHG are entitled to receive collected data about each tola and demographic data for each larger, external loans from CPSL of between Rs500 ($7) and mother and child. The age, sex, weight, length/height and mid- Rs3 000 ($44), provided SHG credit is good. upper arm circumference (MUAC) were recorded for all children There are no restrictions on the use of loans. ► under 5 years of age (and over 6 months for MUAC).9 We used the following equipment for the age groups listed. ► Length: (<2 years) Seca 210 Measuring Mat. Standing trial, based in rural tolas (village neighbourhoods of around 500 height: (≥2 years) Seca 213 Portable Stadiometer (both people of similar socioeconomic status and caste). Seca, Birmingham, UK). ► Weight: (<6 months) Docbel Baby Scales (Popular, Docbel METHODS Industries, New Delhi, India); (6 months–2 years) hanging Study design scales (Venus CHS, Ace, Rajasthan, India); (≥2 years) Libra We conducted a matched pair, cluster randomised controlled Fitness Standing Scale (Edryl, Goa, India). trial (RCT) with a 1:1 allocation ratio. The protocol has been ► MUAC: (>6 months) MUAC tapes (Unicef Supply Division). published,9 and the trial is registered. Our findings are reported Equipment was calibrated, using standard measures, at the in line with the Consolidated Standards of Reporting Trials beginning of each visit. After setting the scales to zero, each child (CONSORT) extension for cluster randomised trials.10 was weighed and measured three times, and the middle value Participants were village women, mostly from scheduled used.13 Children were weighed and measured by CPSL workers, castes. Four administrative blocks in Patna District (Dulhin who were trained by staff from Patna Medical College, prior to Bazar, Naubatpur, Masaurhi and Bikram; figure 1) were chosen the baseline and 18 month visits. Rojiroti then began in the tolas because of proximity to the teams from CPSL and Patna Medical randomised to the intervention. CPSL staff met with women College. We approached the next 60 tolas, due to be offered regularly to record how loans were used. Rojiroti (on the basis of need). SHG membership was open to any woman in the tola. All children in the tola were invited for At 18 months, all children under five present in the tolas were weighing and measuring, irrespective of whether their mother invited for weighing and measurement. Mothers and children was an SHG member. There were no exclusion criteria. who were also present at the baseline survey were identified by unique ID codes. CPSL staff conducted one visit to each tola (to Global child health Consent and randomisation weigh and measure the children) at baseline and follow-up. Data We followed the CONSORT guidelines on consent for cluster were recorded on paper forms, entered electronically in Patna http://adc.bmj.com/ randomised trials.11 Only 46% of women in rural Bihar are and transferred to Nottingham for analysis.